|
| A) | collaboration. | ||
| B) | commitment. | ||
| C) | competence. | ||
| D) | trust. |
The counselor-client relationship impacts ethical decision making and must consider the cultural context of the professional relationship along with ethical principles. The structure of common therapeutic relationship factors includes confidence in the therapist and confidence in the treatment plan, which is built on trust [7].
| A) | Ideals rather than obligatory rules and laws | ||
| B) | Compliance rules | ||
| C) | Jurisdictional law | ||
| D) | Mandatory rules that must be followed |
Ethics in counseling and therapy focuses on ideals rather than obligatory rules. It emphasizes professionals' character and their relationships with their clients. The study of ethics is more than solving a specific ethical or legal dilemma. Although ethics codes speak to many issues, the counselor must recognize that codes are broad and do not cover every ethical issue faced by counselors and therapists. The professional's ethical awareness, behavior, and problem-solving skills will determine how they translate and apply these general guidelines to professional practice. Ethics codes do not provide explicit instructions for every possible situation.
| A) | Social media | ||
| B) | Informed consent | ||
| C) | Educational goals | ||
| D) | Employment status |
Informed consent is an ethical and legal requirement and an integral part of any counseling plan and therapeutic process. Providing clients with information they need to make informed choices promotes the active participation of clients and families in the counseling plan and is critical to achieve a positive outcome. Informed consent educates clients about their rights and responsibilities and builds empowerment for a trusting, collaborative relationship with the therapist or counselor.
| A) | not reveal any individual's confidences to others in the client group without the prior written permission of that individual. | ||
| B) | not reveal all information to members who have signed informed consent. | ||
| C) | reveal information only to adults. | ||
| D) | not reveal any information even with written consent. |
Additionally, the AAMFT notes, as with other information shared in a counseling setting, that marriage and family therapists [11]:
Do not disclose client confidences except by written authorization, waiver, or when mandated by law.
Do not take verbal authorization except when permitted in an emergency situation or when ordered by law.
Do not disclose information outside the treatment context without a written authorization from each individual competent to execute the waiver.
Disclose the nature of confidentiality to clients, as well as the possible limitations of the clients' right to confidentiality.
Review with clients the circumstances where confidential information may be requested and when it can be disclosed.
Understand the circumstances that may necessitate repeated disclosures.
Do not reveal any individual's confidences to others in the client group without the prior written permission of that individual.
| A) | Counselors respect and honor the inherent and legal rights of the parents and legal guardians of minors and incapacitated adults who are legally incapable of giving informed consent. | ||
| B) | They do not give clear guidance on the topic. | ||
| C) | Legal guardians have no rights regardless of age or competence of clients. | ||
| D) | Only through a court order can information be released to parents or guardians. |
The NBCC 2023 Code of Ethics contains the following standards in this area:
Counselors working with minors, incapacitated adults, or other persons unable to give legal consent to release confidential and privileged information, shall protect the confidentiality of information received in the counseling relationship as specified by Federal and State laws, written policies, and applicable ethical standards. In all cases, the counselor shall discuss with the client and their legal representative the limits of confidentiality and the rules concerning the release of any information.
Counselors respect and honor the inherent and legal rights of the parents and legal guardians of minors and incapacitated adults who are legally incapable of giving informed consent. As appropriate, the counselor shall collaborate with the parent(s) or legal guardian, discussing the role of counseling, the confidential nature of the counseling relationship, and the autonomy of the client as required by the NBCC Code of Ethics, State and Federal law, and other applicable ethical standards. When working with minors or incapacitated adults who are legally incapable of giving informed consent, the counselor shall consider the custody agreement, power of attorney document, or legal agreement that may impact the rights of a parent or legal guardian.
| A) | Premature birthrights | ||
| B) | Sexual orientation | ||
| C) | Gender transition | ||
| D) | End-of-life and child welfare issues |
The ACA's general requirement that counselors keep information confidential does not apply when [10]:
Disclosure is required to protect clients or identified individuals from serious and foreseeable harm;
Legal requirements demand that confidential information must be revealed;
The counselor is in doubt as to the validity of the exception and must consult with other professionals; and when
Additional considerations apply to address end-of-life and child welfare issues.
| A) | provide aid to a client or others, or when legally required to do so. | ||
| B) | complete introduction to a client or others, or when legally required to do so. | ||
| C) | provide interpretation to a client or others, or when legally required to do so. | ||
| D) | prevent serious and foreseeable harm to a client or others, or when legally required to do so. |
The NBCC 2023 Code of Ethics provides the following standards [12]:
Counselors shall take proactive measures to avoid harming their clients and avoid imposing personal values on those who receive their professional services. Counselors will seek to minimize unavoidable or unanticipated harm, and where possible seek to address unintentional harm.
Counselors shall not share client information that is obtained through the counseling process without specific written consent by the client or legal guardian except when necessary to prevent serious and foreseeable harm to the client or others, or when otherwise mandated by federal or state law or regulation.
Counselors who provide clinical supervision services shall keep accurate records of supervision goals and the supervisee's progress. All supervision-related information shall be treated as confidential, except to prevent serious and foreseeable harm to a client or others, or when legally required to do so by a court or government agency order.
| A) | The therapist must try to help these families assimilate into today's culture. | ||
| B) | It is difficult to address changes in family composition to adequately counsel them. | ||
| C) | Today, there is no typical family group, and each person in the family may face issues related to their unique family composition. | ||
| D) | There is little training for counseling these groups. |
Today's professional will encounter a variety of nontraditional families and groups. Same-sex or transgender parents; same-sex family members; and biological, surrogate, and stepparents and -children are all within these nontraditional family groups. There is no "typical" family group, and each person in the family may face issues related to their unique family composition. These issues may include discrimination, bullying, loss of employment, child custody issues, antigay prejudices or violence, feeling ostracized or isolated in the community, and feeling devalued by society.
| A) | If it is requested by the client, it is allowed. | ||
| B) | The professional should never do it. | ||
| C) | It is allowed with minor clients. | ||
| D) | It builds rapport. |
Practitioners must use caution with online communication including emails, text messages, blogs, tweets, photos, and other social media posts. Their online presence must be professional and cannot cause harm to a client or anyone viewing the information. Professional counselors and therapists may not cross boundaries and interact as friends in real life; however, clients and others may become confused online with terms like "friending" on Facebook. This is something that the professional should never do. If personal information or a status with someone is posted on Facebook, it is open to be reposted and viewed by anyone who is associated with the person that reposted the information, unless specific privacy settings are in place.
| A) | They cover every possible issue the practitioner will face. | ||
| B) | They are a set of mandates for decision making for all ethical issues. | ||
| C) | When codes do not contain information on a particular issue, the practitioner is still responsible for making correct ethical decisions to protect the welfare of the client. | ||
| D) | They provide clear, simple answers to all ethical questions. |
When codes do not contain information on a particular issue, the practitioner is still responsible for making correct ethical decisions to protect the welfare of the client. The responsibility for making the correct ethical decision is complex, with serious ramifications for the client and practitioner. A sound ethical decision-making process must be applied to lead the practitioner, with assistance from other professionals, to resolve the ethical conflict in accordance with the code of ethics. Reasonable differences of opinion may exist among professionals as they seek to apply values, principles, and ethical standards to resolve a conflict.
| A) | If mental or physical conditions render the counselor unable to provide services | ||
| B) | When they do not share values or believe the client is acting immorally | ||
| C) | When they strongly disagree with the client's beliefs | ||
| D) | When they feel that the client is a danger to themselves and others |
Counselors shall perform only those professional services for which they are qualified by training, education, and supervised experience.
Counselors shall accurately represent their current professional qualifications and credentials in counseling or closely related disciplines.
Counselors shall identify only earned educational degrees in counseling or another mental health discipline with regard to all counseling work, including publications.
Counselors shall seek professional assistance or withdraw from the practice of counseling if their mental or physical condition makes it so that they are unable to provide appropriate services.
Counselors shall obtain supervision or consultation with other qualified professionals when unsure about client treatment and/or professional practice responsibilities.
Counselors shall clearly distinguish honorary educational degrees from earned degrees.
Counselors shall demonstrate multicultural counseling competence in practice. Counselors will not use counseling techniques or engage in any professional activities that discriminate against or show hostility toward individuals or groups based on gender, ethnicity, race, national origin, sex, sexual orientation, disability, religion, or any other legally prohibited basis.
Counselors shall not misuse their professional influence or meet their own needs at the expense of a client's welfare, including, but not limited to, the promotion of services or products.
Counselors shall not solicit testimonials from current clients or their families and friends. Recognizing the possibility of future requests for services, counselors shall not solicit testimonials from former clients within 5 years from the date of service termination.
Counselors, who have reasonable cause to believe that another mental health professional has engaged in unethical behavior, must report the matter to NBCC except when State regulations require immediate reporting.
Counselors shall discuss service termination with clients when there is a reasonable belief that the clients are no longer benefiting from, or are unlikely to benefit from, future services, and provide appropriate referrals.
Counselors shall comply with all NBCC policies, procedures, and agreements, including all disclosure requirements and related instructions.
Counselors shall adhere to legal standards and requirements, including State licensure regulations.
Counselors shall not engage in unlawful discrimination.
Counselors, who make public statements inconsistent with this code or other professional counseling standards, shall state that their opinions represent their personal views.
Counselors providing professional counseling presentations shall ensure that the content is consistent with this code of ethics.
| A) | When it becomes reasonably apparent that the client no longer benefits from services | ||
| B) | When counselor values conflict with the client's values | ||
| C) | When the client is not likely to benefit | ||
| D) | When the client is being harmed by continued counseling |
Counselors shall perform only those professional services for which they are qualified by training, education, and supervised experience.
Counselors shall accurately represent their current professional qualifications and credentials in counseling or closely related disciplines.
Counselors shall identify only earned educational degrees in counseling or another mental health discipline with regard to all counseling work, including publications.
Counselors shall seek professional assistance or withdraw from the practice of counseling if their mental or physical condition makes it so that they are unable to provide appropriate services.
Counselors shall obtain supervision or consultation with other qualified professionals when unsure about client treatment and/or professional practice responsibilities.
Counselors shall clearly distinguish honorary educational degrees from earned degrees.
Counselors shall demonstrate multicultural counseling competence in practice. Counselors will not use counseling techniques or engage in any professional activities that discriminate against or show hostility toward individuals or groups based on gender, ethnicity, race, national origin, sex, sexual orientation, disability, religion, or any other legally prohibited basis.
Counselors shall not misuse their professional influence or meet their own needs at the expense of a client's welfare, including, but not limited to, the promotion of services or products.
Counselors shall not solicit testimonials from current clients or their families and friends. Recognizing the possibility of future requests for services, counselors shall not solicit testimonials from former clients within 5 years from the date of service termination.
Counselors, who have reasonable cause to believe that another mental health professional has engaged in unethical behavior, must report the matter to NBCC except when State regulations require immediate reporting.
Counselors shall discuss service termination with clients when there is a reasonable belief that the clients are no longer benefiting from, or are unlikely to benefit from, future services, and provide appropriate referrals.
Counselors shall comply with all NBCC policies, procedures, and agreements, including all disclosure requirements and related instructions.
Counselors shall adhere to legal standards and requirements, including State licensure regulations.
Counselors shall not engage in unlawful discrimination.
Counselors, who make public statements inconsistent with this code or other professional counseling standards, shall state that their opinions represent their personal views.
Counselors providing professional counseling presentations shall ensure that the content is consistent with this code of ethics.
| A) | shall provide complete information to a client regarding the format of each test and assessment, purpose, outcome, risks, and limitations. | ||
| B) | are not required to provide complete information to a client regarding the format of each test and assessment, purpose, outcome, risks, and limitations. | ||
| C) | may decide not to provide complete information to a client regarding the format of each test and assessment, purpose, outcome, risks, and limitations. | ||
| D) | should not provide complete information to a client regarding the format of each test and assessment, purpose, outcome, risks, and limitations. |
Counselors shall protect the confidentiality and security of client related tests, assessments, reports, data, and any transmission of client-related information in any form.
Counselors shall not release any information related to the client, to any party other than the client without prior written consent, except as required to prevent clear and imminent danger to the client or others; when authorized by written agreement with the client; or, when legally required to do so by a court order or governmental agency.
Counselors shall use or interpret only the specific tests and assessments for which they are qualified, including meeting the qualification of having the required education and supervised experience.
Counselors shall only use current, valid tests and assessments specifically necessary for the provision of quality services, and that have been carefully considered in terms of the instrument's validity, reliability, psychometric limitations, and appropriateness for use with regard to a particular population or client.
Counselors shall recognize results that are clinically significant for a given client test and assessment and shall document in the client's record how the results will be appropriately used in the counseling process.
Counselors who develop tests or assessments for measuring personal characteristics, development, diagnoses, goal attainment, or other appropriate clinical uses shall provide test users with written valid, information regarding the benefits and limitations of test instruments, including appropriate use, test results, and interpretation.
Counselors who develop tests and assessments for measuring personal characteristics, development, diagnoses, goal attainment, or other appropriate clinical uses shall identify other potential sources of comparable information.
Prior to the use of a test or assessment, counselors shall provide complete information to a client regarding the format of each test and assessment, purpose, outcome, risks, and limitations.
Prior to the use of a test or assessment with a client, counselors shall seek information about a test's normative groups and limitations of use that may affect the administration or interpretation of results. If appropriate, the counselor may provide a referral to another qualified professional who specializes in the evaluation of individuals with similar conditions.
Counselors shall follow administration and interpretation protocols for all tests and assessments, including the use of appropriate computer software.
Counselors shall comply with identified information and data security protocols identified by test publishers when using published tests and assessments.
| A) | The NBCC does not recognize the use of distance services for research. | ||
| B) | The NBCC prefers the use of face-to-face research formats. | ||
| C) | The NBCC advises never to use underrepresented groups as subjects. | ||
| D) | Counselors shall provide appropriate disclosures prior to research participation, and appropriately report to and debrief participants. |
Counselors shall protect the welfare of research participants by taking all appropriate precautions to prevent negative psychological or physical effects.
Counselors shall protect the identities of research participants by appropriately disguising data, except when there is a specific written client authorization for an identified appropriate reason.
Counselors conducting research with underrepresented groups must take into consideration their historical, diverse, and multicultural experiences, and only use techniques and approaches based on established, clinically sound theory applicable to underrepresented populations.
Counselors shall take credit only for research activities they have performed or authored.
Counselors shall provide appropriate disclosures prior to research participation, and appropriately report to and debrief participants regarding the subject and features of the study after research data is collected.
Counselors shall provide critical information, through a written informed consent process, to potential research subjects that will assist them in reaching a determination about participation. This information shall include the research purpose, process, duration, risks, potential consequences, and procedures, as well as the participant's right to refuse or withdraw from participation.
Counselors shall accurately report results of research, including limitations and variables that may have impacted the findings.
Counselors shall not employ deceptive techniques in research unless there are no alternatives and there is significant prospective scientific, educational, or clinical value to the research, and will not use any techniques that can be reasonably expected to cause harm.
Prior to conducting research with students, counselors shall carefully follow ethical standards, including requirements regarding participant, supervisee, and client confidentiality and multiple relationships.
Counselors shall comply with applicable guidelines when designing, conducting, or reporting research, including those of the relevant institutional review board.
Counselors shall credit the work of contributors, including students who have contributed to research or publication either by joint authorship, acknowledgment, or other appropriate means.
Counselors shall comply with intellectual property laws and accepted publication guidelines.
| A) | NCCs should always avoid social media with minor clients. | ||
| B) | Technology may be too complex to be secure in storing and transmitting information. | ||
| C) | NCCs should use technology to stay current and reach more clients. | ||
| D) | Counselors shall provide services pursuant to an appropriate written policy that regulates the use of social media and other related digital technology. |
Counselors shall provide services pursuant to an appropriate written policy which regulates the use of social media and other related digital technology with respect to current and former clients. Policy shall also identify that client and counselor personal accounts are distinct from social media accounts used for professional purposes.
Counselors shall be familiar with the use of privacy and security settings of social media and other electronic platforms utilized for telemental health service provision.
Counselors shall not publish confidential client information on any social media platform, including updates, and blogs, without the consent of the client. To facilitate the secure provision of information, counselors shall inform clients prior to or during the initial session about secure and appropriate ways to communicate with them. Counselors also shall advise clients about the potential risks of sending messages through digital technology and social media sources.
Counselors who use digital technology for professional purposes shall only post information related to professional services, such as information concerning advocacy, educational purposes, and marketing, that does not create multiple relationships or threaten client confidentially.
Counselors shall respect the privacy of a client's social media material and accounts and shall not access client social media accounts without specific client permission, a related discussion with the client, documentation of potential risks and benefits, and a specific clinical purpose.
Counselors shall avoid non-professional relationships with clients online. This restriction includes connecting with or following client social media accounts.
| A) | counseling interactions. | ||
| B) | dual relationship. | ||
| C) | social media. | ||
| D) | social and cultural contexts. |
The following are core professional values of the counseling profession according to the ACA, and are detailed in the Code of Ethics:
Enhance human development throughout the life span.
Honor diversity and embrace a multicultural approach in support of the worth, dignity, potential, and uniqueness of people within their social and cultural contexts.
Promote social justice.
Safeguard the integrity of the counselor-client relationship.
Practice in a competent and ethical manner.
| A) | the counselor works for the good of the individual and society by promoting mental health and well-being. | ||
| B) | the client is satisfied and engaged. | ||
| C) | all parties involved in the group counseling setting maintain confidentiality. | ||
| D) | the primary client achieves their goals. |
These core values provide the foundation for the ACA ethical principles that will be outlined in this section. The fundamental principles of professional ethical behavior as determined by the ACA are as follows:
Autonomy, fostering the right to control the direction of one's life.
Nonmalfeasance or avoiding actions that cause harm.
Beneficence, or working for the good of the individual and society by promoting mental health and well-being.
Justice, treating individuals equitably and fostering fairness and equality.
Fidelity, honoring commitments and keeping promises, including fulfilling one's responsibilities of trust in professional relationships.
Veracity, dealing truthfully with individuals with whom counselors come into professional contact.
| A) | Supervisors and clients | ||
| B) | Only aggrieved clients | ||
| C) | Any individual(s) who have reason to believe that an ACA member has violated the ACA Code | ||
| D) | Only ACA-licensed members |
The following individuals may file complaints (i.e., serve as "Complainants"):
Any individual(s) who have reason to believe that an ACA member has violated the ACA Code.
The Co-Chair(s) of the Committee on behalf of the ACA membership when the Co-Chair has reason to believe through information received by or otherwise available to the Committee that an ACA member may have violated the ACA Code.
| A) | When the AAMFT standards and the law conflict, the law must be followed. | ||
| B) | AAMFT members have an obligation to be familiar with the AAMFT Code of Ethics and its application to their professional services. | ||
| C) | The AAMFT members are not bound by their Code of Ethics. | ||
| D) | The AAMFT does not have a binding commitment to address ethical complaints. |
The AAMFT Code of Ethics is binding on members of AAMFT.
AAMFT members have an obligation to be familiar with the AAMFT Code of Ethics and its application to their professional services.
The process for filing, investigating, and resolving complaints of unethical conduct is described in the current AAMFT Procedures for Handling Ethical Matters.
| A) | find the appropriate balance between conflicting goals within the family system. | ||
| B) | support the family structure desired by the parents or guardians. | ||
| C) | solve all conflicts in the family. | ||
| D) | keep the family together and build similar goals among all members. |
Marriage and family therapists advance the welfare of families and individuals and make reasonable efforts to find the appropriate balance between conflicting goals within the family system. This standard includes a discussion of the following categories:
Non-discrimination;
Informed consent;
Multiple relationships;
Sexual intimacy with current and former clients is prohibited;
Reports of unethical conduct;
Abuse of the therapeutic relationship;
Client autonomy in decision-making;
Relationship beneficial to the client;
Referrals;
Non-abandonment;
Written consent to record; and
Relationships with third parties.
| A) | Honesty, integrity, and legality | ||
| B) | Truth, justice, and peer review | ||
| C) | Confidentiality, privilege, and justice | ||
| D) | Justice, publicity, and universality |
The three tests are:
Justice: This test assesses fairness by asking if the decision and treatment would be extended to other clients in similar situations.
Publicity: Would the practitioner allow the ethical decision or course of action to be reported by the press?
Universality: Could they recommend the same decision and course of action to another counselor in the same situation?
| A) | the rights of minors. | ||
| B) | the use of technology for distance counseling and social media for communicating with clients. | ||
| C) | dual relationships. | ||
| D) | counselor and therapist education. |
The major area of revision in the ethics codes involves the use of technology in delivering counseling and therapy services. Technology has led to many complicated ethical issues in mental health service delivery in and beyond the office setting. Virtually every office and agency have sophisticated databases that contain an infinite amount of sensitive personal information. These systems collect, file, preserve, search, share, tabulate, track, transmit, and store information at incredible speeds with no geographic boundaries. A review of the literature reveals that even before the Internet, mental health professionals in the 1960s expressed concerns about the potential risks to individual privacy and confidentiality inherent in computerized data systems.
| A) | occurring simultaneously. | ||
| B) | before the first meeting with the counselor. | ||
| C) | productive and appropriate. | ||
| D) | a service agreement to be considered. |
Asynchronous: Communication is not synchronized or occurring simultaneously.
Electronic communication: Using Web sites, cell phones, e-mail, texting, online social networking, video, or other digital methods and technology to send and receive messages, or to post information so that it can be retrieved by others or used later.
HIPAA compliant: The Health Insurance Portability and Accountability Act (HIPAA), sets the standard for protecting sensitive patient data. Any company that deals with protected health information (PHI) must ensure that all the required physical, network, and process security measures are in place and followed. This includes covered entities (CE), anyone who provides treatment, payment and operations in healthcare, and business associates (BA), anyone with access to patient information and provides support in treatment, payment, or operations. Subcontractors, or business associates of business associates, must also comply.
HITECH: Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 addresses the privacy and security concerns associated with the electronic transmission of health information through several provisions that strengthen the civil and criminal enforcement of the HIPAA rules in the revised HITECH Act Enforcement of Interim Final Rule, 2016.
Synchronous: Communication which occurs simultaneously in real time.
Telesupervision: Refers to the practice of clinical supervision through synchronous or asynchronous two-way electronic communication including but not limited to telephone, videoconferencing, email, text, and instant messaging, for the purposes of developing trainee marital and family therapists, evaluating supervisee performance, ensuring rigorous legal and ethical standards within the bounds of licensure, and as a means for improving the profession of marital and family therapy.
Teletherapy/technology-assisted services: Refers to the practice of marriage and family therapy of diagnosis, evaluation, consultation, intervention, and treatment of behavioral, social, interpersonal disorders through synchronous or asynchronous two-way electronic communication including but not limited to telephone, videoconferencing, email, text, and instant messaging.
| A) | use recognition software from applicable federal and state legal requirements of health information privacy, including HIPAA. | ||
| B) | use video conferencing from applicable federal and state legal requirements of health information privacy, including HIPAA. | ||
| C) | meet or exceed applicable federal and state legal requirements of health information privacy, including HIPAA. | ||
| D) | select some applicable federal and state legal requirements of health information privacy, including HIPAA. |
Adhering to Laws and Rules in Each Jurisdiction
Therapists of one state who are providing marriage and family therapy to clients in another state must comply with the laws and rules of both jurisdictions.
Treatment, consultation, and supervision utilizing technology-assisted services will be held to the same standards of appropriate practice as those in traditional (in person) settings.
Training and Continuing Competency Requirements
Therapists must adhere to their jurisdiction's training requirements for teletherapy prior to initiating teletherapy.
Therapists must review their discipline's definitions of "competence" prior to initiating teletherapy to ensure that they maintain recommended technical and clinical competence for the delivery of care in this manner.
Therapists must have completed basic education and training in suicide prevention.
Therapists must assume responsibility to continually assess both their professional and technical competence when providing teletherapy services.
Therapists must demonstrate competence in a variety of ways (e.g., encryption data, HIPAA compliant connections). Areas to be covered in training must include, but not be limited to, the following seven telebehavioral health competency domains as researched and identified by Maheu et al. and Hertlein et al. [25,26]:
Clinical Evaluation and Care
Virtual Environment and Telepresence
Technology
Legal and Regulatory Issues
Evidence-Based and Ethical Practice
Mobile Health Technologies Including Applications
Telepractice Development
Therapists conducting teletherapy must demonstrate continuing competency in each license renewal cycle in their jurisdiction.
Diversity, Bias, and Cultural Competency
Therapists must be aware of and respect clients from diverse backgrounds and cultures and have basic clinical competency skills providing treatment with these populations.
Therapists must be aware of, recognize, and respect the potential limitations of teletherapy for diverse cultural populations.
Therapists must remain aware of their own potential projections, assumptions, and biases.
Therapists must select and develop appropriate online methods, skills, and techniques that are attuned to their clients' cultural, bicultural, or marginalized experiences in their environments.
Therapists must know the strengths and limitations of current electronic modalities, process, and practice models, to provide services that are applicable and relevant to the needs of culturally and geographically diverse clients and of members of vulnerable populations.
Therapists must be cognizant of the specific issues that may arise with diverse populations when providing teletherapy and make appropriate arrangements to address those concerns (e.g., language or cultural issues; cognitive, physical, or sensory skills or impairments; or age may impact assessment).
Therapists must recognize that sensory deficits, especially visual and auditory, can affect the ability to interact over a videoconference connection. Therapists must consider the use of technologies that can help with visual or auditory deficit. Techniques should be appropriate for a client who may be cognitively impaired or find it difficult to adapt to the technology.
Establishing Consent for Teletherapy Treatment
A therapist who engages in teletherapy services must provide the client with their license number and information on how to contact the board by telephone, electronic communication, or mail, and must adhere to all other rules and regulations in the relevant jurisdiction(s). The consent must include all information contained in the consent process for in-person care including discussion of the structure and timing of services, record keeping, scheduling, privacy, potential risks, confidentiality, mandatory reporting, and billing.
A clinical treatment relationship is clearly established when informed consent documentation is signed.
Therapists must communicate any risks and benefits of the teletherapy services to be offered to the client(s) and document such communication.
Screening for client technological capabilities is part of the initial intake processes. (e.g., This type of screening could be accomplished by asking clients to complete a brief questionnaire about their technical and cognitive capacities).
As appropriate teletherapy services must have accurate and transparent information about the website owner/operator, location, and contact information, including a domain name that accurately reflects the identity.
The therapist and/or client must use connection test tools (e.g., bandwidth test) to test the connection before starting their videoconferencing session to ensure the connection has sufficient quality to support the session.
Identity Verification of Client
Therapists must recognize the obligations, responsibilities, and client rights associated with establishing and maintaining a therapeutic relationship.
The therapist is responsible for assessing and documenting the client's appropriateness for teletherapy treatment.
It is the therapist's responsibility to document appropriate verification of the client's identity.
The therapist must take reasonable steps to verify the location and identity of the client(s) at the onset of each session before rendering therapy using teletherapy.
Therapists must develop written procedures for verifying the identity of clients, their current location, and their appropriateness and readiness to proceed at the beginning of each contact. Examples of verification means include the use of code words, phrases, or inquiries. For example, "is this a good time to proceed?"
Informed Consent: Availability of Professional to Client
The therapist must document the provision of informed consent in the record prior to the onset of therapy.
In addition to the usual and customary protocol of informed consent between therapist and client for in-person therapy the following issues, unique to the use of teletherapy, technology, and/or social media, must be addressed in the informed consent process:
Confidentiality and the limits to confidentiality in electronic communication
Teletherapy training and/or credentials, physical location of practice, and contact information
Licensure qualifications and information on reporting complaints to appropriate licensing bodies
Risks and benefits of engaging in the use of teletherapy, technology, and/or social media
Possibility of technology failure and alternate methods of service delivery
Process by which client information will be documented and stored
Anticipated response time and acceptable ways to contact the therapist
Agreed upon emergency procedures
Procedures for coordination of care with other professionals
Conditions under which teletherapy services may be terminated and a referral made to in-person care
Time zone differences
Cultural and/or language differences that may affect delivery of services
Possible denial of insurance benefits
Social media policy
Specific services provided
Pertinent legal rights and limitations governing practice across state lines or international boundaries, when appropriate
Information collected and any passive tracking mechanisms utilized.
The information must be provided in language that can be easily understood by the client. This is particularly important when discussing technical issues like encryption or the potential for technical failure.
Local, regional, and national laws regarding verbal or written consent must be followed. If written consent is required, electronic signatures may be used if they are allowed in the relevant jurisdiction.
Therapists may be offering teletherapy to individuals in different states at any one time, the therapists must meet each jurisdiction's regulations and rules related to informed consent and document that in the respective record(s). The therapist is responsible for knowing the correct informed consent forms for each applicable jurisdiction.
Therapists must provide clients clear mechanisms to:
Access, supplement, and amend client-provided personal health information (PHI)
Provide feedback regarding the site and the quality of information and services; and register complaints, including information regarding filing a complaint with the applicable state licensing board(s).
Working with Children
Therapists must determine if a client is a minor and, therefore, in need of parental/guardian consent. Before providing teletherapy services to a minor, the therapist must verify the identity of the parent, guardian, or other person consenting to the minor's treatment.
In cases where conservatorship, guardianship, or parental rights of the client have been modified by the court, therapists must obtain and review a written copy of the custody agreement or court order before the onset of treatment.
Acknowledgement of Limitations of Teletherapy
Therapists must:
Determine that teletherapy is appropriate for clients, considering clinical, relational, cultural, cognitive, intellectual, emotional, and physical needs
Inform clients of the potential risks and benefits associated with teletherapy
Ensure the security of the therapist's communication medium
Only commence teletherapy after appropriate education, training, or supervised experience using the relevant technology
Therapists are to advise clients in writing of the risks and of both the therapist's and clients' responsibilities for minimizing such risks.
Therapists must consider nonverbal and verbal communication cues and how these may affect the teletherapy process. Therapists must educate clients on how to prevent and address potential misunderstandings arising from the lack of visual cues and voice intonations when communicating electronically.
Therapists must recognize the members of the same family system may have different levels of competence and preference using technology. Therapists must acknowledge power dynamics when there are differing levels of technological competence within a family system.
Before therapists engage in providing teletherapy services, they must conduct an initial assessment to determine the appropriateness of the client(s) for teletherapy service. An assessment should include examination of the potential risks and benefits to provide teletherapy services for the client's particular needs, the multicultural and ethical issues that may arise, and a review of the most appropriate medium (e.g., video conference, text, email, etc.) or best options available for service delivery.
It is incumbent on the therapist to engage in a continual assessment of the client's appropriateness for teletherapy services throughout the duration of treatment.
Confidentiality of Communication
Therapists utilizing teletherapy must meet or exceed applicable federal and state legal requirements of health information privacy, including HIPAA (https://www.hhs.gov/hipaa/for-professionals/privacy/index.html) and HITECH (https://www.hhs.gov/hipaa/for-professionals/special-topics/hitech-act-enforcement-interim-final-rule/index.html and https://www.hipaajournal.com/new-hipaa-regulations).
Therapists must assess the remote environment in which services will be provided, to determine what impact there might be to the efficacy, privacy and/or safety of the proposed intervention offered via teletherapy.
Therapists must understand and inform their clients of the limits to confidentiality and risks to the possible access or disclosure of confidential data and information that may occur during service delivery, including the risks of access to electronic communications.
Professional Boundaries Regarding Virtual Presence
Reasonable expectations about contact between sessions must be discussed and verified with the client at the start of treatment. The client and therapist must discuss whether the provider will be available for contact between sessions and the conditions under which such contact is appropriate. The therapist must provide a specific time frame for expected response to a between session contact. This must also include a discussion of emergency and crisis management between sessions.
To facilitate the secure provision of information, therapists must provide in writing the appropriate ways to contact them.
Therapists are discouraged from knowingly engaging in a personal virtual relationship with clients (e.g., through social and other media). Therapists must document any known virtual relationships with clients/associated with clients.
Therapists must discuss, document, and establish professional boundaries with clients regarding the appropriate use and/or application of technology and the limitations of its use within the therapy relationship (e.g., lack of confidentiality, circumstances when not appropriate to use).
Therapists must be aware that personal information they disclose through electronic means may be broadly accessible in the public domain and may affect the therapeutic relationship.
Virtual sexual interactions are prohibited.
Therapists must be aware of statutes and regulations of relevant jurisdictions regarding sexual interactions with current or former clients or with known members of the client's family system.
Impact of Social Media and Virtual Presence on Teletherapy
Therapists must develop written procedures for the use of social media and other related digital technology with clients that provide appropriate protections against the disclosure of confidential information and identify that personal social media accounts are distinct from any used for professional purposes.
Therapists separate professional and personal web pages and profiles for social media use to clearly distinguish between the two kinds of virtual presence.
Therapists who use social networking sites for both professional and personal purposes must review and educate themselves about the potential risks to privacy and confidentiality and consider utilizing all available privacy settings to reduce these risks.
Therapists must respect the privacy of their clients' presence on social media unless given consent to view such information.
Therapists must avoid the use of public social media sources (e.g., tweets, blogs, etc.) to provide confidential information.
Therapists must refrain from referring to clients generally or specifically on social media.
Therapists who engage in online blogging must be aware of the effect of a client's knowledge of their blog information on the therapeutic relationship and place the client's interests as paramount.
Documentation/Record Keeping
All client-related electronic communications must be stored and filed in the client's record, consistent with standard record-keeping policies and procedures.
Written policies and procedures for teletherapy must be maintained at the same standard as in-person services for documentation, maintenance, and transmission of records.
Services must be accurately documented as remote services and include dates, place of both therapist and client(s) location, duration, and type of service(s) provided.
Requests for access to records require written authorization from the client with a clear indication of what types of data and which information is to be released. If therapists are storing video or audio recorded data from sessions, these cannot be released unless the client authorization indicates specifically that this is to be released.
Therapists must maintain policies and procedures for the secure destruction of data and information and the technologies used to create, store, and transmit data and information.
Therapists must inform clients on how records are maintained electronically. This includes, but is not limited to, the type of encryption and security assigned to the records, and if/for how long archival storage of transaction records is maintained.
Clients must be informed in writing of the limitations and protections offered by the therapist's technology.
The therapist must obtain written permission prior to recording any part of the teletherapy session. The therapist must request that the client(s) obtain written permission from the therapist prior to recording the teletherapy session.
Payment and Billing Procedures
Prior to initiating teletherapy, the client must be informed of any and all financial charges that may arise from the services to be provided. Payment arrangements must be established prior to beginning teletherapy.
All billing and administrative data related to the client must be secured to protect confidentiality. Only relevant information may be released for reimbursement purposes as outlined by HIPAA.
Therapist must document who is present and use appropriate billing codes.
Therapist must ensure online payment methods by clients are secure.
Emergency Management
Each jurisdiction has its own involuntary hospitalization and duty-to-notify laws outlining criteria and detainment conditions. Professionals must know and abide by the rules and laws in the jurisdiction where the therapist is located and where the client is receiving services.
At the onset of the delivery of teletherapy services, therapists must make reasonable effort to identify and learn how to access relevant and appropriate emergency resources in the client's local area, such as emergency response contacts (e.g., emergency telephone numbers, hospital admissions, local referral resources, a support person in the client's life when available and appropriate consent has been authorized).
Therapists must have clearly delineated emergency procedures and access to current resources in each of their client's respective locations; simply offering 911 may not be sufficient.
If a client repeatedly experiences crises emergencies the therapist must reassess the client's appropriateness for teletherapy and if in-person treatment may be more appropriate. The therapists must take reasonable steps to refer a client to a local mental health resource or begin providing in-person services.
Therapists must prepare a plan to address any lack of appropriate resources, particularly those necessary in an emergency, and other relevant factors which may impact the efficacy and safety of teletherapy service. Therapists must make reasonable effort to discuss with and provide all clients with clear written instructions as to what to do in an emergency (e.g., where there is a suicide risk).
Therapists must be knowledgeable of the laws and rules of the jurisdiction in which the client resides and the differences from those in the therapist's jurisdiction, as well as document all their emergency planning efforts.
In the event of a technology breakdown, causing disruption of the session, the therapist must have a backup plan in place. The plan must be communicated to the client prior to commencement of treatment and may also be included in the general emergency management protocol.
Synchronous Versus Asynchronous Contact with Client(s)
Communications may be synchronous with multiple parties communicating in real time including interactive videoconferencing, telephone, or asynchronous including email, online bulletin boards, storing and forwarding information.
Technologies may augment traditional in-person services including psychoeducational materials online after an in-person therapy session, or be used as stand-alone services, such as therapy provided over videoconferencing. Different technologies may be used in various combinations and for different purposes during the provision of teletherapy services.
The same medium may be used for direct and non-direct services. For example, videoconferencing and telephone, email, and text may also be utilized for direct service while telephone, email, and text may be used for non-direct services or scheduling.
Regardless of the purpose, therapists must be aware of the potential benefits and limitations in their choices of technologies for particular clients in particular situations.
HIPAA Security, Web Maintenance, and Encryption Requirements
Videoconferencing applications must have appropriate verification, confidentiality, and security parameters necessary to be properly utilized for this purpose.
Video software platforms must not be used when they include social media functions that notify users when anyone in contact list logs on skype or g-chat.
Capability to create a video chat room must be disabled so others cannot enter at will.
Personal computers used must have up-to-date antivirus software and a personal firewall installed.
All efforts must be taken to make audio and video transmission secure by using point-to-point encryption that meets recognized standards.
Videoconferencing software must not allow multiple concurrent sessions to be opened by a single user.
Session logs stored by third party locations must be secure.
Therapists must conduct analysis of the risks to their practice setting, telecommunication technologies, and administrative staff, to ensure that client data and information is accessible only to appropriate and authorized individuals.
Therapists must encrypt confidential client information for storage or transmission and utilize such other secure methods as safe hardware and software and robust passwords to protect electronically stored or transmitted data and information.
When documenting the security measures utilized, therapists must clearly address what types of telecommunication technologies are used, such as email, telephone, videoconferencing, or text, how they are used, and whether teletherapy services used are the primary method of contact or to augment in-person contact.
Archiving/Backup Systems
Therapists must retain copies of all written communications with clients. Examples of written communications include email/text messages, instant messages, and histories of chat-based discussions even if they are related to housekeeping issues such as change of contact information or scheduling appointments.
PHI and other confidential data must be backed up to or stored on secure data storage location.
Therapists must have a plan for the professional retention of records and availability to clients in the event of the therapist's incapacitation or death.
Standardized and Non-standardized Testing for Assessment
Therapists must familiarize themselves with the tests' psychometric properties, construction, and norms in accordance with current research. Potential limitations of conclusions and recommendations that can be made from online assessment procedures should be clarified with the client prior to administering online assessments.
Therapists must consider the unique issues that may arise with test instruments and assessment approaches designed for in-person implementation when providing services.
Therapists must maintain the integrity of the application of the testing and assessment process and procedures when using telecommunication technologies. When a test is conducted via teletherapy, therapists must ensure that the integrity of the psychometric properties of the test or assessment procedure, including reliability and validity, and the conditions of administration indicated in the test manual are preserved when adapted for use with such technologies.
Therapists must be cognizant of the specific issues that may arise with diverse populations when administering assessment measures and make appropriate arrangements to address those concerns, such as language or cultural issues; cognitive, physical, or sensory skills or impairments; or age may impact assessment. In addition, therapists must consider the use of a trained assistant, or proctor, to be on premise at the remote location in an effort to help verify the identity of the client(s), provide needed on-site support to administer certain tests or subtests, and protect the security of the testing and/or assessment process.
Therapists must use test norms derived from telecommunication technologies administration if such are available. Therapists must recognize the potential limitations of all assessment processes conducted via teletherapy and be ready to address the limitations and potential impact of those procedures.
Therapists must be aware of the potential for unsupervised online testing, which may compromise the standardization of administration procedures and take steps to minimize the associated risks. When data are collected online, security should be protected by the provision of usernames and passwords. Therapists must inform their clients of how test data will be stored and the electronic database that is backed up. Regarding data storage, ideally secure test environments use a three-tier server model consisting of an internet server, a test application server, and a database server. Therapists should confirm with the test publisher that the testing site is secure and that it cannot be entered without authorization.
Therapists must be aware of the limitations of "blind" test interpretation, that is, interpretation of tests in isolation without supporting assessment data and the benefit of observing the test taker. These limitations include not having the opportunity to make clinical observations of the test taker, such as test anxiety, distractibility, or potentially limiting factors such as language, disability, or to conduct other assessments or interviews that may be required to support the test results.
Telesupervision
Therapists must hold supervision to the same standards as all other technology-assisted services. Telesupervision must be held to the same standards of appropriate practice as those in in-person settings.
Before using technology in telesupervison, supervisors must be competent in the use of those technologies.
Supervisors must take the necessary precautions to protect the confidentiality of all information transmitted through any electronic means and maintain competence.
The type of communications used for telesupervision must be appropriate for the types of services being supervised, the clients and the supervisee needs.
Telesupervision is provided in compliance with the supervision requirements of the relevant jurisdiction(s). Supervisors must review state board requirements specifically regarding face-to-face contact with supervisee as well as the need for having direct knowledge of all clients served by their supervisee.
Supervisors must:
determine that telesupervision is appropriate for supervisees, considering professional, cognitive, cultural, intellectual, emotional, and physical needs
inform supervisees in writing of the potential risks and benefits associated with telesupervision and of both the supervisor's and supervisees' responsibilities for minimizing such risks.
ensure the security of their communication medium
only commence telesupervision after appropriate education, training, or supervised experience using the relevant technology.
Supervisors must be aware of statutes and regulations of relevant jurisdictions regarding sexual interactions with current or former supervisees.
Communications may be synchronous or asynchronous. Technologies may augment traditional in-person supervision, or be used as stand-alone supervision. Supervisors must be aware of the potential benefits and limitations in their choices of technologies for particular supervisees in particular situations.
| A) | No opinions are held in common. | ||
| B) | Two associations oppose the practice. | ||
| C) | All are conducting research. | ||
| D) | All are opposed to the practice of conversion/reparative therapy. |
In the last few years, the second largest area of revision to the ethics codes has been the opposition by ACA, AAMFT, and NBCC to the practice of conversion/reparative therapy.
| A) | They should always be considered. | ||
| B) | They are always part of pro bono service. | ||
| C) | The mental health practitioner should not enter into a dual relationship if the possibility exists that it could exploit or harm the client. | ||
| D) | There is no opinion from the codes at all. |
In all codes of ethics, there are key elements in the guidelines that relate to dual relationships. These key elements are summarized as follows:
A dual relationship exists when a mental health practitioner is in a counseling relationship at the same time that they are in a relationship with the client outside of counseling.
Guidelines also govern a promise or an agreement to enter into another relationship in the future with the client, or a person associated with the client.
The mental health practitioner should not take on a dual role with the client if it would impair the practitioner's assessment, objectivity, competence, effectiveness, communication, or confidentiality as a therapist.
The mental health practitioner should not enter into a dual relationship if the possibility exists that it could exploit or harm the client.
Mental health practitioners are responsible for establishing clear, appropriate, sensitive, and ethical boundaries prior to entering into any dual relationship with the client.
If the mental health practitioner becomes aware that potential harm may occur, or if unintentional harm has already occurred due to a multiple relationship, the practitioner must take immediate action and present evidence that they have attempted to remediate the harm.
Clients may be harmed in counseling relationships if professional boundaries are crossed, and sexual conduct with clients is strictly prohibited.
| A) | They believe a client younger than 16 years of age is a victim of incest, rape, or some other crime. | ||
| B) | They believe the client needs hospitalization to prevent harm to self or others. | ||
| C) | Information is required for research. | ||
| D) | A client request that their records are released to themselves or to a third party and signs consent forms. |
Other circumstances dictate that the counselor must legally report information in the following cases as outlined by law [1]:
Counselors believe a client younger than 16 years of age is a victim of incest, rape, or some other crime.
Counselors believe the client needs hospitalization to prevent harm to self or others.
information is required as an issue in a court action.
Clients request that their records be released to themselves or to a third party.
| A) | writ that provides limited disclosure. | ||
| B) | writ that gives access to information on harm and danger only. | ||
| C) | writ ordering a person to appear before the court and bring relevant documents other tangible evidence for use at a hearing or trial. | ||
| D) | part of California minor consent law. |
J.D.'s personal views and her misinterpretation of the AAMFT's Code of Ethics point to a lack of understanding in many areas. Here are the key features:
If J.D. had referred to the Code, she would know that she was wrong to defy the courts in this case.
She made a mistake by not seeking assistance from other professionals or her administrator when faced with a situation as serious as a court order in a child custody case. In fact, she viewed her own opinion, not based on sound decisions following the code, as more significant than the opinion of the court.
She was not focusing on the best interest of her client by delaying the case and refusing to turn over her notes to inform the court's decision. The delay added to the stress and fear felt by her young client, who was unable to give consent or waive the obligation of confidentiality to disclose the notes.
If a subpoena duces tecum, or subpoena for production of evidence, is issued that requests all files documents, notes, reports, photographs, and recordings in any form, it is clear that case notes are part of that request. The subpoena in this case would have a release signed by the parent in cases with a minor child.
A court order is issued as the result of a hearing before a judge and demands a set of records be disclosed and delivered to the court representative, unless there is an appeal to a higher court. It is the court, not the practitioner, which will ultimately decide what qualifies as protected information.
| A) | health plans only. | ||
| B) | any healthcare provider who transmits health information in electronic form in connection with services or transactions. | ||
| C) | only the employing organization, not the counselor or therapist. | ||
| D) | healthcare clearinghouses. |
The Privacy Rule standards address the use and disclosure of individuals' health information called "protected health information" by organizations under the Privacy Rule called "covered entities." According to the Privacy Rule, as well as all of the Administrative Simplification rules, the term "covered entities" applies to health plans, health care clearinghouses, and to any healthcare provider who transmits health information in electronic form in connection with services or transactions.
| A) | Cultural sensitivity | ||
| B) | Advocacy | ||
| C) | Multicultural training | ||
| D) | Equality |
Advocacy: Actions to promote the welfare of individuals and groups to remove barriers and increase access to reach their full potential. Advocacy includes supporting policy changes to promote these goals for all individuals.