77630 • Codes of Ethics for Counselors and Marriage and Family Therapists

Table of Contents

77630 • Codes of Ethics for Counselors and Marriage and Family Therapists

How to Receive Credit

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Behavioral Health Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. HISTORICAL PERSPECTIVES

3. FOUNDATIONS AND SHARED BELIEFS

CLIENT FOCUS

RIGHT OF INFORMED CONSENT

CONFIDENTIALITY

DUTY TO WARN

MULTICULTURAL ISSUES

TECHNOLOGY-ASSISTED SERVICES

4. ETHICAL DECISIONS

5. CURRENT ETHICAL CODES

6. SUMMARY OF THE NBCC CODE OF ETHICS

CORE VALUES IN THE NBCC CODE OF ETHICS

NBCC ETHICS STANDARDS

DISTANCE SERVICES THROUGH TECHNOLOGY

OVERVIEW OF THE NBCC ETHICAL COMPLAINT PROCESS

7. A SUMMARY OF THE ACA CODE OF ETHICS

ACA CODE OF ETHICS PREAMBLE

MISSION

CORE VALUES

PRINCIPLES

PURPOSE

SECTION A. THE COUNSELING RELATIONSHIP

SECTION B. CONFIDENTIALITY AND PRIVACY

SECTION C. PROFESSIONAL RESPONSIBILITY

SECTION D. RELATIONSHIPS WITH OTHER PROFESSIONALS

SECTION E. EVALUATION, ASSESSMENT, AND INTERPRETATION

SECTION F. SUPERVISION, TRAINING, AND TEACHING

SECTION G. RESEARCH AND PUBLICATION

SECTION H. DISTANCE COUNSELING, TECHNOLOGY, AND SOCIAL MEDIA

SECTION I. RESOLVING ETHICAL ISSUES

THE ACA POLICIES AND PROCEDURES FOR PROCESSING COMPLAINTS OF ETHICAL VIOLATIONS

8. SUMMARY OF THE AAMFT CODE OF ETHICS

PREAMBLE

HONORING PUBLIC TRUST

SEEKING CONSULTATION

ETHICAL DECISION-MAKING

BINDING EXPECTATIONS

ASPIRATIONAL CORE VALUES

ETHICAL STANDARDS

A SUMMARY OF THE AAMFT ETHICS COMPLAINT PROCESS

9. ETHICAL DECISION-MAKING

10. EVALUATING ETHICAL PRACTICE

11. SERVICE DELIVERY THROUGH TECHNOLOGY AND SOCIAL MEDIA

TELETHERAPY AND TELESUPERVISION GUIDELINES II

EMERGENCY PLANS TO SAFEGUARD TELEMENTAL HEALTH SERVICES

HIPAA STANDARDS FOR MOBILE DEVICES

ACA SOCIAL MEDIA TIPS

12. CONVERSION/REPARATIVE THERAPY

13. DUAL RELATIONSHIPS

BARTERING: A COMMON BOUNDARY ISSUE

SEXUAL DUAL RELATIONSHIPS

14. CONFIDENTIALITY AND DUTY TO WARN

ETHICAL QUESTIONS: TARASOFF CASE ON DUTY TO WARN

ETHICAL DECISIONS: KEY POINTS FROM THE TARASOFF CASE

RECORD ACCESS BY FAMILY MEMBERS

15. CASE STUDIES

REPARATIVE/CONVERSION THERAPY

DUAL RELATIONSHIPS

DUTY TO WARN

RECORD ACCESS BY FAMILY MEMBERS

16. SUMMARY OF THE HEALTH INSURANCE PORTABILITY ACCOUNTABILITY ACT (HIPAA) PRIVACY RULE

17. GLOSSARY

18. RESOURCES

19. CONCLUSION

Works Cited

77630 • Codes of Ethics for Counselors and Marriage and Family Therapists

Deborah Converse, MA, NBCT

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

This course provides a comprehensive review of ethical standards and professional responsibilities for counselors and therapists based on the NBCC, ACA, and AAMFT Codes of Ethics. Participants will explore key topics including professional competence, informed consent, confidentiality and its exceptions, recordkeeping requirements, and ethical considerations in working with diverse populations. The course also addresses decision-making frameworks, duty to warn, standards for working with minors and vulnerable individuals, the use of technology in practice, and guidelines related to advocacy and prohibited practices. Additionally, learners will gain insight into the ethical complaint process and potential sanctions for violations, supporting ethical and compliant practice across settings.

77630 • Codes of Ethics for Counselors and Marriage and Family Therapists

Education Category. Ethics - Human Rights

Release Date. 05/01/2026

Expiration Date. 12/31/2027

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/3459 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

This course provides a comprehensive review of ethical standards and professional responsibilities for counselors and therapists based on the NBCC, ACA, and AAMFT Codes of Ethics. Participants will explore key topics including professional competence, informed consent, confidentiality and its exceptions, recordkeeping requirements, and ethical considerations in working with diverse populations. The course also addresses decision-making frameworks, duty to warn, standards for working with minors and vulnerable individuals, the use of technology in practice, and guidelines related to advocacy and prohibited practices. Additionally, learners will gain insight into the ethical complaint process and potential sanctions for violations, supporting ethical and compliant practice across settings.

Audience

This course is designed for counselors and therapists in all practice settings.

Accreditations & Approvals

NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors #MHC-0021. This course is considered self-study by the New York State Board of Mental Health Counseling. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015.This course is considered self-study by the New York State Board of Marriage and Family Therapy.

Designations of Credit

NetCE designates this continuing education activity for 6 NBCC clock hour(s). NetCE is authorized by IACET to offer 0.6 CEU(s) for this program. This course meets the qualifications for 6 hours of continuing education credit for LMFTs, LPCCs, and LEPs in the area of Law and Ethics as required by the California Board of Behavioral Sciences.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Special Approvals

This course fulfills the Florida requirement for 3 hours of Professional Ethics and Boundaries education. This course has been approved by NetCE, as a NAADAC Approved Education Provider, for educational credits, NAADAC Provider #97847. NetCE is responsible for all aspects of their programming. NetCE is approved as a provider of continuing education by the California Consortium of Addiction Programs and Professionals. Provider Number 5-08-151-0626. NetCE is approved as a provider of continuing education by the California Association for Alcohol/Drug Educators. Provider Number CP40 889 H 0626. NetCE designates this continuing education activity for 6 continuing education hours for addiction professionals.

Course Objective

The purpose of this course is to provide counselors and therapists with a comprehensive understanding of ethical standards and professional responsibilities outlined by NBCC, ACA, and AAMFT, including competence, confidentiality, informed consent, multicultural considerations, and ethical decision-making across diverse practice settings.

Learning Objectives

Upon completion of this course, you should be able to:

1. Identify and define the standards of the NBCC, ACA, and AAMFT codes of ethics for professional competence, informed consent, confidentiality, dual relationships, and duty to warn.

2. Discuss fundamental principles of the ACA Code of Ethics.

3. Explain the requirements for client records in the NBCC, ACA, and AAMFT codes of ethics.

4. Identify exceptions that allow disclosure of confidential information.

5. Discuss assessment guidelines in the NBCC Code of Ethics.

6. List and define competencies for multicultural diversity sensitivity from the ACA and AAMFT codes of ethics.

7. Explain the term "foreseeable harm" related to confidentiality of client disclosures.

8. Discuss components of ethical decision making in therapy and counseling.

9. List ethical standards specific to minor clients and incapacitated or incompetent individuals.

10. Explain standards that guide long-distance counseling or therapy using technology and social media from the NBCC, ACA, AAMFT, Code of Ethics, and AMFTRB guidelines.

11. Discuss the NBCC, ACA, and AAMFT directives opposing conversion-reparative therapy and counseling.

12. Identify standards for advocacy from the ACA and AAMFT codes of ethics.

13. List the complaint process and sanctions for ethics violations.

Faculty

Deborah Converse, MA, NBCT, holds an MA in Education for Emotionally Disabled Students from the University of Central Florida, a BA and MA in Psychology, and was awarded National Board Certification in 2000 as an Exceptional Needs Specialist, Birth-21+ endorsement. She has dedicated her career to building knowledge and acceptance of individuals with special needs within their families, schools, and communities, and has addressed education and employment issues for students facing challenges that include developmental, emotional and behavioral challenges, mental illness, mobility, and chemical dependency within the public school system setting. She has authored numerous instructional programs and presented them at state, national, and international conferences on education and mental health.

Faculty Disclosure

Contributing faculty, Deborah Converse, MA, NBCT, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Scott Deatherage, PhD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Mental health professionals today face complex ethical considerations related to a host of factors. Increasing client diversity, changing family dynamics, and new methods of providing counseling and therapy through digital technology and social media bring new ethical challenges. Ethical practice requires counselors and therapists to reconsider issues of confidentiality, informed consent, multiple relationships, patient privacy, and records security.

The practitioner must keep pace with revised ethical standards of practice and the needs of an increasingly diverse population. A working knowledge and daily application of revised ethical guidelines are required of all mental health counselors, therapists, and staff to provide the highest level of service to their clients.

- "Ethics" refers to the beliefs that individuals hold about what is right and what is wrong.

- "Morals" are similar and have been described as a person's individual values that guide their behavior based on their beliefs of right and wrong.

- "Ethical conduct" refers to the behaviors exhibited by the counselor and the therapist. Good ethical conduct in counseling and therapy is grounded in moral principles, professional standards, decision making skills, understanding ethical codes, and a commitment to client welfare.

Both laws and ethical codes regulate the practice of therapists and counselors. Professional organizations do not enforce laws; rather, they develop standards and guidelines to assist the practitioner in delivering services based on ethical principles. Laws are defined and enforced by governmental definitions of the minimum standards of conduct that are acceptable to society.

Common types of ethical violations that occur in the counseling profession include errors in informed consent, breach of confidentiality, inappropriate relationships with clients, false or misrepresented statements, fraudulent billing practices, and boundary violations.

In order to educate and guide counselors and therapists, professional associations have developed codes of ethics as resources, as well as processes to review ethics complaints to protect clients. Recent revisions to these codes will be discussed, with policies and procedures to address ethical complaints if a violation is alleged.

The "Standards for Privacy of Individually Identifiable Health Information," or the Privacy Rule, establishes a set of national standards to protect health information. The U.S. Department of Health and Human Services (HHS) issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Privacy Rule addresses the use and disclosure of individuals' health information by professionals subject to the Privacy Rule [1].

The major goal of the Privacy Rule is to ensure that health information is properly protected while allowing the flow of information to promote quality healthcare and protect the public's health. The HIPAA Privacy Rule and the codes of ethics for mental health practitioners complement each other and were developed to ensure privacy, confidentiality, and the well-being of individuals and society.

This course reviews the codes of ethics and guidelines from several different organizations, including:

- The National Board for Certified Counselors (NBCC)

- The American Counselors Association (ACA)

- The American Association of Marriage and Family Therapy (AAMFT)

- The Association of Marital Therapy Regulatory Board (AMFTRB)

The codes and guidelines for each of these associations will be summarized. Some codes have been recently revised, and all should be reviewed in their entirety on their respective websites included in the resource section at the end of this course.

2. HISTORICAL PERSPECTIVES

Standards of practice and the idea of accountability can be traced back to ancient Egypt. The code of Hammurabi was established as far back as 2000 B.C.E. It contained a description of physicians' responsibilities and the consequences and punishments if a patient's health did not improve.

The Hippocratic Oath, written in 400 B.C.E., can be viewed as an early example of a code of ethics to guide the practice of medical professionals and define obligations to their profession, practice, and patients. This ancient oath is the foundation for the values and ethical principles in our current codes of ethics.

The writings of Aristotle concluded that ethics provided guidelines for virtuous and moral action. In his rule, the "Gold Mean," Aristotle defined an ethical choice as one that falls in the middle of two extremes, one of excess and the other of deficiency [2].

After World War II, the American Psychological Association (APA) saw the need to develop a code of ethics due to a change in the type of professional activity requested of its members. Psychologists were called to address the mental health needs of soldiers returning home from the war and were responsible for developing psychological assessments to determine eligibility for the draft. A committee was formed to identify ethical issues to effectively guide psychologists' practice. It covered concepts that included the psychologists' responsibilities when treating clients, training students, and consulting colleagues as well as ethical research practices [3].

Throughout the years, other mental health organizations developed codes of ethics and enacted subsequent revisions to address the continuing changes in society and the needs of their clients.

The ACA can trace its roots to 1952 when independent member associations held a joint convention. These associations included the National Vocational Guidance Association (NVGA); the National Association of Guidance and Counselor Trainers (NAGCT); the Student Personnel Association for Teacher Education (SPATE); and the American College Personnel Association.

They established the American Personnel and Guidance Association (APGA) to form a professional group that united all counselors. A Code of Ethics was first developed and adopted in 1963. In 1983, the association adopted the name American Association of Counseling and Development. It was changed again on July 1, 1992, to the American Counseling Association (ACA). This new membership association unified the various counseling professions into one entity that reflected shared goals, purpose, and commitment to ethical practice.

The ACA developed a professional Code of Ethics that has been adopted by licensing boards who use the code as the basis in counseling decision-making on ethical issues. The ACA Code has been revised every 7 to 10 years: The recent revision adopted in 2014 replaces the 2005 edition. The American Counseling Association now services professional counselors in the United States and in 50 other countries in Europe and Latin America, as well as the Philippines and the Virgin Islands. In addition, the ACA is associated with a comprehensive network of 19 divisions and 56 branches [4].

The American Association for Marriage and Family Therapy (AAMFT) was founded in 1942 to address the needs and changing demands of couples and family relationships. This membership association supports research and provides education, tools, and resources to provide effective services in the field of marriage and family therapy. The AAMFT's goal is to ensure that trained, ethical professionals meet the needs of clients and society. This association is now the professional membership association for the field of marriage and family therapy, with more than 50,000 marriage and family therapists throughout the United States, Canada, and around the world.

The National Board for Certified Counselors, Inc. and Affiliates (NBCC) is a not-for-profit, independent certification organization that was established in 1982 [5]. The organization was founded to create a voluntary national certification system and to identify certified counselors by maintaining a registry of membership. Since then, NBCC divisions and affiliates have expanded their commitment to include advancement of the profession with the goal of improving mental health around the world.

Today, there are more than 69,000 National Certified Counselors (NCCs) in more than 40 countries. These counselors volunteer to obtain certification through a rigorous program to achieve national standards, set by the profession, based on research, written dissertations, and examinations. Certified NCCs are encouraged to mentor other counselors to improve their practice and obtain certification as an NCC. NCCs may be members of associations such as ACA and AAMFT, depending on their area of expertise.

3. FOUNDATIONS AND SHARED BELIEFS

Trust appears to be the common thread throughout ethical counseling and marriage and family therapy practice. Therapists, patients, and students view trust as fundamental to psychotherapy [6].

One shared belief among therapists and counselors is that professionals must do the right thing and make ethical decisions that are in the best interest of the client.

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].

Confidentiality is essential in developing an effective relationship between mental health practitioners and their clients. Research supports the ethical principle in counseling and therapy that asserts effective practice is based on trust and confidentiality between the practitioner and client. The client may approach a counselor or therapist feeling vulnerable and seeking assistance in times of crisis. The client may be fearful, ashamed, or unwilling to share feelings at first. If the client believes that the information shared will be kept confidential, there is a greater possibility of developing an effective collaborative relationship with the therapist and a positive outcome for the client.

Over the last decade, ethical issues faced by counselors have received increased attention in counseling literature, and no area of study is more important in the practice of counseling [8]. Counselors are often confronted with situations that require sound ethical decision-making. Determining the appropriate course of action when faced with difficult ethical conflicts can be challenging and should never be done in isolation.

Codes of conduct are designed to protect clients and society. Counselors and therapists encounter ethical issues and challenges that require complex decisions, and they must be familiar with the ethical codes for their association. They must know what areas and issues are problematic to avoid potential risks of ethical violations that may harm clients and families.

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.

CLIENT FOCUS

Counselors and therapists must be aware that their focus on their clients' welfare takes precedence over their own. Practitioners must understand their own needs, as well as their potential for imposing personal values and biases that may impact service to clients. Professionals have a responsibility to continually expand self-awareness and recognize areas of biases, prejudices, and vulnerabilities.

RIGHT OF INFORMED CONSENT

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.

Informed consent is not a single form or procedure and must be revisited throughout the counseling/therapeutic process whenever changes or new components are introduced.

CONFIDENTIALITY

Confidentiality is a standard of conduct that prevents the professional from disclosing information concerning clients. State and federal statutes, administrative codes, regulations, and case law interpret rulings by the court and include components of confidentiality. Confidentiality is fundamental to the counseling and therapeutic relationship, and professionals must not disclose client information without prior consent. The ethics codes, as well as state and federal laws, provide some exceptions to confidentiality standards that will be discussed.

Confidentiality is based on our society's belief that individuals have a right to privacy and to decide what information they will share and with whom. Confidentiality is an ethical principle that holds the practitioner responsible for respecting the client's privacy and protecting information disclosed during therapy. Both the Code of Ethics and the HIPAA Privacy Rule provide explicit, detailed provisions that cover client consent for disclosure of information and which entities can receive information. Privileged communication, resulting from a therapy or counseling session, is a legal concept that protects the client from having confidential information disclosed without their consent.

Confidentiality in the professional–client relationship is consistent with the obligation to serve as an advocate for the client and for the greater society. Confidentiality, as addressed in ethics codes and case study examples of violations, will be presented in this course. The Tarasoff v. University of California case and its resulting legal actions led to revisions to the codes of ethics [9]. This precedent-setting case has led to changes in many state laws concerning the release of confidential information, duty to warn, and protection from harm.

Confidentiality in Group Counseling

Providing services to a family or group presents ethical challenges when the practitioner works with multiple clients at the same time. The counselor or therapist must inform all members of the group of their rights to confidentiality at the onset of services and include a statement that the practitioner will not disclose any information that one family member offered in a private discussion. Some practitioners decide to address this situation by meeting only in a group setting with the family and never with one member individually.

The practitioner working with a family or a group may need to assess progress frequently as new issues may emerge that must be addressed and added to the written services agreement. Interventions that were planned for one member of the family may not be appropriate for others or may have a negative effect on some members. The practitioner must always maintain their view of the family as a unit and not appear to focus on one member of the group. The practitioner must also keep everyone informed of their obligation to maintain confidentiality. Informed consent is an ongoing process as the treatment plan or service agreement evolves.

In most cases, the initial contact to the therapist or counselor's office for assistance is made by one of the group members. The other members may not share this desire or commitment to participate in the treatment plan. Informed consent by all group members is particularly important in these situations, especially with minors who cannot legally provide consent. The reluctance on the part of some members may complicate the delivery of effective services, including maintaining confidentiality. The therapist or counselor must avoid being viewed as biased toward one member over another and must work to establish the trust of all members. Establishing trust is important to encourage sharing, communication, and participation among members, and respect for confidentiality rules. The therapist or counselor should avoid contact with any members outside of the professional setting to avoid any appearance of favoritism and potential ethical boundary violations.

When counseling groups or families, confidentiality may be difficult to accomplish. Each client has different behaviors, levels of maturity, affiliations, loyalties, and attitudes toward the counseling or therapy. There are also levels of varying commitments to keep information from the group sessions private. In all codes of ethics, there are statements that guide the counselor to build commitment to confidentiality:

- Inform all clients in the group of the rules of confidentiality.

- Define ground rules and parameters for the group to support positive, productive discussions among members.

- Identify who the client is in the counseling setting.

- Discuss how confidentiality matters will be addressed.

- Determine how information by one member may be disclosed to other members by the counselor.

- Discuss how to disclose information that was previously held as secret in the group counseling session.

- Provide rules for communication, fairness, and respect in the group.

- Explain that confidentiality cannot be guaranteed in the group setting.

- Identify and discuss the impact of distance counseling regarding confidentiality.

The ACA suggests that counselors clearly explain the importance and parameters of confidentiality as it applies to members of the group [10].

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.

The foregoing information serves as a guideline only and it is recommended that the entire AAMFT Code of Ethics be reviewed to understand the complex nature of confidentiality in group therapy.

The NBCC 2023 Standards include the following directives:

- Counselors shall clearly identify in writing the primary client in the record.

- Counselors will also identify in the record those individuals who are receiving related professional services in connection with such client relationship.

- In the context of couple, family, or group counseling, the counselor shall not reveal any individual client's confidences to others without the prior written permission of that individual.

Confidentiality Laws with Minors or Incapacitated Clients

Federal and state laws mandate the reporting of suspected child abuse or neglect. Additionally, statutes require the protection of others who may not have the ability to protect themselves, such as elderly individuals or those who are residing in institutions. Counselors and therapists who work with these clients are mandated reporters and must study applicable state laws that detail procedures for reporting abuse, including the required time limits, representatives to contact and their phone numbers.

Counselors and therapists must provide informed consent to minor or incapacitated clients as well. They must also take care to discuss the rules of confidentiality at their clients' developmental or cognitive levels. The language used must be appropriate so that clients will understand that there are times when parents, guardians, or other officials must be notified concerning the information that they share.

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.

The practitioner should have expertise in working with these clients and should be competent in communication with them. A statement should be included in the plan of service that indicates (1) what was told to the client, and (2) that the practitioner took steps to inform them of disclosure in the following situations:

- If they report they are being abused;

- If they say they plan to hurt themselves; and

- If they say they plan to hurt others.

If the practitioner believes any of the three indicators of harm are credible, the practitioner must follow the appropriate steps to report abuse or neglect and to warn others if the threat is deemed a serious one. The rules that govern the actions to take in these cases vary from state to state; therefore, the practitioners must follow the mandates within their jurisdictions of practice and licensure, as well as the code of ethics. Case studies and additional considerations will be covered in subsequent sections.

DUTY TO WARN

The confidentiality requirement of nondisclosure does not apply when imminent danger to the client or others exists. This duty to warn was a result of the Tarasoff case in California and has been added to many states'' laws across the nation. The laws may vary across the states concerning the therapist's obligation to warn and include such terms as:

- Whether the practitioner "must" warn of imminent danger or "may" warn of imminent danger.

- What constitutes a serious, foreseeable, and imminent danger?

- Which individuals must be given a warning of imminent danger and when?

- What circumstances warrant the therapist's obligation to warn of imminent danger?

- Must the practitioner need to have firsthand information of the danger, or can a credible source inform them?

- Who is a credible source?

- What is the practitioner's assessment of danger conflicts with opinions from medical or law enforcement personnel?

- Is the practitioner legally accountable if they issue a warning and danger was not imminent?

It is imperative that any counselor or therapist confronted with a potential duty to warn situation seeks legal consultation for the best course of action.

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.

The foregoing statements are addressed in detail in the ACA Code of Ethics, which must be studied in its entirety to understand the complexities of confidentiality between the client and the counselor.

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.

The AAMFT Code of Ethics includes the following standards [11]:

- Marriage and family therapists disclose to clients and other interested parties at the outset of services the nature of confidentiality and possible limitations of the client's right to confidentiality.

- Therapists review with clients the circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. Circumstances may necessitate repeated disclosures.

- Marriage and family therapists do not disclose client confidences, except by written authorization or waiver or where mandated or permitted by law.

- Verbal authorization will not be sufficient except in emergency situations, unless prohibited by law.

MULTICULTURAL ISSUES

A major focus of the ACA Code of Ethics' expanded revision in 2014 was multicultural diversity competency. Multicultural diversity is a major component of the NBCC and AAMFT ethics codes as well. As the population increases and becomes more diverse, increased proficiency in multicultural diversity must be considered, and therapists and counselors must consider their personal values and biases.

Cultural influences must be recognized and appreciated in order to build trust and collaboration for effective counseling and therapeutic relationships. These influences are complex, and counseling and therapy methods must be individualized and specific to the diverse needs of the client. Counselors and marriage and family therapists may work with client groups that represent multiple sexual orientations, genders, cultures, ethnic, racial, generational, and religious groups; therefore, multicultural diversity awareness and acceptance is central to effective therapy.

Ethical challenges in multicultural diversity may begin with the validity of assessments because appropriate evaluation tools must be used. It is crucial to locate a culture fair or a culture-free method of assessment. The APA defines a culture-fair test and cross-cultural testing as follows [13]:

- A test based on common human experience and considered to be relatively unbiased with respect to special background influences. Unlike some standardized intelligence assessments, which may reflect predominantly middle-class experience, a culture-fair test is designed to apply across social lines and to permit equitable comparisons among people from different backgrounds.

- Cross-cultural testing is the assessment of individuals from different cultural backgrounds. The use of instruments that are free of bias is essential to valid cross-cultural testing, as it provides for the measurement equivalency necessary to ensure that outcomes have the same meaning across diverse populations of interest. For example, scores on a coping questionnaire that possesses bias may be a legitimate measure of coping if they are compared within a single cultural group, whereas cross-cultural differences identified on the basis of this questionnaire may be influenced by other factors, such as translation issues, item inappropriateness, or differential response styles.

Therapists should strive to be culturally aware and learn about the cultural identities they serve. The client's cultural identity impacts assessment, communication, client goals, and methods of service, and counselors must expand their strategies and skills to be effective in a variety of cultural contexts.

Problems may also arise when making a diagnosis in a multicultural context when using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition Text Revision (DSM-5-TR). There are many cultural beliefs and experiences that influence diagnosis, and the DSM-5-TR revision in 2022 incorporated greater cultural sensitivity and understanding in the diagnostic process [14]. Some changes implemented in DSM-5-TR include language that challenges the view that races are discrete and natural entities:

- The term "racialized" is used instead of "race/racial" to highlight the socially constructed nature of race.

- The term "ethnoracial" is used in the text to denote the U.S. Census categories, such as Hispanic, White, or African American, that combine ethnic and racialized identifiers.

- The terms "minority" and "non-White" are avoided because they describe social groups in relation to a racialized "majority," a practice that tends to perpetuate social hierarchies.

- The emerging term "Latinx" is used in place of Latino/Latina to promote gender-inclusive terminology.

- The term "Caucasian" is not used because it is based on obsolete and erroneous views about the geographic origin of a prototypical pan-European ethnicity.

- Prevalence data on specific ethnoracial groups were included when existing research documented reliable estimates based on representative samples.

In addition, information is provided on variations in symptom expression, attributions for disorder causes or precipitants, and factors associated with differential prevalence across demographic groups. Cultural norms that may affect the level of perceived pathology are also reported. Attention was paid to the risk of misdiagnosis when evaluating individuals from socially oppressed ethnoracial groups.

Clearly, it is impossible to be an expert in working with all cultures. Many researchers in this field report that it is important to look at the universal principles and standards that are at the core of therapy and counseling. These are basic human rights, and promoting an individual's mental health to reach full potential is fundamental. A counselor should work beyond their cultural beliefs and social systems and strive to understand clients from their viewpoints. A counselor must be aware of a client's external influences that may impact the development of service plans.

There are many training and educational programs to help build competence in multicultural diversity and to help the practitioner appreciate the social and cultural influences that shape a client's view of the world. Practitioners who do not consider these influences may incorrectly evaluate, or label, the client. They risk diagnosing behavior as pathological or impaired, although it may be an accepted and normal practice in the client's culture.

Multicultural awareness in counseling and therapy is critical for the counselor or therapist to communicate effectively in a way that is culturally sensitive. The practitioner must consider the effects of the client's culture in all phases of the service plan to deliver effective, individualized service.

In addition to training and educational programs, practitioners should increase their own multicultural competencies through hands-on experiences with local cultures in their communities of practice. This could include attending special events; volunteering; consulting professionals in the community; and participating in workshops, advocacy programs, and discussion groups along with consulting supervisors or other colleagues who have experience with the community. These activities, combined with guidelines from the code of ethics, may help practitioners develop competencies to further serve clients from diverse cultures.

Practitioners must identify and understand their own cultural perspective as it impacts their practice with diverse populations.

While there may be situations that show blatant discrimination toward others or ignorance of other cultures, many cultural insensitivities or negative behaviors have been termed "micro-aggressions," which are defined as, "A comment or action that subtly and often unconsciously or unintentionally expresses a prejudice" [15]. Well-meaning therapists who believe that they are culturally sensitive and open minded may offend members of another culture without being aware that they are doing so.

Micro-aggressions are linked to implicit bias (see glossary) that may be subtle, unconscious, and unintentional as well. According to the APA, [16]:

- Implicit bias is thought to be shaped by experience and based on learned associations between particular qualities and social categories, including race and/or gender.

- Individuals' perceptions and behaviors can be influenced by the implicit biases they hold, even if they are unaware they hold such biases.

- Implicit bias is an aspect of implicit social cognition: the phenomenon that perceptions, attitudes, and stereotypes can operate prior to conscious intention or endorsement.

Therapists and counselors must be careful to identify their potential for bias and stereotyping clients from other cultural backgrounds and should complete implicit bias training as part of their professional preparation for practice.

Nontraditional Family 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.

The family or group counselor or therapist should acquire specialized skills and experiences to understand the complexities of nontraditional family groups in order to practice in a nonjudgmental, supportive manner. The following issues may present:

- Sexual or gender orientation within the family group may lead to prejudice, discrimination, or bias in the community.

- Minority sexual orientation or gender issues may be the focus in custody issues the family is facing.

- Co-parenting and blended families may present added stress to all family members.

- Children may face issues at school or within the community due to their family composition.

- Same-sex or transgender couples may experience discrimination related to adoption or conceiving a child through the use of a surrogate.

- There may be conflicts between the biological parent and a stepparent who now has custody of the child.

- Extended families may not accept the nontraditional family members.

- Parents may need support to help their children feel confident and comfortable with a lifestyle that contradicts what they see and experience outside of their homes. The parents may require strategies to help their children face discrimination, isolation, and any negative stereotypes that they may encounter.

- Teens and children may face challenges due to their sexual or gender identity.

- It may take additional time to build trusting, collaborative relationships with members of the group to overcome their reluctance to share their feelings due to negative, judgmental experiences that they may have had in the past.

- A member of the family may be questioning sexual orientation or gender or may be in transition and need support through the process. The family may need services to help them adjust to the changes within the family.

Microaggressions that are related to gender expression and sexual identity can occur when working with members of the LBGTQ community. For example, the counselor or therapist should ask in their first session which gender pronoun the client prefers.

TECHNOLOGY-ASSISTED SERVICES

The computer age has presented new areas of ethical concerns that have affected every mental health organization today. Computers and other forms of technology are now the standard methods for recording, storing, retrieving, and transmitting patient information, clinical records, session notes, insurance information, evaluation results, and all other data involved in a client's case.

Massive amounts of information can now be stored on increasingly smaller, faster, and more portable electronic devices. Audio and visual records of every part of the therapeutic and counseling service can now be easily recorded and accessed. The convenience, ease of use, and portability of these systems can unfortunately lead to confidential information being stolen, lost, or transmitted accidentally. The constant upgrades and expansions among these systems lead to increasing possibilities of privacy violations and other ethical concerns for confidentiality maintenance in cyberspace.

Email interception by unauthorized parties is a widespread problem and is a violation of a client's privacy. Some companies and agencies feel justified in monitoring worksite email accounts and Internet usage because they view these employee email accounts as the company's property and a part of the company's technological infrastructure. Another justification is that they claim to determine whether personal business is being conducted on work time or if inappropriate Internet sites have been accessed. An example of this is within school systems where specific words and content are regularly flagged to monitor student and faculty use. If a school counselor or therapist reports that a child threatened to kill themself, the word "kill" may be red flagged in email correspondence by a county technology official who is monitoring the account in an office in another city and may trigger an investigation by individuals outside of the counseling relationship. This type of monitoring is a common practice in many public-school systems for all students and staff.

Technology has taken therapy and counseling out of the office and moved it across geographic borders. It allows a practitioner to work with clients from any location any time of day or night. This may be convenient for both parties; however, it opens many opportunities for confidentiality breaches and privacy right violations that will be covered in detail in subsequent sections.

In addition to crossing geographic boundaries, technology leads to boundary issues that cross the line from professional to personal with clients. Counselors and therapists may have websites and social media pages that are professional, in addition to personal online pages. These two types of social media must be kept separate at all times to maintain appropriate boundaries with clients. An example of this might be a Facebook page that can be used for professional purposes; however, the profile can also include personal information that may include interactions with friends.

A greater concern is the publishing or posting of information and photos by others that the therapist is unable to control. The counselor or therapist should always be aware of information or pictures online that can be accessed by the public, and the lack of security of online postings.

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.

Any counselor or therapist with a professional website, networking site, or social media page should review their code of ethics as well as any state or federal laws that regulate technology or practice in and outside the state boundaries of the professional license.

In recent years, many systems have been compromised, hacked, or cracked. These violations have resulted in lost or stolen personal, medical, and financial information. The practitioner can never be completely confident that they can protect the privacy rights of their clients when using technology for communication or distance services. Practitioners must follow numerous safeguards and be vigilant when using technology in their practice.

Revisions to the code of ethics have addressed the benefits and the risks of technology use and the provision of distance services. The use of technology affects the components of confidentiality, privilege, legal jurisdiction, client safety, duty to warn, and quality of the practitioner–client relationship. HIPAA laws provide extensive regulation of any information gathered, transmitted, and stored using all forms of technology including audio, visual, computer, fax, and phone.

The expanded use of technology and social media in service delivery brought many ethical conflicts to the forefront. The revised codes in this course contain guidelines in this area; however, as the technology continues to change the therapist and counselor must remain vigilant, review the sections on ethical technology use, and collaborate with other professionals to make sound ethical decisions. The course will address the guidelines in codes of ethics and the requirements defined within the HIPAA Privacy Rule, which governs the use of new technology and social media to prevent unintentional, or accidental, violations of privacy.

In addition, the counselor and therapist must maintain close contact with their professional associations and stay abreast of any code revisions and guidance. They must also stay informed to identify changes in state and federal laws related to informed consent, confidentiality, duty to warn, and privacy when using technology.

4. ETHICAL DECISIONS

Ethical decision-making is a process that involves the informed judgment of the counselor and the therapist. The codes advise that there will be issues with clients that contain ethical questions with no simple answers. The practitioner should consider how their actions would be judged in a peer review process and what ethical standards would apply. The codes stress that the practitioner should seek consultation from professionals in their employing organizations, state board, or professional associations regarding ethical decisions. When in doubt, it is important to seek collaboration and never to act alone.

The practitioner must review ethical principles and standards in their decision-making process. They must apply knowledge from the code of ethics for their association, the standards and principles of their employing organization, and state and federal statutes that apply.

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.

Appropriate time and resources should be given so that all stakeholders in the process feel confident in the decision to resolve the ethical issue. At any point, professionals should discuss the issue with their supervisors, administrators, or professional associations to include them in the process.

According to the NBCC 2023 revised Code of Ethics: 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.

AAMFT Standard 2.2 advises:

- Marriage and family therapists do not disclose client confidences, except by written authorization or waiver or where mandated or permitted by law. Verbal authorization will not be sufficient except in emergency situations, unless prohibited by law.

- See the subsequent sections on theTarasoff v. Regent's case for further details.

5. CURRENT ETHICAL CODES

A revision of the ACA Code of Ethics was completed in 2014. Changes were made that impacted professional counselors across all settings and specialties. The revised 2014 ACA Code of Ethics was the first new edition of the Code of Ethics since 2005. The AAMFT Code was revised on January 1, 2015; the NBCC Code was revised May 15, 2023. Major changes in the new codes involve distance counseling using technology and social media for client communication. These codes cover guidelines to address ethical considerations for confidentiality, client verification, safeguards, and effectiveness of therapy that must be considered while using these new forms of service delivery with clients.

Other new additions in the codes provide guidance in order to avoid any influence or bias toward clients based on the imposition of the counselor's personal values. The revised codes replace all others and provide additional guidelines for ensuring confidentiality, maintaining boundaries in dual relationships, increasing focus on multicultural diversity, safeguarding methods for record-keeping and securing information, assessing and diagnosing mental illness, as well as the selection of interventions.

The growing population of clients older than age 60 led to the inclusion of guidelines in the codes to handle counseling issues and ethics related to end-of-life care, managed care, and Medicaid/Medicare. Service payments for these clients are particularly complex. Although some of the services have been expanded through the federally mandated Affordable Care Act, some states have opted out of paying for additional services that are not covered under this Act. Some states with a large population of citizens older than 65 years of age have opted out of additional Medicaid and Medicare program funding. As a result, this has affected payments for mental health services, including counseling and therapy.

A review of the ethics codes for the National Board for Certified Counselors (NBCC), the American Counseling Association (ACA), the American Association of Marriage and Family Therapists (AAMFT), and the Association of Marital Therapy Regulatory Boards (AMFTRB) reveals similarities in the values, principles, and standards that guide the counseling professions. All of these organizations' missions seek to enhance human development and well-being, recognize diversity, and promote self-worth, dignity, potential, and independence for all people within their social and cultural contexts. These associations have ethics codes that apply to scientific, educational, and professional roles. They share common terms and definitions and are based on the premise that the client's welfare always has the highest priority.

These codes clarify the ethical responsibilities of professional practice and provide guidelines when professional obligations conflict or ethical uncertainties arise. The code for each association includes information in the following areas:

- Building trust for effective, collaborative client relationships

- Communication, informed consent, privacy, and confidentiality

- Multicultural diversity in practice

- Professional responsibility for ethical behavior and practice

- Evaluation, assessment, and interpretation of data

- Ethical use of technology and social media

- Training, teaching, and supervision

- Research and publication

- Relationships, consultation, and ethical responsibilities with colleagues and other professionals

- Ethical responsibilities to society

- Resolving ethical issues, complaints, or inquiries.

This course reviews and discusses key elements of the codes of ethics for marriage and family therapy and professional counseling, ethical decision-making, and associations' policies and procedures for addressing ethical complaints. It is not a comprehensive guide for compliance or a source of legal information or advice. The codes of ethics state that they are not able to address every possible ethical dilemma that therapists or counselors may face in their practice. The practitioner must seek professional assistance and collaboration as directed by their association, or employing agency, and refer to code guidelines on a regular basis. In addition, all professional associations can assist with questions related to ethical practice; therefore, contact information will be included.

6. SUMMARY OF THE NBCC CODE OF ETHICS

The National Board for Certified Counselors (NBCC) certifies licensed counselors who volunteer to enter the program from a variety of specialty areas and professional associations. NBCC offers general counselor certification as well as a choice of specialty areas in accordance with the counselor's specific practice. The NBCC Code of Ethics is applicable to all NBCC applicants and National Certified Counselors (NCCs) regardless of their area of practice or their choice of professional association membership [12].

According to the organization, the NBCC's Code represents the standards for ethical behaviors and seeks to provide an assurance of ethical behavior among counselors that provide professional practice as an NCC. The code's standards provide directives for ethical behavior and practice, and all NCC are expected to follow the code in their service to clients. The code serves as a resource for the professional counselor and provides recourse for clients who suspect an ethical violation has been committed by an NCC.

Applicants and credentialed NCC holders under this code will be sanctioned by the NBCC if the association determines that any directive or standard in the NBCC Code of Ethics has not been followed, which constitutes an ethical violation.

The NBCC is available to assist in ethical decisions and can be contacted by phone at 336-547-0607 or by email at nbcc@nbcc.org.

CORE VALUES IN THE NBCC CODE OF ETHICS

The following information is from the most recent revision of the of the code. It may be further viewed in its entirety on the NBCC website (https://nbcc.org) [12].

- Counselors will be civil in their actions and words, avoiding arrogance, assumptions, and hubris. Counselors seek to listen to others with intention and respond with respect. When engaged in challenging dialogues, counselors do so to seek answers not confrontations or harm. Counselors strive to be sensitive to differences in attitudes and culture. Counselors always seek to minimize undue harm and take particular care of those who are vulnerable or in anguish. With respect to all clients and work, counselors seek to be mindful of their humanity as they fulfill their counseling duties.

- Counselors strive to enhance the social and mental well-being of their clients while supporting the overall physical health of each client. Counselors must engage in self-care and self-reflection.

- Access and equity are essential to the profession of counseling and fundamentally important for the success of any society. Counseling services should be provided to achieve the best mental health outcomes. Counselors provide services to all of those in need, utilizing available resources, and advocating for the expansion of resources in underserved communities.

- Certified counselors and candidates demonstrate their commitment to ethical behaviors by demonstrating, and representing to their clients, sensitivity to multicultural issues, avoiding discrimination, oppression, and/or any form of social injustice.

NBCC ETHICS STANDARDS

The following standards are from the 2023 revision and are summarized [12]. You can review them in their entirety at https://www.nbcc.org/assets/ethics/nbcccodeofethics.pdf.

Professional Responsibilities

- 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.

Counseling Relationships

- Counselors shall take proactive measures to avoid harming their clients, avoid imposing personal values on those who receive their professional services, seek to minimize unavoidable or unanticipated harm, and address unintentional harm.

- Counselors shall respect each client's privacy and shall solicit only information that contributes to the identified counseling goals or facilitates the counseling process and is also consistent with counseling protocols.

- 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 generally shall not accept goods or services from clients in return for counseling services in recognition of the possible negative effects, including perceived exploitation. Counselors may accept goods or services only in cases where: no referrals are possible; the arrangement is discussed with the client in advance; they are of a reasonable equivalent value; they do not place the counselor in an unfair advantage; they are not harmful to the client and documented in the counseling services agreement.

- Counselors shall not accept gifts from clients except in cases when it is culturally appropriate or therapeutically relevant and shall consider the value of the gift and the effect on the therapeutic relationship before accepting.

- Counselors shall be mindful of engaging in counseling relationships with those individuals with whom another relationship, such as a community connection, friendship, or work relationship exists (i.e., multiple relationships). If a multiple relationship develops in an unforeseen manner, the counselor shall discuss the potential effects with the client, and take reasonable steps to resolve the situation, including termination and the provision of referrals.

- Counselors will exercise caution and avoid exploitation or the appearance of exploitation before entering into a non-counseling relationship with a former client. A period of 5 years is recommended, and counselors shall exercise caution and avoid exploitation of former clients.

- Counselors will not engage in any form of sexual or romantic contact with a client or former client for at least 5 years following the date of counseling service termination.

- Counselors will not engage in any type of harassing behavior towards clients, defined as any verbal, nonverbal, electronic, or physical act that is known, or reasonably understood, to be unwelcome or that reasonably would be perceived as harassment.

- Counselors will take proactive measures to avoid interruptions of counseling services due to illness, vacations, or unforeseen circumstances. To prevent the harm that may occur if clients are unable to access professional assistance, identify other qualified professionals with whom the counselor has a working agreement or local emergency service agencies that can respond to a client in a mental health crisis.

- Counselors shall protect against unauthorized access to confidential client information in all formats. Counselors will inform and ensure all other persons with access to confidential information will observe confidentiality procedures and protocols.

- Counselors shall create and follow written procedures regarding client confidentiality rules and the handling of client records in the event of the counselor's death, incapacitation, unforeseen and lengthy interruption of services, and end of employment.

- Counselors shall discuss with prospective clients and document the appropriateness of counseling services offered. If there is cause to believe a client will not benefit from counseling services, counselors will explore alternative forms of treatment and/or discuss and/or facilitate a referral to another provider.

- Counselors working independently will retain and protect client records as directed by State or Federal law.

- Counselors shall make efforts to inform clients and former clients of the court-ordered release of confidential client information prior to such release in a prompt and timely manner. The counselor may request that a court withdraw any order to release confidential information, due to the potential harm to the client or the counseling relationship, and release only that information required by the court or agency and document the release.

- Counselors shall inform clients of the purposes, goals, procedures, limitations, and potential risks and benefits of services and techniques either prior to or during the initial counseling session. Counselors also will provide information about client's rights and responsibilities, billing arrangements, collection procedures, confidentiality and its limitations, and records and service termination policies. Information will be provided to the client in verbal and written forms and counselors will confirm that the client understands the information. Counselors will obtain written informed consent to participate in counseling and document any client concerns related to the information provided in the client's record.

- Counselors understand that clients own the content of their clinical records, and counselors work to provide reasonable access to the content of the records when requested in a timely manner. If there is a reasonable basis to believe that direct review of the record will cause the client harm, the counselor will discuss the request and possible effects. In the case of minors, counselors may limit access to the minor client or responsible guardian if there is compelling evidence that other access may cause harm.

- Counselors shall obtain a client's written consent prior to the provision of services.

- Counselors shall work collaboratively with clients in the creation of written plans of treatment that offer attainable goals and use appropriate techniques consistent with the client's psychological and physical needs and abilities.

- Counselors shall update and modify the client's record throughout the counseling relationship when changes occur in the treatment plan, including changes relating to goals, roles, techniques, and diagnoses. Counselors shall obtain each client's written approval for such changes.

- Counselors shall clearly identify in writing the primary client in the record and record those individuals who are receiving related professional services in connection with such client relationship. In the context of couple, family or group counseling, the counselor shall not reveal any individual client's confidences to others, without the prior written permission of that individual.

- 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.

- Counselors are encouraged to consult with both parents or other family members prior to delivery of services in joint custody arrangements to ensure agreement with treatment planning and record sharing. Counselors will seek permission of an appropriate parent or legal guardian to disclose information and obtain voluntary and informed consent to release confidential information when counseling minors or adults who are legally incapable of providing consent.

Supervision

- Counselors who provide clinical supervision shall obtain appropriate training, including continuing education concerning current clinical trends, in order to meet the needs of their supervisees and the clients they serve.

- Counselors who provide supervision services shall provide accurate written information to supervisees regarding the counselor's credentials, as well as information regarding the process of supervision.

- Counselors who act as counselor educators, field placement supervisors, or clinical supervisors shall not engage in sexual or romantic intimacy, in-person or electronically, with current and former students or supervisees for at least 5 years from the date of the last academic and/or supervision contact, whichever is later.

- Counselors who provide clinical supervision services shall keep accurate records of supervision goals and the supervisee's progress 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.

- Counselors who provide clinical supervision services shall intervene in situations where a supervisee is impaired or incompetent and potentially placing the client(s) at risk. The supervisor also may take steps to end the supervisee's services to protect the client and may only resume services after the completion of any recommended or required remediation.

- Counselors who provide clinical supervision services shall not have multiple relationships with a supervisee that may interfere with the supervisor's professional judgment or exploit the supervisee. Supervisors shall not supervise friends, family, or relatives.

- Counselors who provide supervision services shall provide supervisees with regular and substantive feedback through-out the supervision process.

- Counselors shall promote the welfare and continued education of supervisees by discussing ethical and legal standards and practices related to supervision.

- Counselors who provide clinical supervision services shall establish procedures for responding to crisis situations related to supervisees and the supervisee's clients. These procedures shall be provided both verbally and in writing to their supervisees. A clear protocol and guidelines shall be made available and communicated to the supervisee in the event of the supervisor's absence. Contact information for an alternative supervisor shall be provided to the supervisee in the absence of the supervisor.

Consultation

- Counselors who seek or receive case consultation services from another professional shall document consultation in the relevant client records.

- Counselors who seek clinical supervision and consultation (consultees) shall promote the welfare of the client by selecting qualified professionals.

- Counselors who provide supervision services to supervisees who are practicing under the supervision of more than one supervisor shall exchange contact information and communicate about the shared supervisee's performance.

- Counselors who act as a university, field placement, or clinical supervisor shall ensure that supervisees provide accurate information to clients about the supervisee's professional status.

- Counselors who seek consultation (consultees) shall protect the client's identity and confidential information, and unnecessary invasion of privacy, by providing only the client information relevant to the consultation.

- Counselors who provide consultative services (consultants) shall establish a written plan with the professional seeking assistance.

- Counselors who provide consultative services (consultants) shall use and provide to consultees accurate information regarding their consultation qualifications and credentials related to the identified concerns or situations.

- Counselors who act as university, field placement, or clinical supervisors shall require that supervisees provide the supervisor's name, credentials, and contact information to the supervisee's clients.

Testing and Appraisal

- 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.

Research

- 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.

Counselor Education

Competence

- Counselor educators shall stay current with, and be well informed about, counseling-related professional issues and developments.

- Counselor educators shall engage in teaching and student supervision activities only with respect to their areas of professional knowledge and competence.

- Counselor educators shall ensure that all teaching activities are based on current research and evidence-based practices.

- Counselors who are counselor educators shall maintain professional licensure and/or certification consistent with their practice and teaching activities, including specialization areas, such as school, clinical mental health, rehabilitation counseling.

- Counselors who are counselor educators shall maintain competency in the delivery models and tools they use for teaching, supervision, and research.

Multiple Relationships:

- Counselor educators shall avoid non-academic relationships with counseling students during the student's participation in the educator's training program.

- Counselor educators shall not engage in intimate or sexual relationships with current students or individuals who were students enrolled in the counselor's program within the past 5 years. Prohibited sexual or romantic intimacy engagements include physical contact and electronic interactions.

Gatekeeping

Counselor educators shall serve as professional gatekeepers and assume responsibilities related to the evaluation of their students' professional behaviors and dispositions. Counselor educators shall establish clear, written behavioral and dispositional expectations for students, including student remediation.

Advocacy

Counselor educators shall advocate for counseling students to address programmatic barriers and obstacles that hinder student academic growth and development.

Cultural Identity

Counselor educators will practice cultural responsiveness in their teaching, and respect the cultural identity, values, sexual orientation, and gender identity, of their students.

DISTANCE SERVICES THROUGH TECHNOLOGY

The Board of Directors for NBCC addressed the potential impact of computers on the counseling profession beginning in 1997. The NBCC adopted the Standards for the Ethical Practice of Web Counseling, which was the first time a national association in the mental health profession had addressed standards in this critical area. Technology is constantly changing, so the NBCC Board of Directors continues to review and revise the standards and policies. The Board approved the current revision in 2023 to guide the practice of online counseling. The entire document should be reviewed at the NBCC website before proceeding with distance services. The NBCC 2023 revised Code of Ethics continues as follows:

Telemental Health

- Counselors shall provide only those telemental health services for which they are qualified by education and experience.

- Counselors shall carefully adhere to legal requirements when providing telemental health services. This requirement includes legal regulations from the State(s) in which the counselor and client are located and document relevant State requirements in the relevant client record(s).

- Counselors shall ensure that the electronic means used in providing telemental health services are following current Federal and State laws and regulatory standards concerning telemental health service.

- Counselors shall ensure that all electronic technology communications with clients are encrypted and secure.

- Counselors shall maintain records of all clinical contacts with telemental health service clients.

- Counselors shall set clear expectations and boundaries with telemental health service recipients about the type(s) and timing of communications that will be included in service provision. These shall be communicated in writing in disclosure documents provided to clients.

- Counselors shall provide written information to all telemental health clients regarding the protection of client records, accounts and related passwords, electronic communications, and client identity. This information should include a description of the nature of all communication security measures that are used by the counselor, including any risks or limitations related to the provision of telemental health services.

- Counselors shall communicate information regarding security to clients who receive telemental health services.

- Counselors shall screen potential telemental health service clients to determine whether such services are appropriate. These considerations shall be documented in the client's record. Counselors shall advise telemental health services clients that they must be intentional about protecting their privacy and confidentiality, including advice concerning viewing employer policies relating to the possible prohibitions concerning the use of work on computer systems for personal communications, and not using "auto-remember" usernames and passwords.

- During the screening or intake process, Counselors shall provide potential clients with a detailed written description of the telemental health counseling process and service provision including:

- The appropriateness of telemental health counseling in relation to the specific goal;

- The format of service delivery;

- The electronic equipment requirements such as the need for a computer with certain capabilities;

- The limitations of confidentiality; privacy concerns; the possibility of technological failure;

- Anticipated response time to electronic communication;

- Alternate service delivery processes; and,

- Any additional considerations necessary to assist the potential client in reaching a determination about the appropriateness of the telemental health service delivery format for their needs, and document such information and the discussion of alternative service options and referrals in the client's record.

- Counselors shall prevent the distribution of confidential telemental health client information to unauthorized individuals and discuss actions the client may take to reduce the possibility that such confidential information is sent to unauthorized individuals in error.

- Counselors shall provide clients of telemental health services with information concerning their professional preparation and/or credentials related to telemental health and identify the relevant credentialing organization websites.

- Counselors, either prior to or during the initial session, shall inform clients of the purposes, goals, procedures, limitations, potential risks and benefits of telemental health services and techniques, and information about rights and responsibilities as appropriate to the telemental health service.

- In the event that the client of telemental health services is a minor or is unable to provide legal consent, the counselor shall obtain a legal guardian's consent prior to the provision of services unless otherwise required by State law.

- Counselors shall retain documentation indicating the legal guardian's identity and consent in the client's file.

- Counselors will provide clients of telemental health services with specific written procedures regarding emergency assistance situations related to a client. This information shall include the identification of emergency responders near the client's location.

- Counselors shall take reasonable steps to secure referrals for recipients when needed for emergencies.

- Counselors shall provide information to clients concerning the importance of identifying personal contacts in the event of identified emergency situations and shall ask clients to identify such contacts.

- Counselors also shall identify to the clients the circumstances in which the counselor will communicate with emergency contacts, and the information that will be shared with emergency contacts.

- Counselors shall develop written procedures for verifying the identity of each telemental health client, their current location, and readiness to proceed at the beginning of each contact. Examples of verification include the use of code words, phrases, or inquiries, such as "Is this a good time to proceed?"

- Counselors shall limit use of client information obtained through social media

- sources (e.g., Facebook, LinkedIn, Twitter) in accordance with established practice procedures provided to the client at the initiation of services and as adopted through the ongoing informed consent process.

- Counselors shall retain telemental health service records for a minimum of 5 years unless applicable state laws require additional time.

Social Media and 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.

OVERVIEW OF THE NBCC ETHICAL COMPLAINT PROCESS

The NBCC developed a process to review alleged ethics violations by their NCCs and administer discipline if warranted. NCCs are bound by the decisions of NBCC. NCCs should have complete knowledge of these procedures and should visit the nbcc.org website to review the entire ethics section.

The complaint process is very detailed, and for the purpose of this course, they are summarized as follows from the 2023 website on filing an ethics complaint [17].

If you wish to file a complaint against a National Certified Counselor (NCC), you may do so by completing an Ethics Complaint Statement, including all information required by the form, and submitting it to the NBCC Department of Ethics. The Ethics Complaint Statement is a formal written communication from a complainant describing in detail the concerns regarding an NBCC certificant or candidate and is the only form of complaint submission accepted [17].

Overview of Complaint Procedures

1. The complainant (person filing the complaint) must complete an Ethics Complaint Statement, including all information required by the form, and email it to the NBCC Department of Ethics at ethics@nbcc.org.

2. When a completed Ethics Complaint Statement is received by NBCC, the NBCC Director of Ethics will (a) review the material received and assign a case number to the matter; (b) review the complaint(s) made; (c) determine whether the complaint(s) is presented in sufficient detail to permit NBCC to conduct a preliminary inquiry; and, if necessary, (d) contact the complainant and request additional factual material.

3. The NBCC Director of Ethics will send a letter to the complainant and respondent stating whether the complaint(s) submitted is accepted or rejected for a formal ethics review.

4. If an ethics complaint is accepted for a formal inquiry, the NBCC Director of Ethics will issue an Ethics Complaint Summary identifying each term that may have been violated and the basis for each. This notification will be delivered to the respondent and the complainant at the last known address(es) by regular mail, email, or other verifiable delivery service.

5. Within 30 days of the mailing date of an Ethics Complaint Summary, the respondent must submit an Ethics Complaint Response according to the instructions in the Summary. The Ethics Complaint Response must include the following: (a) a full answer to each item identified in the Ethics Complaint Summary, (b) the identification and a copy of each document that the respondent believes to be relevant to the resolution of the ethics complaint, and (c) any other information that the respondent believes will assist NBCC in considering the ethics complaint fairly.

6. The NBCC Director of Ethics will forward a copy of the submitted Ethics Complaint Response to the complainant within approximately 10 days following its receipt by NBCC. The complainant may submit a Reply to the Response by letter or similar document within 14 days of the complainant's receipt of the Response. If submitted, this Reply must fully explain any additional information that the complainant wishes to present to the Director of Ethics concerning the Ethics Complaint Response. The optional Reply will be provided to the respondent, who may submit a Final Response to NBCC within 14 days of the respondent's receipt of the Reply.

7. For questions about the complaint process and to submit a completed Ethics Complaint Statement, email ethics@nbcc.org.

7. A SUMMARY OF THE ACA CODE OF ETHICS

Members are committed to serve all clients and recognize and appreciate multicultural diversity. They work across cultures with the goal of increasing opportunities to maximize the potential in all people. The code was not written to mandate how the counselor will practice; rather, it serves as a guide for professional behavior and ethical practice based on their commitment, values, and dedication to ethical counseling.

The 2014 revision, the most current one, will be summarized in this section. The complete ACA Code of Ethics should be studied and can be found at https://www.counseling.org/resources/ethics.

ACA CODE OF ETHICS PREAMBLE

The American Counseling Association (ACA) is an educational, scientific, and professional organization whose members work in a variety of settings and serve in multiple capacities. Counseling is a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals.

MISSION

The mission of the American Counseling Association is to enhance the quality of life in society by promoting the development of professional counselors, advancing the counseling profession, and using the profession and practice of counseling to promote respect for human dignity and diversity [10].

CORE VALUES

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.

PRINCIPLES

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.

PURPOSE

The ACA Code of Ethics contains the following:

- The code sets forth the ethical obligations of members and provides guidance intended to inform the ethical practice of professional counselors.

- The code identifies ethical considerations relevant to professional counselors and counselors-in-training.

- The code enables the association to clarify for current and prospective members, and for those served by members, the nature of the ethical responsibilities held in common by its members.

- The code serves as an ethical guide designed to assist members in constructing a course of action that best serves those utilizing counseling services and establishes expectations of conduct with a primary emphasis on the role of the professional counselor.

- The code helps to support the mission of ACA.

- The standards contained in the code serve as the basis for processing inquiries and ethics complaints concerning ACA members.

The ACA Code of Ethics includes nine sections that serve as a guide to the counselor in the following areas:

- The counseling relationship

- Confidentiality and privacy

- Professional responsibility

- Relationships with other professionals

- Evaluation, assessment, and interpretation

- Supervision, training, and teaching

- Research and publication

- Distance counseling, technology, and social media

- Resolving ethical issues

SECTION A. THE COUNSELING RELATIONSHIP

Counselors facilitate client growth and development in ways that foster the interest and welfare of clients and promote the formation of healthy relationships. This section covers:

- Client welfare, primary responsibility

- Records and documentation

- Counseling plans

- Support network involvement

- Informed consent in the counseling relationship

- Inability to give consent

- Mandated clients

- Avoiding harm and imposing values

- Prohibited non-counseling roles

- Personal virtual relationships with current clients

- Managing and maintaining boundaries and professional relationships

- Role changes in the professional relationship

- Roles and relationships at individual, group, institutional, and societal levels

- Confidentiality and advocacy

- Multiple clients and group work

- Fees and business practices

- Self-referral

- Unacceptable business practices, bartering, and receiving gifts

- Termination and referral

SECTION B. CONFIDENTIALITY AND PRIVACY

Counselors recognize that trust is a cornerstone of the counseling relationship. This section provides details in the following areas:

- Respecting client rights

- Multicultural diversity considerations

- Explanation of limitations and exceptions

- Serious and foreseeable harm and legal requirements

- Confidentiality regarding end-of-life decisions

- Contagious, life-threatening diseases.

- Court-ordered disclosure

- Minimal disclosure and release, sharing and transmission of information

- Subordinates and interdisciplinary teams

- Confidential settings

- Third-party payers

- Deceased clients

- Groups and families

- Clients lacking capacity to give informed

- Parents and legal guardians

- Records and documentation

- Permission to record and observe

- Client access, assistance with records

- Storage and disposal after termination

- Case consultation, privacy, and disclosure.

When addressing a client's HIV status, counselors may need to determine if they are permitted to disclose that a client is HIV-positive, especially if the client confides that unsafe sexual activity has occurred. Standard B.2.b of the ACA Code of Ethics addresses contagious, life-threatening diseases as follows:

- When clients disclose that they have a disease commonly known to be both communicable and life threatening, counselors may be justified in disclosing information to identifiable third parties, if the parties are known to be at serious and foreseeable risk of contracting the disease. Prior to making a disclosure, counselors assess the intent of clients to inform the third parties about their disease or to engage in any behaviors that may be harmful to an identifiable third party. Counselors adhere to relevant state laws concerning disclosure about disease status.

Additionally, counselors must refer to state laws regarding disclosure: Some states allow counselors to disclose HIV-positive statuses to identifiable third parties, although the majority may assign this responsibility to medical professionals.

SECTION C. PROFESSIONAL RESPONSIBILITY

Counselors aspire to open, honest, and accurate communication when dealing with the public and other professionals. The following topics are covered in detail in the code:

- Knowledge and compliance with standards

- Professional competence and boundaries

- New specialty areas of practice and qualifications for employment

- Monitoring effectiveness

- Consultations on ethical obligations

- Continuing education

- Impairment, counselor incapacitation, death, retirement, or termination of practice

- Advertising, soliciting clients, testimonials, or products

- Recruiting through employment

- Professional qualifications, credentials, educational degrees, accreditation status and professional membership

- Public responsibility

- Reports to third parties

- Media presentations

SECTION D. RELATIONSHIPS WITH OTHER PROFESSIONALS

Counselors develop positive working relationships and systems of communication with colleagues to enhance services to clients. This section discusses the following components:

- Relationships with colleagues, employers, and employees

- Different approaches

- Interdisciplinary teamwork

- Establishing professional and ethical obligations and confidentiality

- Personnel selection and assignment

- Employer policies

- Protection from punitive action

- Provision of consultation services and competency

- Informed consent in formal consultation

- Contributing to the public good (pro bono publico)

SECTION E. EVALUATION, ASSESSMENT, AND INTERPRETATION

Counselors promote the well-being of individual clients or groups of clients by developing and using appropriate educational, mental health, psychological, and career assessments.

- Assessment services and security, scoring, interpretation, and reporting results;

- Competence to use and interpret assessment instruments;

- Informed consent in assessment;

- Release of data to qualified personnel;

- Diagnosis of mental disorders;

- Referral information;

- Technological administration;

- Historical and social prejudices in the diagnosis of pathology;

- Multicultural issues and diversity in assessment;

- Forensic evaluation for legal proceedings; and

- Avoid potentially harmful relationships.

SECTION F. SUPERVISION, TRAINING, AND TEACHING

Counselor supervisors, trainers, and educators aspire to foster meaningful and respectful professional relationships and to maintain appropriate boundaries with supervisees and students in both face-to-face and electronic formats. The code contains details on the following components:

- Counselor supervision and client welfare

- Supervisor and student responsibilities

- Counselor supervision competence

- Emergencies and absences

- Standards for supervisees

- Termination of the supervisory relationship

- Supervisory relationship and student welfare

- Counseling supervision evaluation, remediation, and endorsement

- Responsibilities of counselor educators

- Evaluation and remediation

- Multicultural/diversity competence in counselor education and training programs

SECTION G. RESEARCH AND PUBLICATION

Counselors who conduct research are encouraged to contribute to the knowledge base of the profession and promote understanding of conditions that will lead to a healthy and just society.

- Research responsibilities

- Roles and relationships between counselor educators and students

- Rights of research participants

- Student/supervisee participation

- Client participation

- Confidentiality of information

- Informing sponsors

- Research records custodian

- Managing and maintaining boundaries

- Reporting results

- Replication studies, publications, and presentations

- Student research

- Professional review

SECTION H. DISTANCE COUNSELING, TECHNOLOGY, AND SOCIAL MEDIA

Counselors understand that the profession of counseling may no longer be limited to face-to-face interactions. They understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how resources may be used to better serve their clients. Counselors understand concerns related to the use of distance counseling, technology, and social media and make every attempt to protect confidentiality and meet legal and ethical requirements for the use of such resources.

- Knowledge and legal considerations

- Laws and statutes

- Informed consent, security, and disclosure

- Confidentiality maintained by the counselor

- Acknowledgment of limitations

- Client verification

- Distance counseling relationship

- Benefits and limitations

- Professional boundaries in distance

- Effectiveness of services

- Access

- Communication differences in electronic media

- Records and web maintenance

- Client rights

- Electronic links

- Multicultural and disability considerations

- Social media

- Virtual professional presence

- Social media as part of informed consent

- Client virtual presence

- Use of public social media

SECTION I. RESOLVING ETHICAL ISSUES

Counselors strive to resolve ethical dilemmas with direct and open communication among all parties involved and seek consultation with colleagues and supervisors when necessary. Counselors become familiar with the ACA Policy and Procedures for Processing Complaints of Ethical Violations and use it as a reference for assisting in the enforcement of the ACA Code of Ethics [10]. This section includes details in the following categories:

- Standards and the law

- Ethical decision-making

- Conflicts between ethics and laws

- Suspected violations

- Informal resolution

- Reporting ethical violations

- Consultation

- Organizational conflicts

- Unwarranted complaints

- Unfair discrimination against complainants and respondents

- Cooperation with ethics committees

THE ACA POLICIES AND PROCEDURES FOR PROCESSING COMPLAINTS OF ETHICAL VIOLATIONS

The ACA Governing Council approved these policies and procedures in 2005, and they were revised July 31, 2020. The ACA's directives for processing complaints of alleged violations, and resolving an ethical complaint, are detailed and extensive. This course includes a summary as follows, and the complete ACA policies and procedures should be downloaded and reviewed at https://www.counseling.org/docs/default-source/bylaws-and-policies/aca-policies-procedures-9-2022.pdf.

General

- The American Counseling Association, hereafter referred to as the "Association" or "ACA," is dedicated to promoting the professional development of counselors, advocating for the profession, and ensuring ethical, culturally inclusive practices that protect those using counseling services.

- The Association, in furthering its objectives, administers the ACA Code of Ethics, hereafter referred to as the "ACA Code," which has been approved by the ACA Governing Council.

- This ACA Policies and Procedures for Processing Complaints of Ethical Violations (the "Procedures") document provides guidance and procedures for handling and resolving ethics complaints brought against Charged Members under the ACA Code. It specifies the procedures for processing complaints and for the work of the ACA Ethics Committee ("Committee"). It sets forth: the standards and options for judging the ethical conduct of members, and as appropriate, imposing sanctions, and identifies appeals procedures.

Jurisdiction

To be accepted, an ethics complaint must pertain to a "Charged Member," meaning an individual who:

a. Is a current member of the American Counseling Association; or

b. Was an ACA member when the alleged violations occurred.

Eligibility to File Complaints

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.

Ethics Committee Members

- The Ethics Committee is a standing committee of the Association with 9 appointed members, which includes 2 Co-Chairs.

- Generally, three Committee members are appointed each year by the President-Elect for 3-year terms, subject to confirmation by the ACA Governing Council.

Timelines

- The timelines set forth in these standards are guidelines only and have been established to provide a reasonable time framework for processing complaints.

- The Committee may consider complaints received less than five years after the alleged conduct either occurred or was discovered by the complainant.

- The Co-Chairs have the authority, in their discretion when justified by circumstances, to grant extensions of deadlines upon request by a Complainant or Charged Member.

- The Co-Chairs have the latitude to adjust procedures for good cause as they deem necessary to protect any party, participant, or subject of a complaint.

- Adjudication of the complaint shall correspond with the version of the ACA Code of Ethics in effect at the time of the alleged violation.

Nature of Communication

- Communications and complaints must be legibly printed or typed.

- Correspondence related to ethical complaints may be provided by hard copy via certified means or electronic means, but complaints and Committee decisions must be signed.

- Correspondence related to ethical complaints are to be addressed to the ACA Staff Liaison at the ACA Headquarters and marked "confidential," if provided by certified mail.

Intake and Finalizing of Submitted Complaints

- Complainants are required to contact the ACA Staff Liaison prior to filing a formal complaint.

- Complainants must identify who the complaint is about so that the ACA Staff Liaison can determine whether the person is subject to the jurisdiction of the ACA Ethics Code.

- Complainants are sent a copy of these Policies and Procedures, the ACA Ethics Complaint Form, and a copy of the ACA Code. They are told that they will have to provide authorization for the release of information to and from the Charged Member about the complaint, in order for the complaint filing to proceed (as this is not an anonymous process).

- If there is jurisdiction, the Complainant describes the reason for the complaint to the ACA Staff Liaison, who sends a formal Ethics Complaint form for the Complainant to identify: (a) the name and last known address of the Complainant, the Charged Member, and anyone who has knowledge of the facts involved; and (b) an explanation of how the code was violated.

- The Complainant then works with the ACA Staff Liaison in order to accurately identify the ACA Ethics Code sections that apply, as necessary, to identify any evidence and witnesses the Complainant wants to offer. To then finalize the complaint, steps will be taken in setting forth into separate charges according to the sections of the ACA Ethics Code that were allegedly violated.

- The Complainant maintains the right to approve or make any or none of the suggested changes made by the ACA Staff Liaison.

- Once the Complainant is satisfied with the contents of the completed formal complaint, Complainants must sign the complaint to begin the formal adjudication process.

- If the ACA Staff Liaison is unable to obtain a response from potential complainants for 45 business days after repeated attempts, those are treated as incomplete cases and are reported to the Co-Chairs and subsequently to the Committee as administratively dismissed but can be refiled by the Complainant in accordance with this policy.

Sanctions to address ethical violations may include letters of reprimand, suspension, or revocation of membership in the association. Documentation from the complaint process outlined previously may be obtained through subpoena and become part of a legal action against the counselor. If a violation of state or federal law occurs, criminal sanctions may result if convicted in a court of law. This may result in fines, suspension, or revocation of the license to practice, and/or criminal adjudication depending on the offense.

8. SUMMARY OF THE AAMFT CODE OF ETHICS

Counseling and therapy practice emphasize evidence-based interventions and methods of service, often using integrated therapies tailored to the needs of a specific set of clients. The practice of marriage and family therapy continues to be influenced by societal and cultural changes as well as politics and economics, such as the Affordable Care Act, managed care, and the increasing number elderly and disabled citizens who rely on Medicaid or Medicare. The trend toward research-based models that integrate several approaches may be more effective for families than one specific approach. Therapy that involves an integrated model for intervention requires the therapist to match the therapeutic approach to the specific members of the family. This process increases the number of interventions for the therapist to consider and may make the decisions and judgments more complex and dynamic as the therapy progresses. The complexity of group therapy increases the ethical considerations for confidentiality and informed consent.

Multicultural, generational, and developmental factors, as well as lifestyles, belief sets, sexual orientations, race, ethnicity, gender, religious affiliation, group affiliation, and intrafamilial issues impact the group approach to marriage and family therapy. The nature of the group therapy process involves an infinite number of variables and ethical issues to consider.

Complicating this process further is the growing application of technology for distance therapy with multiple clients, jurisdictional requirements, licensing restraints, state and federal laws, and organizational mandates that must be reviewed if services are delivered across state lines.

The following section is taken from the American Association for Marriage and Family Therapy's (AAMFT) Code of Ethics and is only a summary of the major components [11]. The entire code should be reviewed to ensure best ethical practice guidelines are followed.

PREAMBLE

The Board of Directors of the American Association for Marriage and Family Therapy (AAMFT) hereby promulgates, pursuant to Article 2, Section 2.01.3 of the Association's bylaws, the Revised AAMFT Code of Ethics, effective January 1, 2015.

HONORING PUBLIC TRUST

The AAMFT strives to honor the public trust in marriage and family therapists by setting standards for ethical practice as described in this code. The ethical standards define professional expectations and are enforced by the AAMFT Ethics Committee.

Commitment to Service, Advocacy, and Public Participation

Marriage and family therapists are defined by their dedication to professional and ethical excellence, which includes the following components:

- Commitment to service, advocacy, and public participation.

- Participation in activities that contribute to a better community and society, regardless of financial return.

- Concern with developing laws and regulations pertaining to marriage and family therapy and altering laws and regulations that are not in the public interest.

- Professional competence in these areas is essential to the character of the field, and the well-being of clients and their communities.

SEEKING CONSULTATION

The standards are not exhaustive and marriage and family therapists uncertain about the ethics of a particular course of action are encouraged to seek counsel from consultants, attorneys, supervisors, colleagues, or other appropriate authorities.

ETHICAL DECISION-MAKING

- Therapists must consider the AAMFT Code of Ethics and applicable laws and regulations.

- If the AAMFT Code of Ethics prescribes a standard higher than the law, therapists must meet the higher standard of the AAMFT.

- Therapists must comply with the mandates of law, maintain their commitment to the AAMFT Code of Ethics and try to resolve any conflict between the code, the law, and the mandates of their employment organization.

- The AAMFT supports legal mandates for reporting of alleged unethical conduct.

- Therapists must remain accountable to the AAMFT Code of Ethics at all times.

BINDING EXPECTATIONS

- 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.

ASPIRATIONAL CORE VALUES

These core values are aspirational in nature and are distinct from ethical standards.

- Acceptance, appreciation, and inclusion of a diverse membership.

- Excellence in training, knowledge, and expertise in systemic and relational therapies.

- Excellence in service to members.

- Diversity, equity, and excellence in clinical practice, research, education, and administration.

- Integrity evidenced by a high threshold of ethical and honest behavior within Association governance and by members.

- Innovation and the advancement of knowledge of systemic and relational therapies.

ETHICAL STANDARDS

Ethical standards are rules of practice upon which the marriage and family therapist is obliged and judged.

Standard I. Responsibility to Clients

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.

Standard II. Confidentiality

Marriage and family therapists have unique confidentiality concerns because the client in a therapeutic relationship may be more than one person. Therapists respect and guard the confidences of each individual client. This standard defines the following components:

- Disclosing limits of confidentiality;

- Written authorization to release client information;

- Client access to records;

- Confidentiality in non-clinical activities;

- Protection of records;

- Preparation for practice changes; and

- Confidentiality in consultations.

Standard III. Professional Competency and Integrity

Marriage and family therapists maintain high standards of professional competence and integrity.

- Maintenance of competency;

- Knowledge of regulatory standards;

- Seeking assistance;

- Conflicts of interest;

- Maintenance of records;

- Development of new skills;

- Harassment;

- Exploitation;

- Gifts;

- Scope of competence;

- Public statements; and

- Professional misconduct.

Therapists may be in violation of this Code and subject to termination of membership or other action if they are:

- Convicted of a felony;

- Convicted of a misdemeanor related to their qualifications or functions;

- Engaged in conduct leading to conviction of a felony, or misdemeanor related to their qualifications or functions;

- Expelled or disciplined by other professional organizations;

- Disciplined by regulatory bodies or have their licenses or certificates suspended or revoked;

- Practicing marriage and family therapy while no longer competent due to physical or mental impairment, abuse of alcohol or other substances;

- Not cooperating with the association throughout proceedings regarding a complaint.

Standard IV. Responsibility to Students and Supervisees

Marriage and family therapists do not exploit the trust and dependency of students and supervisees.

- Exploitation;

- Therapy with students or supervisees;

- Sexual intimacy with students or supervisees is prohibited;

- Oversight of supervisee competence and professionalism;

- Confidentiality with supervisees; and

- Payment for supervision.

Standard V. Research and Publication

Marriage and family therapists do not exploit the trust and dependency of students and supervisees. This standard includes information on the following areas:

- Therapists respect the dignity and protect research participants, are aware of applicable laws, regulations, and standards of research;

- Institutional approval;

- Informed consent to research;

- Right to decline or withdraw participation;

- Confidentiality of research data;

- Publication;

- Authorship of student work;

- Plagiarism; and

- Accuracy in publication.

Standard VI. Technology-Assisted Professional Services

This standard addresses basic ethical requirements of offering therapy, supervision, and related professional services using electronic means.

- Technology assisted services;

- Consent to treat or supervise;

- Clients and supervisees must be made aware of the risks and responsibilities associated with technology-assisted services;

- Confidentiality and professional responsibilities;

- Technology and documentation;

- Location of services and practice; and

- Training and use of current technology.

Standard VII. Professional Evaluations

Marriage and family therapists aspire to the highest of standards in providing testimony in various contexts within the legal system.

- Performance of forensic services;

- Testimony in legal proceedings;

- Competence;

- Informed consent;

- Avoiding conflicts and dual roles;

- Separation of custody evaluation from therapy;

- Professional opinions;

- Changes in service; and

- Familiarity with rules.

Standard VIII. Financial Arrangements

Marriage and family therapists make financial arrangements with clients, third-party payers, and supervisees that are reasonably understandable and conform to accepted professional practices.

- Financial integrity;

- Disclosure of financial policies;

- Notice of payment recovery procedures;

- Truthful representation of services;

- Bartering;

- Withholding records for non-payment.

Standard IX. Advertising

Marriage and family therapists engage in appropriate informational activities, including those that enable the public, referral sources, or others to choose professional services on an informed basis.

- Accurate professional representation;

- Promotional materials;

- Professional affiliations and identification;

- Educational credentials;

- Employee or supervisee qualifications;

- Specialization; and

- Correction of misinformation.

All practitioners must study the entire code, which is available online on the AAMFT website at https://aamft.org/Legal_Ethics/Code_of_Ethics.aspx.

A SUMMARY OF THE AAMFT ETHICS COMPLAINT PROCESS

The AAMFT Ethics Committee, hereafter the Committee, investigates ethical complaints made against AAMFT members as described in the AAMFT Procedures for Handling Ethical Matters [18]:

Initiating a Complaint

- Complaints must be initiated by someone with personal knowledge of the alleged behavior or by someone in a position to supply relevant reliable testimony or evidence on the subject.

Preliminary Review of a Complaint

- AAMFT staff review the complaint materials for jurisdiction and completeness.

- Complainants must waive therapist-client confidentiality and permit AAMFT to use their name and forward a copy of the allegations to the member, if charged with a violation of the AAMFT Code of Ethics.

Determining Whether to Open a Case

- The Chair, in consultation with AAMFT's legal and ethics staff, determines whether the allegations, if factual, constitute a violation of the Code.

Consideration by the Full Committee

- The case will be submitted to the full Committee at its next meeting.

- If the Committee determines that a violation has occurred, they will recommend an appropriate sanction based on the severity of the violation.

Appeal to Judicial Committee

- The member will be notified and given the opportunity to appeal the Committee's findings and recommendations to the Judicial Committee.

- The member must provide a written request for a hearing within 15 days after receiving notice of the Ethics Committee's findings and recommendations. If the member does not appeal within the allotted time, the Ethics Committee's decision becomes final.

Manner of Judicial Committee Hearing

- The member may choose either an in-person hearing or a written review process. In-person hearings are typically held in Alexandria, VA before a Judicial Committee Panel.

- The Judicial Committee panel is required to render its decision within 30 days of the hearing. If the member requests a written review process, the member and the Ethics Committee will provide written submissions to a Judicial Committee Panel, which will review the materials and render its decision within 30 days of the review.

Appeal to AAMFT Board of Directors

- A member may make a final appeal to the AAMFT Board of Directors if the member believes that a procedural violation substantially impaired the member's ability to defend against the charges.

- The Board will review the appeal at its next scheduled meeting and will render a decision within 30 days of the meeting.

Confidentiality of Ethics Matters

- All information obtained by the Ethics Committee and all case proceedings are confidential with limited exceptions.

- At this time, termination of membership with a permanent bar to readmission is the only sanction that is routinely published in AAMFT's Family Therapy Magazine. In cases that involve a finding of no violation(s) and cases that involve lesser sanctions, typically the only notification is to the member and complainant. The Procedures permit AAMFT to provide a limited report on an ethics case to a regulatory body or another professional association upon request. If such a report is provided, a copy of the report is sent to the member.

Professional association ethics committees, such as the one described previously, as well as any peer review, consultant, or decision-making team, can be viewed as a "third party." When disclosing confidential material, the guidelines from the code and HIPAA rules regarding confidentiality and disclosure to third parties are applicable in these situations. Counselors, therapists, and other members of professional associations related to the case have a duty to respond as required by the ethics committee, licensing board, courts, or other regulatory agencies; however, they must always follow basic procedures for confidentiality, privacy, and informed consent.

If the ethics committee asks for confidential information, or for a statement from the practitioner in reference to a client, the practitioner should ask for a copy of the consent or waiver of confidentiality from the complainant before responding to the request. The ethics committee cannot conduct a review or require a response concerning client record without signed waiver of consent from the client, and that document serves as a waiver of the practitioner's duty to maintain confidentiality.

A complaint packet may be obtained via email to ethics@aamft.org. Contact AAMFT by phone at 703-838-9808. If a therapist needs assistance or information regarding an ethical question, they can consult with an AAMFT Ethics Case Manager at ethics@aamft.org or 703-253-0471. Members may obtain a formal ethical opinion from the AAMFT Ethics Committee [18].

9. ETHICAL DECISION-MAKING

Ethical decision-making is a process that involves the informed judgment of the therapist or counselor. There are many situations where simple answers are not available for ethical questions, or where the complexity of the situation crosses several standards with different possible interpretations. Ethics related to diversity, discrimination, privacy, confidentiality, privilege, informed consent, dual relationships, and duty to warn may overlap as these are all areas where ethical violations may occur. The practitioner should consider how the issues would be judged in a peer review process where ethical standards would be applied. In all cases, the practitioner must review values, principles, and ethical standards relevant to the situation. They should have thorough knowledge of ethics codes for their organization or employer, and applicable state and federal statutes.

Again, even when codes do not contain specific guidelines covering a particular issue, the practitioner is responsible for making correct ethical decisions. If practitioners are faced with ethical dilemmas that are difficult to resolve, they are expected to engage in an ethical decision-making process that aligns with ethics codes. This process may involve consulting outside resources and collaboration with other professionals. Reasonable differences of opinion may exist among individual counselors or therapists in respect to values, principles, directives, and how standards would be applied when they conflict.

There is no specific ethical decision-making model identified to be most effective. Professionals should be familiar with evidence-based models of decision-making that involve a professional team and will stand up to public scrutiny. In the absence of a clear answer to the particular ethical issue, or when conflicts arise among the team concerning interpretation, the team must implement an ethical decision-making model. Through the decision-making processes counselors and therapists can make ethical decisions for the welfare of clients.

Most decision-making models include the following components in some form:

- Identify the problem and ethical issue(s).

- Consult relevant professional association and organizational codes of ethics for guidance.

- Review state and federal statutes that regulate ethical practice.

- Consult professionals from several sources to obtain multiple, objective perspectives.

- Identify relevant client communications or concerns.

- Brainstorm potential strategy options, considering all suggestions and opinions.

- Discuss potential outcomes or consequences for each option.

- Develop the action plan with roles, responsibilities, and timelines for stakeholders.

- Be sure the plan aligns with all ethics codes, legal statutes, and regulations.

- Implement the plan and assess progress.

- Revise the plan as needed.

After the team has agreed on a course of action and a plan to move forward, they should review the plan to see if it presents any new considerations involving ethics and client welfare. Stadler suggests applying three simple tests to the course of action to be sure it is appropriate [19]. These tests are referenced in current ACA guidelines [20].

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?

If the team believes that they can meet these three tests, they should feel confident that their decision is ethically sound. The practitioner can then move forward with the client. When one or more of the tests cannot be answered in the affirmative, the team should analyze the reasons why the decision has failed in that test. They can then revisit the decision-making process to review the part of the test that has not been met and identify the part of the plan that is not just, would not meet public scrutiny, or lacked universality, for example.

If the course of action presents new ethical issues, the counselor or team will go back to the beginning and reevaluate each step of the process to address that issue.

Practitioners should periodically apply formative assessment methods to monitor and judge the effectiveness of their plan as they progress through sessions. This is especially important when implementing a new decision or a plan to resolve an ethical issue. The evaluation may be informal; it should answer the following questions:

- Did the course of action, based on the decision, result in the anticipated effect?

- Did positive consequences result from the decision or course of action?

- Was the decision or course of action aligned with the plan of service?

- Was client assessment culture fair?

- Did the decision or course of action promote the client's goals?

- Is the course of action in the best interest of client's welfare?

- Is the client positive and participating in the course of action?

- Is there anything that should change in method or practice to be more effective for the client?

When making any practice decisions about a counseling plan, with or without an identified ethical issue, it is important to follow an organized, thorough, collaborative process for decision making. The process must be grounded in skills of professional competence and knowledge of client needs that will inform the appropriate method(s) of practice. Applying the decision-making process, based on these skills, can inform the appropriate counseling method and plan.

Clients should be included whenever possible in decisions about their counseling and therapy plan. They should be informed about the process and encouraged to be active participants in all sessions. The following the components should be part of the planning and delivery process with clients:

- Discuss with the client the problem or dilemma that prompted them to seek assistance.

- Identify potential barriers to progress including any language or cultural considerations. Use an objective translator as needed, not a family member or friend.

- Discuss assessment measures and explain the rationale for use prior to conducting them. Always explain the results of assessment and how they inform delivery of services.

- Include the client in the decision-making process, when possible, to build ownership and autonomy skills.

- Identify and discuss various courses of action and consequences of each.

- Form a plan and set goals with the client, check for understanding and agreement through the informed consent process.

- Implement the course of action with clear objectives and timelines for progress.

- Provide resources and to support the client in reaching their goal.

- Review the plan, assess progress, and revise the plan as necessary. Any changes to the plan must be reflected in the informed consent document.

- Seek consultation from more than one source to gain multiple perspectives.

Counselors and therapists should be vigilant in their practice to identify potential ethical concerns and areas that require consultation, review effectiveness of the service, and employ a decision-making model when warranted. This may include the practitioner's self-evaluation to ensure they are maintaining clarity, objectivity, competence, and appropriate boundaries, free of bias, to prevent ethical violations in practice.

10. EVALUATING ETHICAL PRACTICE

How can counselors or therapists self-monitor to know if they are practicing in an ethical manner? They may not encounter an ethical issue in their practice that necessitates the need for a decision-making team process but want assurances that they are following the ethics codes and practicing ethically.

Van Hoose and Paradise suggested a process for judging professional practice against ethical standards [21]. Their work has stood the test of time and serves as the basis for significant research on ethical practice today as referenced in current ACA publications [20]. The counselor or therapist is probably acting ethically by evidence that they:

- Maintained personal and professional honesty.

- Can demonstrate they have acted in the best interest of the client's welfare as their priority.

- Acted without malice or personal gain.

- Consulted with other professionals in the field.

- Can demonstrate fair and just actions.

- Would be comfortable with a peer review process to evaluate their practice.

- Could publicly report and defend their action.

- Can support their actions based on the best practice of the profession.

- Can show documentation of appropriate informed consent procedures and record keeping.

- Maintained client confidentiality following ethical and legal requirements.

- Employed a sound decision making model.

- Consistently followed their code of ethics.

It is also important for counselors and therapists to consider the following components in, addition to the foregoing, when assessing their practice related to ethics:

- Issues related to the specific client including levels of comprehension, informed consent, participation, cultural factors, goal achievement, and satisfaction of the client through the service delivery.

- Appropriate formative and summative assessment of client needs and progress to inform and guide the plan of service.

- Counselor bias, emotions, personality, and other factors specific to the counselor that may have impacted their practice during the service delivery.

- The dynamics of the counselor/client relationship.

- Review of evaluations, goal achievement, and client satisfaction with the outcomes and success of the service plan.

11. SERVICE DELIVERY THROUGH TECHNOLOGY AND SOCIAL MEDIA

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.

Computer networks are used to manage records concerning assessment and evaluation, treatment, billing/payments, and communications between therapists and their clients. Many practitioners deliver services via real-time distance technology. The ever-expanding use of new technology systems, such as mobile media devices, computers, e-mail, faxes, cell phones, video conferencing, and social media may lead to breaches in confidentiality and potential ethical dilemmas.

Technology in counseling settings requires ongoing security considerations to avoid new risks for unintentional confidentiality breaches. Counselors must carefully review their association's and employing agency's ethical guidelines prior to implementing technology-based therapy or counseling.

Technology is continually changing, increasingly varied, complex, and in demand by many clients and practitioners who prefer audio/video conferencing with increased speed capacities for information transmitting, and storing, over traditional methods of service. Skype, instant messaging, face time, e-mail, social media, mobile media using iPad and iPhone, and other technology methods for delivering distance practice expand the access to counseling and may make it more convenient for the client and professional.

Many clients are more comfortable with online distance services than with traditional, in-person counseling because they provide more anonymity and privacy, avoiding the stigma of going to an office for services. These individuals may access and continue online counseling when they would not have done so in a face-to-face setting, which may increase that number of clients receiving services.

Technology presents many challenges to the counselor or therapist, including the following:

- Counselors, therapists, staff, and clients may lack competence in using technology. Training must take place prior to service delivery requiring additional time.

- Frequent system failures may block or interrupt services altogether.

- During a time of crisis, it can be stressful and dangerous if a connection is lost, or service is unavailable. This may cause the counselor to lose all contact with the client.

- The practitioner may receive multiple messages from different clients simultaneously.

- Guidelines and boundaries must be established concerning times, length, and frequency of contact between the practitioner and client.

- Communicating at a distance, especially on devices that do not have a video component, may impact the client's authentic response and interfere with relationship development between practitioner and client.

- Third parties may hear or see interactions, which erodes privacy and privilege.

All of the professional counseling and therapy associations in this course detail their ethical and legal obligation to keep records secure and have developed guidelines specific to technology, social media, and distance service delivery.

In addition to the ethics codes, practitioners must comply with the HIPAA Privacy Rule. This rule dictates the "who, what, when, where, why, and how" of storage, transmission, disclosure, right of privacy, and the duty to safeguard confidential information under penalty of federal law.

Distance technology includes other challenges when compared to conventional therapy. The professional may have more difficulty assessing body language including facial expressions, gestures, voice quality, tone, mood, and other subtle cues that do not translate well, if at all, depending on the technology being used. The practitioner and the client should discuss and agree on a plan to evaluate the therapy's effectiveness in the treatment plan. Either party may determine that long-distance service may be terminated or altered if not effective or if the welfare of the client is at risk. Service delivery may include a combination of distance and face-to-face methods.

Ethical concerns and potential risks associated with technology cannot be completely avoided in practice today. The ethical codes, state and federal regulations, and case studies described in this course, serve as a starting point for counselors and therapists to deepen their understanding of ethical use of technology and social media in their specific area of practice. All practitioners must review their state statutes, employer guidelines, revised association codes, and HIPAA requirements specific to technology use and distance services. Remember that distance services across state lines mandates compliance with all state statutes for ethical practice and licensure requirements for all jurisdictions.

TELETHERAPY AND TELESUPERVISION GUIDELINES II

In addition to the guidelines previously covered from the NBCC, ACA, and AAMFT, one of the most current and detailed set of teletherapy guidelines, Teletherapy and Telesupervision Guidelines II, was published by the Association of Marital and Family Therapy Regulatory Boards (AMFTRB) in 2021. These guidelines incorporate reference information from research in the fields of counseling, social work, marriage and family therapy, and the HIPAA Privacy Rule.

Due to the length of the guidelines, they will be summarized here and should be viewed in their entirety at https://amftrb.org/wp-content/uploads/2021/09/AMFTRB-Teletherapy-Guildelines-9-21.pdf [22,23,24].

Teletherapy and Telesupervision Glossary

- 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.

AMFTRB Guidelines for the Regulation of Teletherapy Practice

1. Adhering to Laws and Rules in Each Jurisdiction

1. 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.

2. 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.

2. Training and Continuing Competency Requirements

1. Therapists must adhere to their jurisdiction's training requirements for teletherapy prior to initiating teletherapy.

2. 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.

3. Therapists must have completed basic education and training in suicide prevention.

4. Therapists must assume responsibility to continually assess both their professional and technical competence when providing teletherapy services.

5. 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]:

1. Clinical Evaluation and Care

2. Virtual Environment and Telepresence

3. Technology

4. Legal and Regulatory Issues

5. Evidence-Based and Ethical Practice

6. Mobile Health Technologies Including Applications

7. Telepractice Development

6. Therapists conducting teletherapy must demonstrate continuing competency in each license renewal cycle in their jurisdiction.

3. Diversity, Bias, and Cultural Competency

1. Therapists must be aware of and respect clients from diverse backgrounds and cultures and have basic clinical competency skills providing treatment with these populations.

2. Therapists must be aware of, recognize, and respect the potential limitations of teletherapy for diverse cultural populations.

3. Therapists must remain aware of their own potential projections, assumptions, and biases.

4. 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.

5. 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.

6. 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).

7. 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.

4. Establishing Consent for Teletherapy Treatment

1. 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.

2. A clinical treatment relationship is clearly established when informed consent documentation is signed.

3. Therapists must communicate any risks and benefits of the teletherapy services to be offered to the client(s) and document such communication.

4. 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).

5. 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.

6. 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.

5. Identity Verification of Client

1. Therapists must recognize the obligations, responsibilities, and client rights associated with establishing and maintaining a therapeutic relationship.

2. The therapist is responsible for assessing and documenting the client's appropriateness for teletherapy treatment.

3. It is the therapist's responsibility to document appropriate verification of the client's identity.

4. 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.

5. 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?"

6. Informed Consent: Availability of Professional to Client

1. The therapist must document the provision of informed consent in the record prior to the onset of therapy.

2. 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:

1. Confidentiality and the limits to confidentiality in electronic communication

2. Teletherapy training and/or credentials, physical location of practice, and contact information

3. Licensure qualifications and information on reporting complaints to appropriate licensing bodies

4. Risks and benefits of engaging in the use of teletherapy, technology, and/or social media

5. Possibility of technology failure and alternate methods of service delivery

6. Process by which client information will be documented and stored

7. Anticipated response time and acceptable ways to contact the therapist

1. Agreed upon emergency procedures

2. Procedures for coordination of care with other professionals

3. Conditions under which teletherapy services may be terminated and a referral made to in-person care

8. Time zone differences

9. Cultural and/or language differences that may affect delivery of services

10. Possible denial of insurance benefits

11. Social media policy

12. Specific services provided

13. Pertinent legal rights and limitations governing practice across state lines or international boundaries, when appropriate

14. Information collected and any passive tracking mechanisms utilized.

3. 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.

4. 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.

5. 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.

6. Therapists must provide clients clear mechanisms to:

1. Access, supplement, and amend client-provided personal health information (PHI)

2. 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).

7. Working with Children

1. 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.

2. 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.

8. Acknowledgement of Limitations of Teletherapy

1. Therapists must:

1. Determine that teletherapy is appropriate for clients, considering clinical, relational, cultural, cognitive, intellectual, emotional, and physical needs

2. Inform clients of the potential risks and benefits associated with teletherapy

3. Ensure the security of the therapist's communication medium

4. Only commence teletherapy after appropriate education, training, or supervised experience using the relevant technology

2. Therapists are to advise clients in writing of the risks and of both the therapist's and clients' responsibilities for minimizing such risks.

3. 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.

4. 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.

5. 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.

6. 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.

9. Confidentiality of Communication

1. 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).

2. 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.

3. 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.

10. Professional Boundaries Regarding Virtual Presence

1. 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.

2. To facilitate the secure provision of information, therapists must provide in writing the appropriate ways to contact them.

3. 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.

4. 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).

5. 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.

6. Virtual sexual interactions are prohibited.

7. 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.

11. Impact of Social Media and Virtual Presence on Teletherapy

1. 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.

2. Therapists separate professional and personal web pages and profiles for social media use to clearly distinguish between the two kinds of virtual presence.

3. 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.

4. Therapists must respect the privacy of their clients' presence on social media unless given consent to view such information.

5. Therapists must avoid the use of public social media sources (e.g., tweets, blogs, etc.) to provide confidential information.

6. Therapists must refrain from referring to clients generally or specifically on social media.

7. 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.

12. Documentation/Record Keeping

1. All client-related electronic communications must be stored and filed in the client's record, consistent with standard record-keeping policies and procedures.

2. Written policies and procedures for teletherapy must be maintained at the same standard as in-person services for documentation, maintenance, and transmission of records.

3. 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.

4. 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.

5. 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.

6. 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.

7. Clients must be informed in writing of the limitations and protections offered by the therapist's technology.

8. 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.

13. Payment and Billing Procedures

1. 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.

2. 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.

3. Therapist must document who is present and use appropriate billing codes.

4. Therapist must ensure online payment methods by clients are secure.

14. Emergency Management

1. 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.

2. 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).

3. 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.

4. 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.

5. 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).

6. 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.

7. 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.

15. Synchronous Versus Asynchronous Contact with Client(s)

1. 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.

2. 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.

3. 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.

4. 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.

16. HIPAA Security, Web Maintenance, and Encryption Requirements

1. Videoconferencing applications must have appropriate verification, confidentiality, and security parameters necessary to be properly utilized for this purpose.

2. 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.

3. Capability to create a video chat room must be disabled so others cannot enter at will.

4. Personal computers used must have up-to-date antivirus software and a personal firewall installed.

5. All efforts must be taken to make audio and video transmission secure by using point-to-point encryption that meets recognized standards.

6. Videoconferencing software must not allow multiple concurrent sessions to be opened by a single user.

7. Session logs stored by third party locations must be secure.

8. 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.

9. 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.

10. 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.

17. Archiving/Backup Systems

1. 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.

2. PHI and other confidential data must be backed up to or stored on secure data storage location.

3. 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.

18. Standardized and Non-standardized Testing for Assessment

1. 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.

2. Therapists must consider the unique issues that may arise with test instruments and assessment approaches designed for in-person implementation when providing services.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

19. Telesupervision

1. 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.

2. Before using technology in telesupervison, supervisors must be competent in the use of those technologies.

3. Supervisors must take the necessary precautions to protect the confidentiality of all information transmitted through any electronic means and maintain competence.

4. The type of communications used for telesupervision must be appropriate for the types of services being supervised, the clients and the supervisee needs.

5. 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.

6. Supervisors must:

1. determine that telesupervision is appropriate for supervisees, considering professional, cognitive, cultural, intellectual, emotional, and physical needs

2. 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.

3. ensure the security of their communication medium

4. only commence telesupervision after appropriate education, training, or supervised experience using the relevant technology.

7. Supervisors must be aware of statutes and regulations of relevant jurisdictions regarding sexual interactions with current or former supervisees.

8. 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.

EMERGENCY PLANS TO SAFEGUARD TELEMENTAL HEALTH SERVICES

Contingency plans must be developed, written, and signed that give consent to service as well as outline procedures to handle technical difficulties and/or crisis situations. If the counselor or therapist is not in the same location as the client or family, then there must be a plan to handle emergency situations in the client's home or employment area. This requires that the practitioner identifies and collaborates with professional contacts in facilities that are immediately available to assist the client, if needed. These resources should include professional colleagues' contact information, crisis hotlines, mental health outreach programs, clinics, hospitals, mental health facilities, and law enforcement agencies. These contacts must also be shared with clients and included in their treatment or counseling plans. Procedures that effectively outline when and how to contact these resources, as well as when to call 911, must be written out and discussed with the client. Crisis contingency plans must also be included in the informed consent documents signed by the client. Any informed consent would include the client's understanding of all of the risks involved in technology, long-distance service, and the implementation of the crisis plan.

HIPAA STANDARDS FOR MOBILE DEVICES

HIPAA outlines the national standards developed by the Department of Health and Human Services to secure electronic protected health information (ePHI) that is "created, received, used, or maintained by a covered entity" [24]. The security of a client's health information may be at risk when using mobile devices because the data is stored within the device in its onboard memory through the use of a security information module (SIM) card. This card identifies the owner and stores data and can be removed from the cellular device. The device may also have a memory chip, which is a microchip that can be plugged into a computer to provide more memory. An eSIM card is hardwired into the phone so it cannot be removed or stolen, making it more secure.

Mobile devices may not have the capability to restrict access to data by encryption and authentication, so practitioners must be cautious when sharing ePHI using mobile devices. Sending or receiving information through publicly available Wi-Fi, or unsecured cellular networks, risks exposing ePHI to anyone. To ensure that ePHI is not compromised or stolen when using a mobile device, the practitioner must use a secure website or a virtual private network (VPN) that encrypts information as it is received and sent from the device.

Another risk is that mobile devices are small, light, and portable so they can be easily lost or stolen, with theft as a primary form of security breach.

Ethical codes and the HIPAA Privacy Rule will continue to be revised but may not keep pace with the constant changes in these technologies. Therapists are always responsible for protecting client privacy and information disclosed to them in confidence. Telemental health delivery requires sophisticated equipment and safety precautions for various technology systems. It is advisable to contact a technology consultant to design an appropriate system with privacy and security safeguards that will meet all requirements of the jurisdictions being served.

ACA SOCIAL MEDIA TIPS

Practitioners must be cautious to avoid the negative effects of social media and the inherent ethical concerns when using these platforms. It should be noted that cyber bullying on social media is a major problem and has been linked to severe psychological distress and suicide among youth [27].

Social Media: 10 Tips for Professional Counselors

1. Make sure professional social media accounts are separate from personal accounts. It is a good idea to keep personal accounts private (ACA Code of Ethics H.6.a.).

2. Learn everything about social media platforms prior to use. Be sure to understand the various platforms' purposes and operations, including their privacy controls (H.1.a.).

3. Do not share confidential information on social media, even in closed/private settings. Nonprofessionals may have access to that information (H.6.d.).

4. Do not disclose/identify individuals in social media posts, even if they are public figures.

5. If you would not say it in real life, do not post it online. Statements have weight (C.6.c.). Keep in mind that values and beliefs shared online may be viewed by clients, employers, counseling education programs, membership organizations, other professionals, and the general public.

6. Be accurate and appropriate in the portrayal of education, licensure, accreditation, expertise, and memberships. The ACA advertising/promotion ethical standards apply to social media, too (C.3.).

7. Do not view a client's social media profile without permission, even if it is public (H.6.c.). Keep in mind that personal virtual relationships with current clients are prohibited (A.5.e.).

8. Counselors and counseling-related organizations must develop a social media policy. Information about this policy must be included in informed consent documents for clients and should be posted on professional social media pages and websites (A.2.b.).

9. Social media policies should cover the risks, especially to confidentiality, and benefits of interacting with counselors on social media, as well as the expectations clients should have when interacting with a counselor's professional social media account (H.6.b.).

10. Follow all of the social media guidelines listed in the 2014 ACA Code of Ethics.

12. 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.

Many counselors have consulted ACA staff and leaders concerning the ethics involved in the practice of conversion therapy, also known as reparative therapy. Many state and federal initiatives have enacted proposals to ban the practice entirely. The ACA ethics committee shared its formal interpretation of specific sections of the Code of Ethics concerning the practice of conversion therapy, which is a practice designed to change sexual orientation from homosexual to heterosexual [28]. The ACA published the following information on their website in 2015 and republished it in 2023:

Dr. David Kaplan, ACA's Chief Professional Officer, testified before the Washington, D.C. Committee on Health in support of a bill banning conversion therapy for minors. "The American Counseling Association has adopted an unequivocal policy against reparative therapy. Reparative therapy is not congruent with the American Counseling Association's Code of Ethics as the effects of efforts to change sexual orientation have been found to cause damage to individuals who have been exposed to it," Dr. Kaplan said. Additionally, the American Psychological Association has found the practice to be "unlikely to be successful and involve some risk of harm." In his testimony, Dr. Kaplan also said the following: "The word 'therapy' should really not be used when talking about sexual orientation change efforts. 'Therapy' is a clinical word and refers to a mental health intervention. 'Reparative therapy' is not a mental health intervention since it does not address the diagnosis of a mental disorder. The mental health field has concluded that same-sex attraction is not a deficit and therefore homosexuality is not categorized as a psychiatric disorder in the Diagnostic and Statistical Manual (DSM)."

The ACA will assist any parties in their efforts to ensure all Americans are protected from these dangerous and unethical mental health practices, and the association commended the White House for speaking out on this topic [28].

AAMFT has also spoken out against the practice of conversion/reparative therapy. Like the ACA's opinion on the topic, AAMFT's policy, adopted in 2009 by their Board of Directors, states that homosexuality is not considered a disorder that requires treatment, so there is no basis for therapy. AAMFT advises members to conduct therapy based on the best research and clinical evidence available following their Code of Ethics. The following information was obtained from the 2015 AAMFT website, and reprinted on the 2023 website, and shows the commitment and action of the association to support same-sex couples [29]:

AAMFT has joined with the American Psychological Association and other mental health associations in filing briefs in federal court that support the right of same-sex couples to marry under state law. For example, on March 6, 2015, AAMFT, along with the Michigan Association for Marriage and Family Therapy, joined in a brief filed with the U.S. Supreme Court that is in support of parties who are challenging laws in four states that deny the status of marriage to same-sex couples. The purpose of these briefs, known as an amicus brief, is to alert a court of issues relevant to the lawsuit that parties in the lawsuit might not adequately address.

Many professional mental health associations file such briefs concerning issues of importance to their members. These briefs are written by individuals not involved in a legal case who have expertise to offer the court in support of a specific cause.

The NBCC provides the following directives from their code in response to this topic [12,30]:

- 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.

- Counselor educators will practice cultural responsiveness in their teaching, and respect the cultural identity, values, sexual orientation, and gender identity, of their students.

- Sexual Orientation Change Content Restriction: The program content of continuing education providers cannot present or include information promoting Sexual Orientation Change Efforts as a therapeutic method.

13. DUAL RELATIONSHIPS

When reviewing revised codes of ethics, considerable information addresses dual relationships that counselors may have with the client. Mental health professionals must have guidelines, often referred to as boundaries, which are designed to minimize the opportunity for therapists to use clients for their own gain and to ensure the welfare of clients who disclosed confidential information to the therapist. Dual relationships are sometimes referred to as "multiple-role relationships," which occur when the counselor assumes two or more concurrent or sequential roles that involve the client in and out of the professional relationship. The dual relationship may include a second role that could be social, financial, educational, or professional.

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.

BARTERING: A COMMON BOUNDARY ISSUE

Current revisions summarized in this code advise against bartering. These revisions provide exceptions, however, as long as the bartering causes no harm. Therapists generally enter bartering arrangements with clients with good intention of offering services to those with limited finances, yet potential problems may exist. If the intent is to help a client with limited funds, delivering services pro bono, without bartering, may be an option.

Although bartering with the client for goods or services is not directly prohibited, it is not recommended as a customary practice. The therapist should carefully review the ethics code for their association. Some sections include regulations surrounding bartering or inappropriate relationships with clients that refer to trading or exchanging services in lieu of payment but do not use the term "bartering."

There is much disagreement among practitioners about whether or not bartering is ethical. Client services may not equal the monetary value of the hourly rate for therapy. Clients fall further behind in the amount owed for therapy or counseling and may feel trapped or resentful. The quality of barter services might also become problematic as the therapist or the client may feel shortchanged resulting in resentment and damage to the therapeutic relationship.

The exchange of goods, instead of traditional payments, may result in disputes over negotiating the equivalent number of therapy sessions for the bartered goods.

The following list provides general guidelines that are summarized and commonly held from the various ethical codes for mental health practitioners:

- Bartering arrangements create the potential for conflicts of interest and inappropriate boundaries with clients.

- Bartering should occur only in limited circumstances and if it is an accepted practice in the community.

- The mental health practitioner assumes the full burden of demonstrating that this arrangement will cause no harm to the client.

- Bartering arrangements should not put the mental health practitioner at an unfair advantage.

- Bartering agreements should be discussed, and the counselor and client should sign a clear written contract.

Establishing a friendship or a social relationship due to bartering may produce a conflict of interest that impairs objectivity for professional judgment. The dual relationship and/or friendship forms a special interest for the counselor or therapist beyond the professional one. For example, a therapist may hesitate to raise a certain issue with the client who is also a friend due to concerns of damaging the friendship.

SEXUAL DUAL RELATIONSHIPS

One of the oldest ethical mandates in the healthcare profession is the prohibition of sexual intimacies with clients. Clients may suffer reactions similar to victims of rape, spousal abuse, incest, abandonment, and post-traumatic stress disorder. Additionally, feelings of guilt, rage, isolation, confusion, and an impaired ability to trust may occur.

Harm from sexual relationships with the practitioner is universally accepted and easy to prove. There are no credible opinions in the profession that defend sexual relationships with clients.

The codes of ethics for all mental health organizations include established moratoriums, timeframes, and strict regulations concerning sexual contact with clients. The mental health practitioner must review the sections of their association's and employing organization's code of ethics and regulations that govern sexual contact with clients in their entirety.

The following list contains information held in common among major codes of ethics regarding regulations for sexual contact between mental health practitioners and clients:

- Mental health practitioners do not engage in sexual intimacies with current therapy clients/patients.

- Mental health practitioners do not engage in sexual contact with former clients, according to the limits set in their organization's code of conduct.

- Sexual intimacy with former clients is likely to be harmful.

- Even after the appropriate time period allowed in the professional's code of conduct, the burden shifts to the therapist to demonstrate there has been no exploitation or injury to the client or the client's immediate family.

- Whether such contact is consensual or forced, under no circumstances will the counselor engage in sexual activities or sexual contact with current clients.

- Mental health practitioners should not engage in sexual activity with anyone associated directly with the client, such as friends, family members, or colleagues.

The indecency of sexual conduct with clients is widely acknowledged. Clients who sue for damages have an excellent chance of winning their lawsuits if allegations are true. Civil lawsuits by clients in these cases may include the following allegations against practitioners:

- Malpractice

- Negligent infliction of emotional distress

- Battery

- Intentional infliction of emotional distress

- Fraudulent misrepresentation

- Breach of contract

- Breach of warranty

- Spousal loss of consortium

Some state legislators have passed laws that automatically make it illegal for mental health professionals to engage in sexual relationships with their clients. These laws encourage victimized clients to sue.

Clients who sue must still prove the sexual relationship harmed them, but harm is broadly defined as mental, emotional, financial, or physical. Sexual dual relationships will always be clear ethical violations. Nevertheless, these relationships continue to occur.

Counselors and therapists must be aware that even the smallest form of physical contact, or even close proximity, may be perceived as threatening, suggestive, an invasion of privacy, or offensive to some clients. A client who has been sexually assaulted may be revulsed by even a tap on the back; handshake, certain gestures, or close contact may be offensive to certain cultural groups. It may become an ethical boundary violation if it is harmful, rejected by the client, or is determined to be the result of the counselor's personal needs.

14. CONFIDENTIALITY AND DUTY TO WARN

Anyone familiar with the previous 1995 ACA Code of Ethics will notice the omission of "clear and imminent danger" and the substitution of "serious and foreseeable harm" in the revisions. This change was a direct outcome from the legal case Tarasoff v. Regents of the University of California.

This landmark case from 1969 involved a counselor working with a client who admitted he intended to murder his partner. The study of confidentiality in the mental health field must include a thorough review of Tarasoff v. Regents of the University of California. Analysis of the legal case has been the subject of much historical literature in the field of mental health ethics. A brief summary follows.

Prosenjit Poddar, a student from India, was born into the Harijan, or the "untouchable" caste. He came to UC Berkeley as a graduate student in September 1967 and briefly dated a fellow student named Tatiana Tarasoff. Ms. Tarasoff was not interested in a serious, exclusive, relationship, and that during the summer of 1969, she went to South America. Poddar felt betrayed, became depressed, and sought counseling with a psychologist at UC Berkeley University's Health Service Department.

During counseling, Poddar confided his intent to buy a gun and kill his former girlfriend. His psychologist concluded Poddar posed a significant danger. This conclusion came not only from Poddar's statements but also from assessment results that indicated a pathological attachment to Tarasoff. The psychologist consulted with professional colleagues and notified police, both orally and in writing, of his belief that Poddar posed a significant danger to Tarasoff. The psychologist believed that Poddar was suffering from acute, severe, paranoid schizophrenia. The psychologist also told the police of Poddar's plans to shoot and kill Tarasoff. The psychologist requested that the campus police detain Poddar and also requested that the police take Poddar to a facility for hospitalization so that an evaluation under California's civil commitment statutes could be administered in order to commit him as a dangerous person.

Poddar was detained but shortly thereafter released because he appeared rational, and the police believed he was not a significant danger to his girlfriend. Poddar agreed that he would stay away from Ms. Tarasoff, but Poddar then befriended Tatiana's brother and even moved in with him. Poddar stopped seeing his psychologist, and neither Tatiana nor her parents received any warning of the threat he revealed to the psychologist. Poddar carried out his plan and killed Tatiana Tarasoff by stabbing her with a kitchen knife.

Poddar was sentenced to second degree murder for manslaughter and served four years of a five-year sentence. Poddar's original sentence was overturned because the jury was not adequately informed of his mental illness. He was allowed to avoid a second trial by agreeing to return to India, and reports indicate he is married and living happily in India today.

Tatiana Tarasoff's parents sued the psychologist, the University of California, and the health center staff involved in the consultation, as well as the police. Both trial and appeals courts initially dismissed the case because, at that time, no legal basis existed under California law concerning the duty to warn. The Tarasoff family appealed their case to the Supreme Court of California. The court ruled the defendants knew of the danger prior to the tragedy and had a duty to warn Ms. Tarasoff, or her family, of Poddar's potential for significant danger due to his severe mental illness and stated plans to kill their daughter. The family believed that the mental health professionals should have insisted on Poddar's confinement and should have taken steps to ensure he was hospitalized to protect their daughter.

In 1974, the court ruled that the therapists did have a duty to warn Ms. Tarasoff. The defendants and several organizations responded and petitioned the court for a new hearing. This petition was granted, and the second hearing in 1976 resulted in the ruling that released the police from liability. It established, however, that mental health therapists were responsible and placed them under obligation to warn by imposing a duty that they use reasonable care to protect third parties against any dangers posed by a patient.

The ruling included the following indicators on the duty to warn to protect the intended victim [9]:

- If the therapist concludes, or should have concluded based on the professional standards, that the client was a serious, violent danger to society, they had the duty to warn.

- The therapist had an obligation to use reasonable care, based on what he knew, to protect the intended victim from danger.

- Depending on the specifics of the case, the therapist may have had to make numerous contacts to notify and warn the potential victim(s), notify law enforcement, contact medical or psychiatric facilities, or persist in taking all steps necessary to warn and protect.

ETHICAL QUESTIONS: TARASOFF CASE ON DUTY TO WARN

Since the Tarasoff case, many laws and association standards and codes of ethics have changed to mandate the duty to warn. There are still a number of issues to consider related to ethics today:

1. Was the counselor competent to deal with the cultural aspects and the mental health diagnoses?

2. What information concerning cultural contexts existed?

3. Was the counselor competent to deal with dangerous or violent clients?

4. Can the counselor violate this ethical standard of confidentiality if they are no longer seeing the client?

5. What should be done if clients pose a significant danger to others and need therapy but do not return to therapy, placing the client and society at increased risk?

6. What if clients avoid therapy because the therapist may disclose their shared information to law enforcement?

7. What if clients are not forthcoming with their true feelings and intentions because they believe the counselor will disclose them to law enforcement or mental health facilities?

8. What is the responsibility of the therapist or counselor, who believes the client poses a danger, to follow up after a client is released from a facility? For how long?

Hint: To answer these questions, remember what exceptions to confidentiality rules are allowed in HIPAA and association standards in cases of foreseeable harm to self or others.

Resulting court opinions form the basis for a general acceptance of the notion that treating professionals have a duty to protect if they know there are intended victims. This is important and relates to the general principles of beneficence, meaning "striving to benefit," and nonmalfeasance, meaning to do no harm.

In Tarasoff v. Regents of the University of California, it was ruled that if the patient poses a significant risk of violence to another party, the therapist "bears a duty to exercise reasonable care to protect the foreseeable victim of the danger." States differ in their requirements for identifying foreseeable danger or intended victims, as well as the scope or the degree of possible danger. These are important factors to be considered and acted on to protect both individuals and society.

ETHICAL DECISIONS: KEY POINTS FROM THE TARASOFF CASE

The following precedents were set, following this case, that altered legal statutes and professional standards for ethical practice.

- Therapists have specialized knowledge due to the therapeutic relationship of the therapist and client that should inform the duty to protect in this case.

- The Tarasoff case, and cases that followed, support the therapist's duty to warn/protect intended victim(s), not the community at large.

- Counselors must be competent to identify and evaluate clients' potential for violent behavior and assess their potential to commit dangerous acts.

- If a patient poses a significant risk of violence to another party, the therapist "bears a duty to exercise reasonable care to protect the foreseeable victim of danger."

- One standard by which the breach of confidentiality and the duty to warn will be judged is the standard of what a reasonable professional in the community under the circumstances would do. This is supported by laws and professional standards.

- Counselors must be competent to work with clients with those diagnoses that may include violent behavior or refer those clients to other professionals. Counselors and therapists work only within their area of expertise.

- Client records are critical to document that the therapist understood the nature of the situation in relation to the client's diagnosis.

- Counselors must take reasonable steps based on their knowledge of the facts.

- Counselors should consult with colleagues if they are unsure of how to proceed according to their code of ethics and the law of their state.

- A therapist is liable for a negative outcome if their actions fall below the expected level of care.

Only supporting professional standards from the ethics codes are listed subsequently, so the identifying numbers will not be consecutive:

ACA Standards

- B.2.a. Serious and Foreseeable Harm and Legal Requirements. The general requirement that counselors keep information confidential does not apply when disclosure is required to protect clients or identified others from serious and foreseeable harm or when legal requirements demand that confidential information must be revealed.

- C.2.a. Boundaries of Competence Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience.

- C.2.e. Consultations on Ethical Obligations Counselors take reasonable steps to consult with other counselors, the ACA Ethics and Professional Standards Department, or related professionals when they have questions regarding their ethical obligations or professional practice.

- I.1.a. Knowledge Counselors know and understand the ACA Code of Ethics and other applicable ethics codes from professional organizations or certification and licensure bodies of which they are members. Lack of knowledge or misunderstanding of an ethical responsibility is not a defense against a charge of unethical conduct.

NBCC Standards

- 1. Counselors shall perform only those professional services for which they are qualified by training, education, and supervised experience.

- 19. 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.

AAMFT Standard

- 1. Marriage and family therapists do not disclose client confidences except by written authorization or waiver, or where mandated or permitted by law. Verbal authorization will not be sufficient except in emergency situations, unless prohibited by law.

- 3.2 Knowledge of Regulatory Standards. Marriage and family therapists pursue appropriate consultation and training to ensure adequate knowledge of and adherence to applicable laws, ethics, and professional standards.

- 3.10 Scope of Competence. Marriage and family therapists do not diagnose, treat, or advise on problems outside the recognized boundaries of their competencies.

Components of the Tarasoff case judgement were expanded in subsequent cases involving confidentiality, disclosure, informed consent, and duty to warn and protect. It is important to review the state and federal laws and administrative codes for each state of practice for direct or distance counseling. States differ in requirements concerning identifying victims and determining the scope of the danger. The following examples show some of the resulting changes from the case.

- Some cases have recognized the duty to warn all foreseeable victims, not just those clearly identified.

- Legislative and regulatory bodies have attempted to clarify and define this duty across numerous states.

- All 50 states have mandatory reporting requirements for child abuse.

- In cases of communicable diseases, such as HIV, the counselor may attempt to diffuse the risks to the client before making an exception to the confidentiality rule if the level of risk or level foreseeable harm allows it. Examples would be to:

- Have the client present when the partner is notified

- Include this in part of the therapy

- Have the partner or a client voluntarily divulge the disclosure

- Have the parties participate in other partner notification programs.

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.

RECORD ACCESS BY FAMILY MEMBERS

The ACA 2014 Code of Ethics includes exceptions to the confidential information that include end of life care as follows:

B.2.b. Confidentiality Regarding End-of-Life Decisions

Counselors who provide services to terminally ill individuals who are considering hastening their own deaths have the option to maintain confidentiality, depending on applicable laws and the specific circumstances of the situation and after seeking consultation or supervision from appropriate professional and legal parties.

B.2.c. Contagious, Life -Threatening Diseases

When clients disclose that they have a disease commonly known to be both communicable and life threatening, counselors may be justified in disclosing information to identifiable third parties if the parties are known to be at serious and foreseeable risk of contracting the disease. Prior to making a disclosure, counselors assess the intent of clients to inform the third parties about their disease or to engage in any behaviors that may be harmful to an identifiable third party. Counselors adhere to relevant state laws concerning disclosure about disease status.

B.2.d. Court-Ordered Disclosure

When ordered by a court to release confidential or privileged information without a client's permission, counselors seek to obtain written, informed consent from the client or take steps to prohibit the disclosure or have it limited as narrowly as possible because of potential harm to the client or counseling relationship.

The NBCC Code of Ethics provides the following directives [12]:

- 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.

AAMFT includes these sections related to disclosure of information [11]:

1. Standard I: Responsibility To Clients

1. 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.

2. 1.2 Informed Consent
When persons, due to age or mental status, are legally incapable of giving informed consent, marriage and family therapists obtain informed permission from a legally authorized person, if such substitute consent is legally permissible. The content of informed consent may vary depending upon the client and treatment plan; however, informed consent generally necessitates that the client: (a) has the capacity to consent; (b) has been adequately informed of significant information concerning treatment processes and procedures; (c) has been adequately informed of potential risks and benefits of treatments for which generally recognized standards do not yet exist; (d) has freely and without undue influence expressed consent; and (e) has provided consent that is appropriately documented.

2. Standard II: Confidentiality

1. Marriage and family therapists have unique confidentiality concerns because the client in a therapeutic relationship may be more than one person. Therapists respect and guard the confidences of each individual client.

2. 2.1 Disclosing Limits of Confidentiality.
Marriage and family therapists disclose to clients and other interested parties at the outset of services the nature of confidentiality and possible limitations of the clients' right to confidentiality. Therapists review with clients the circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. Circumstances may necessitate repeated disclosures.

3. 2.2 Written Authorization to Release Client Information.
Marriage and family therapists do not disclose client confidences except by written authorization or waiver, or where mandated or permitted by law. Verbal authorization will not be sufficient except in emergency situations, unless prohibited by law.

4. 2.3 Client Access to Records.
Marriage and family therapists provide clients with reasonable access to records concerning the clients. When providing couple, family, or group treatment, the therapist does not provide access to records without a written authorization from each individual competent to execute a waiver. Marriage and family therapists limit client's access to their records only in exceptional circumstances when they are concerned, based on compelling evidence, that such access could cause serious harm to the client. The client's request and the rationale for withholding some or all of the records should be documented in the client's file. Marriage and family therapists take steps to protect the confidentiality of other individuals identified in client records.

15. CASE STUDIES

The following section summarizes case studies and includes legal judgements and rationales. This information should not be construed as legal reference material or guidance. Professionals should always seek the assistance of their professional association and consult employing agency legal counsel for any questions regarding ethical/legal issues.

REPARATIVE/CONVERSION THERAPY

During the third session of counseling, a 30-year-old client reported that he was gay and stated that he no longer wanted to follow this lifestyle. He wanted to participate in conversion therapy so that he no longer felt an attraction to men. His goal was to become attracted to a woman and have a traditional marriage with children.

At the suggestion of a friend, the client read about reparative/conversion therapy and researched the approach on the Internet. Even after his research, he was convinced this is the route he wants to take.

The counselor listened and asked questions in a clinically appropriate manner. The counselor informed the client that although she felt that she could be effective in counseling with him, she could not ethically engage in reparative/conversion therapy and felt it would not be effective in reaching his desired goals. She explained that she could find no scientific evidence or support for the approach; she even consulted her association, who advised her that it was not a supported form of therapy. The client understood but indicated he was disappointed that the counselor could not help him through that type of counseling.

He then asked for a referral to another counselor or therapist who would help him change his sexual orientation and reach his goals. Ethical question: Should the counselor make a referral for conversion therapy?

Analysis

The ACA Ethics Committee considered many factors and arrived at a consensus opinion that addressed several sections of the Code of Ethics and moral principles of practice presented in this scenario.

They started with the basic goal of reparative/conversion therapy: to change an individual's sexual orientation from homosexual to heterosexual. Counselors who conduct this type of therapy view same-sex attraction and its behavior as abnormal, unnatural, or immoral. They also believe that a change, or a "cure," can be achieved through the use of therapy.

The belief that same-sex attraction and behavior is abnormal and in need of treatment is in opposition to the position taken by national mental health organizations, including the ACA, APA, and AAMFT. The ACA Governing Council resolution specifically noted that the ACA opposes the portrayals of lesbian, gay, and bisexual individuals as mentally ill due to their sexual orientation. This resolution supported dissemination of accurate information about sexual orientation, mental health, and appropriate interventions and instructed counselors to report research accurately and in a manner that minimizes the possibility that results may be misleading.

The ACA found that the majority of the studies on this topic had been expository in nature and had no scientific evidence published in psychological peer-reviewed journals that stated the effectiveness of conversion therapy. They did not find any longitudinal studies conducted to follow the outcomes of those individuals who had engaged in this type of treatment. They concluded that research published in peer-reviewed counseling journals indicated that conversion therapy may harm clients.

These findings bring several questions to the forefront:

1. Is a counseling professional who offers conversion therapy practicing ethically?

2. Since ACA has taken the position that it does not endorse reparative therapy as a viable treatment option, is it ethical to refer a client to someone who does engage in conversion therapy?

3. If the client insists on obtaining a referral, what guidelines can a counselor follow?

4. What are the conditions that allow the professional counselor to refer this case to another counselor?

ACA committee members agreed that it is of primary importance to respect the client's autonomy to request a referral for services which are not offered by the counselor. If counselors determine an inability to be of professional assistance to clients, they avoid entering or continuing the counseling relationship. Counselors act to avoid harming their clients, trainees, and research participants and to minimize or to remedy unavoidable or unanticipated harm [10].

Referring a client to a counselor who engages in a treatment modality not endorsed by the profession may in fact cause harm, does not promote the welfare of clients, and opposes the basic purpose of the code.

There is no professional training condoned by ACA, ACA, AAMFT, APA, or other prominent mental health association that would prepare counselors and therapists to provide conversion therapy. Additionally, all professional associations and related mental health agencies have spoken out against any form of conversion therapy or counseling. The counselor or therapist would be practicing outside the boundaries of their expertise because there is no professional training for conversion therapy. This would violate the ethics code.

The ACA Code requires counselors to "recognize history and social prejudices in the misdiagnosis and determination of pathology of certain individuals and groups and the role of mental health professionals in perpetuating these prejudices through diagnosis and treatment" [10].

Today, some religions and segments of the population in the United States continue to view same-sex relationships as immoral sexual behavior that is pathological, sinful, and in need of therapy and counseling. In the past decade, increasing acceptance of same-sex lifestyle choices has been noted, including the number of states that recognize marriages between same-sex partners.

Referring a client to someone who engages in conversion therapy signifies to the client that same-sex attraction and behaviors are deviant and need to be changed. This would violate the ACA Code of Ethics, The AAMFT Code of Ethics, the NBCC Code of Ethics, and the APA Diagnostic and Statistical Manual; therefore, the ethical decision would be to refuse the referral request.

DUAL RELATIONSHIPS

Case 1

A professional artist complained to an ethics committee that his therapist's actions caused him stress and anxiety when she did not carry out her promises. The therapist had treated the artist for over one year, during which time the therapist complimented the client's artwork, attended art shows with him, and promised to introduce her art gallery contacts to her client. The client stated he began to feel so self-confident that he terminated therapy and expected the therapist's interest in his career to continue. The therapist stopped returning the ex-client's phone calls, which left the client frantic. An ethics committee contacted the therapist. She explained that she always provided unconditional positive regard to her clients; however, since this particular individual was no longer a client, she felt no further obligation to him.

Analysis

The ethics committee found in favor of the client. They determined that the therapist had maintained a dual relationship by combining their professional and private lives outside of counseling together. This caused confusion and harm to the client, and the therapist did nothing to resolve the client's distress and dependency and chose to ignore him, which increased his anxiety.

Case 2

The therapist and her ex-client decided they would become friends because the past therapeutic relationship was very harmonious. A month into the friendship, the ex-client perceived that the therapist was controlling and overbearing in their new relationship. He then questioned the therapist's overall competence and stability, to the point of distancing himself from the post-therapeutic friendship. The ex-client decided that the therapist had caused him to feel exploited, hurt, and confused. He then consulted another therapist who advised him to press charges against the previous therapist.

Analysis

An ethics committee determined that incompetence could not be conclusively proven; however, both the complainant and respondent were surprised by the findings of a dual role violation.

The investigation uncovered that the therapist planned their developing relationship and a longer-term continuation while the client was still in active therapy. The therapist had actually presented these facts as a defense against the client's accusations.

This case shows how personas may change from one context to another, and the resulting change may be viewed as negative. The client responded well to the therapist's authoritative personality in therapy but not in a social context. This case shows the problems that occur when personal and professional boundaries are crossed and the resulting ethical issue that harmed both client and counselor.

Case 3: Bartering

A counselor provided services to a man with anxiety that adversely affected his work and personal life. He eventually lost his job and his health insurance due to his anxiety. The counselor agreed to hire the client to do maintenance on his house and yard work to help him earn some money while he looked for a job. The counselor paid him minimum wage but continued the counseling sessions at no charge. A month later, the man attempted suicide and was admitted to an inpatient mental health facility. He was assigned to a psychiatrist who learned of the exchange of work for counseling services. The psychiatrist questioned the ethics of the relationship and considered it a boundary violation and an inappropriate dual relationship that caused harm to the client. He reported it to the state licensing board, and they opened an investigation.

Analysis

The therapist was not paying the fair market value for the labor being performed, so the relationship was not a beneficial one for the client, even though he was able to continue counseling for free. The quality and the effectiveness of the counseling services were called into question in light of the firing and subsequent suicide attempt.

The ethics committee ruled in favor of the client.

Professional liability insurance policies may exclude coverage pertaining to business relationships with clients. Liability insurance carriers may view bartering arrangements between mental health professionals and clients as business relationships and therefore refuse to defend a covered therapist if complications arise in therapy that leads to litigation. Bartering arrangements have the potential for client exploitation, impaired professional judgement and objectivity, conflicts of interest, damage to the therapeutic relationship, and unsatisfactory outcomes to both parties.

Case 4: Sexual Boundary Violation

A therapist had delivered services to a client for two months and felt an attraction to her. He decided to invite her to go with him to a presentation on autism because her nephew had been recently diagnosed with the disorder. The client believed that it was not a date but rather an educational event, so she accepted. After the lecture, they went to dinner at the invitation of the therapist.

When the client went to the next therapy session, she was given a DVD for the nephew that was produced by the speaker from the presentation. Following a subsequent therapy session, they again went to dinner, and after a few drinks, they returned to the client's house, where they engaged in sexual intercourse. The relationship continued for a month and ended when the therapist started dating a previous girlfriend again.

The client was hurt and angry. She ended the therapy sessions and brought a malpractice suit against the therapist on the grounds that he was unprofessional and that the relationship violated professional boundaries. She claimed that the relationship caused her such mental distress that she was unable to sleep, which subsequently affected her work. The review board ruled in favor of the client and awarded a large damage award as a result of her civil malpractice complaint.

Analysis

The therapist has the burden of proving that no exploitation took place in relation to the client's mental status and severity of their presenting issues, the ability to comprehend the risk, a level of independence, and the autonomy to act in their best interest. As a professional with inherent power in the relationship due to the potential to coerce or influence a client, therapists may have difficulty defending themselves against a claim of sexual misconduct Any diagnosis, such as depression, previous abuse, or various personality or emotional disorders, suggests vulnerability or susceptibility to exploitation and would influence the case against a therapist The therapist or counselor must, in all ways, put the client's welfare above his or her own. Sexual relationships with current, former, or potential clients are always an ethical violation.

DUTY TO WARN

Case 1

M.K. was a 15-year-old client of a New Jersey psychiatrist for two years. The client was open with the therapist about his use of illegal drugs and his violent thoughts about a fantasy to threaten people with a knife to control and rob them. He also told the therapist about his sexual relationship with a 20-year-old neighbor. It was clear that he had a strong emotional attachment to the young woman; however, M.K. often expressed his anger and jealousy that the woman was dating other men.

The therapist observed that M.K. showed symptoms of severe anxiety when he spoke of the woman. In a subsequent session, M.K. told the therapist that he once fired a BB gun at her car as she drove by his house.

M.K. stole a prescription pad from the therapist and attempted to forge his signature in an attempt to purchase 30 Xanax pills. The pharmacist noticed that M.K. was acting suspiciously and, because of his age, called the therapist. The therapist told the pharmacist to disregard the prescription, and M.K. went home. He later stole a gun and shot the young woman to death.

The therapist had attempted to reach M.K. by phone to discuss the stolen prescription forms but did not reach him before the woman was shot. The woman's father had heard of the Tarasoff case, and the family hired an attorney to bring a civil suit against the therapist. The suit charged him with the wrongful death of their daughter and his failure to warn and protect her.

The therapist hired an attorney who argued to dismiss the suit claiming that the Tarasoff principle should not apply in New Jersey based on the following:

- The ability to predict danger is unreliable.

- Violating the client's confidentiality would have interfered with effective treatment.

- Instituting the Tarasoff principle might deter therapists from treating potentially violent patients.

- A ruling on the Tarasoff principle could lead to unwarranted commitments to institutions.

Analysis

The court rejected all these arguments and declined to dismiss this case. The court instead ruled that the duty to warn is valid under New Jersey law. The court decision stated that even though therapists could not be expected to accurately predict danger or harm in 100 percent of the situations, they have the ability to make a professional judgment in the relationships of the client with others. This therapist observed several warning signs, and the client's own statements and actions of a violent nature should have provided the therapist with enough evidence to decide that a warning concerning the potential of danger was in order.

The court made an analogy and compared the situation with the responsibility to warn communities and individuals about carriers of a contagious disease. The court stated that the client/therapist confidentiality must be secondary to the greater welfare of the community. In cases of imminent or potential danger, the therapist has the duty to warn. The therapist faced the jury and was not held liable for damages, but the Tarasoff principle of duty to warn and protect was adopted in New Jersey.

Case 2

A PhD and marriage and family therapist (MFT) had treated a client, a former policeman, for three years. The therapy centered on work-related injuries and the breakup of a 17-year relationship with a woman who began to date someone else. The client allegedly told the therapist that he was having suicidal thoughts in early June. The therapist recommended hospitalization and asked for permission to speak with the client's father. The father told the therapist that his son was deeply depressed, had lost his desire to live, and had mentioned harming the man his former girlfriend was currently dating.

The client checked himself into the hospital as a voluntary patient on June 17. The therapist received a phone call from the client's father the next morning stating that the hospital would soon release his son. The therapist then called the admitting physician and urged him to maintain the client's hospitalization for further observation through the weekend. The psychiatrist disagreed and released the client. The client did not contact his therapist after he was released from the hospital.

No one from the hospital contacted the therapist after releasing the client. On June 23, the client shot the boyfriend of his ex-partner and then killed himself with the same handgun.

The parents of the new boyfriend filed a wrongful death lawsuit and named the therapist as one of the defendants. The lawsuit claimed the therapist had a duty to warn their son of the risk from the client. A judge dismissed the case against the therapist, who asserted that his client did not disclose a threat to the new boyfriend directly to him.

Ultimately, the California Court of Appeals reinstated the case, explaining, "When the communication of a serious threat of physical harm is received by a therapist from the patient's immediate family and is shared for the purpose of facilitating and furthering the patient's treatment, the fact that the family member is not technically the patient is not crucial."

Analysis

The court expressed that psychotherapy does not occur in a vacuum and that for therapy to be effective, therapists must be aware of the context of a client's history and their personal relationships. The court advised that communications from clients' family members in the context comprised a "patient communication." Mental health professionals, however, must use caution when accepting the warnings of third parties, such as parents or spouses, who are emotionally involved as they may have ulterior motives. This ruling required that if the therapist determines that individuals have credible information, then that constitutes patient communication and necessitates the duty to warn.

RECORD ACCESS BY FAMILY MEMBERS

Case 1: Record Access by Family Members

D.C. battled cancer for many years and received the assistance of a counselor on several occasions. She did not have regularly scheduled sessions, but D.C. would consult the counselor when she faced medical issues and treatments that intensified her anxiety and depression.

During a planned surgery, there were complications, and D.C. had to be resuscitated. This left her in a coma on life support. Her physicians informed her family of the possibility that she would remain on life support and her prognosis for recovery was bleak, at best. Members of her family decided to approach the court for authorization to take D.C. off of life-support.

The family was instructed by the court to locate any information they could find that would shed some light on D.C.'s wishes concerning end-of-life issues. The family asked the counselor if any of the records from her counseling sessions might help to provide some guidance to the court concerning D.C.'s end of life plans in order to make decisions about her treatment. The counselor refused and decided to consult a colleague. The family turned to the court for an order to compel the counselor and the counselor's colleague to release all information and communication concerning D.C.'s end-of-life wishes. The courts issued a subpoena for all records and communications. The counselor eventually complied to avoid sanctions by the court.

Analysis

Family members have many reasons to seek access to the records of other family members. Some are legitimate; others have the potential to harm the client or lead to an ethical violation if mistakes are made in disclosing information to the wrong party.

In this situation, the client was incapacitated and could not make her wishes known. In these cases, the courts recognize a surviving line of consent as follows:

- The first in line in the chain to grant consent is the spouse. This is true even if they are estranged and living apart, but not divorced.

- Next would be the children of legal age: each child would be given equal weight in the decision.

- Next are parents or grandparents, followed by siblings, each having equal weight.

- If there are no family members, the courts may appoint the next closest relative or close friend.

The ethics codes are clear that in cases with clients who are minors, or clients who meet criteria as legally incompetent, that parents or legal guardians will be given full access to records. Therapists must understand the complex nature of confidentiality, informed consent, and privacy when serving minors and their families. Even if a client is a minor or is incompetent to understand at the expected level, the therapist should make every attempt to communicate in a way that can be understood at their developmental or cognitive level.

The practitioner must be sensitive to the needs and feelings of these clients and must realize that the client may understand more than is readily apparent or may have an inability to respond. At the beginning of any counseling or therapeutic relationship, each member should receive information about confidentiality in the treatment relationship. A legal parent or guardian must be established before services begin so that the practitioner knows who may be contacted, consulted, and involved in the client's treatment.

Counselors and therapists may be reluctant to provide access to records and notes to clients, parents, and guardians because they may believe they will not understand or may misconstrue the information. Misunderstandings could cause harm to the client, impede the treatment plan, or result in a lawsuit. The ethics codes of the NBCC, AAMFT, and ACA provide guidelines concerning the rights of the client and the obligation of the provider in this area. When information is shared, the practitioner must take the time to be sure the client understands the information and must involve interpretation and explanation. Records should never be turned over to the client or guardian without a conference that includes all parties that have any legal authority to review the information so that the therapist or counselor can explain the contents and answer questions.

Case 2: Privilege Applied to Child Safety and Custody

The laws that govern mandatory reporting of child abuse will always take precedence over client privilege laws in all states. In cases of child abuse or neglect, the therapist or the counselor may be compelled to testify in court for the welfare of the child.

The following case from the Alabama Supreme Court (Marks v. Tenbrunsel) demonstrates these important facts [31]:

- Client Marks consulted a psychologist, Dr. Tenbrunsel, for mental health services. It was the client's understanding that anything he shared with the therapist would be confidential information that would never leave the office. He believed the therapist told him that there would be protection under client privilege when they initially met.

- During a subsequent therapy setting, Marks confided that he had sexually abused two girls under the age of 12 years.

- The therapist consulted a professional colleague and made the decision to tell Marks that as a mandated reporter he was compelled to report the incident to child protective services and that the confidentiality agreement would be void in this case.

- Marks alleged malpractice, hired an attorney, and filed a civil case against the therapist as well as the colleague he consulted. He also claimed in the lawsuit that the therapist caused him to be prosecuted, lose his job, suffer mental anguish, and ruined him financially.

- The therapist's counsel filed a motion to have the case dismissed, which was granted. Marks appealed the judgment of dismissal; however, the Alabama Supreme Court upheld the dismissal.

Analysis

The court, after reviewing rulings in other cases, found when a person issues a report of child abuse or neglect in good faith, or is called to testify in the judicial process related to the report, the person would have "immunity from any liability, civil or criminal, that might otherwise be incurred or imposed."

The court stated, "because Marks admitted to the abuse of the two children the psychologists had reasonable causes to suspect that children were being abused and therefore were acting in good faith when they determined that a report should be made."

In the review of other cases, the court found decisions that the psychotherapist-client privilege was second to the child abuse reporting statute and that child abuse statutes, "vitiated the privilege and the therapist could be compelled to reveal the alleged sexual abuser's medical records in a civil action for damages."

The court found, in most cases, that the child abuse reporting statute abrogates a privilege that may otherwise be applicable with respect to proceedings involving child abuse or neglect.

Some states allow information in the report of child abuse to be disclosed, along with all other privileged information; others simply act on the fact that the report was made and substantiated in these cases of privilege brought against the therapist or counselor. For prosecution of the alleged abuser, all privileged information would be discovered.

In situations of child custody, there are a number of positions of privilege taken by the courts depending on the jurisdiction. Some courts will deny privilege to allow every piece of information to be reviewed to make the best possible custody decision. Some courts will strictly adhere to rulings of privilege. The courts will have to resolve any conflicts that may result based on these two positions and the circumstances of each case.

In cases of custody disputes, the mental health of one or both parents and the effects that this may have on the child may come into question. The court will decide based on the particular evidence regarding the mental health of the parents or the child. Again, states vary on their positions of privilege in these cases depending on the severity of the mental health issues of the parents or child. Today, states recognize privilege in the relationships of clients and mental health practitioners. Counselors and therapists should consult state statutes or case law in the state of their licensure and/or jurisdiction of practice to be familiar with the concept of privilege in their state.

Case 3: Court Access to Records

J.D. is a licensed MFT who found herself in an ethical dilemma when faced with a court order to release certain client records from her files. J.D. refused to release treatment notes as ordered by the courts as part of a custody dispute involving a young client. She believed that there were two exceptions to the confidentiality and client privilege, including knowledge of child abuse or if the client threatens suicide or homicide.

J.D. stated that the notes were sometimes just phrases of her interpretations, thoughts, and topics to refresh her memory and would not be understood by anyone but herself. She believed that it was unethical to disclose her notes and decided to provide only a general summary. The attorney brought the summary to the judge who issued an order for the complete set of notes, but J.D. decided to defy the court order.

J.D. was arrested and fined $2,000 on a contempt charge, which cost her $900 in bail in lieu of being incarcerated. In the end, J.D. decided to disclose the notes to the court.

Analysis

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.

If the therapist is ordered to testify and the client requests that the therapist should not disclose privileged information, the therapist may explain to the court the possible harm to the therapeutic relationship if a disclosure is made. If the judge requires the therapist to testify, they should disclose only the information related to the request. Under court order, the counselor or therapist is not in violation of privacy rules or privilege because they are complying with the judge's order. The court order is defense against any charge of ethical wrongdoing if the counselor is later sued over a breach of confidentiality.

16. SUMMARY OF THE HEALTH INSURANCE PORTABILITY ACCOUNTABILITY ACT (HIPAA) PRIVACY RULE

The Standards for Privacy of Individually Identifiable Health Information established a set of national standards for the protection of certain health information. The U.S. HHS issued the Privacy Rule to implement the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

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.

HIPAA also includes standards for individuals' privacy rights to understand and control how their health information is used. A major goal of the Privacy Rule is to ensure that individuals' health information is properly protected while allowing sharing of health information to provide high-quality health care and to protect public health.

Therapists and counselors must adhere to directives of the HIPAA Privacy Rules that apply to all healthcare providers. The rule permits the use of information, while protecting the privacy of people who seek care and treatment. Psychotherapy notes are treated in a different way from other records under the HIPAA Privacy Rule. According to HIPAA:

"Psychotherapy notes" means notes recorded, in any medium, by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

Release of this information requires a HIPAA compliant release form signed by the client with a few exceptions:

1. To carry out the following treatment, payment, or health care operations:

1. Use by the originator of the psychotherapy notes for treatment;

2. Use or disclosure by the covered entity for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or

3. Use or disclosure by the covered entity to defend itself in a legal action or other proceeding brought by the individual; and

2. A use or disclosure that is required by another law, such as reporting abuse or disclosures to avoid harm to patient or others.

The mention of "another law" exception covers the mandatory duty to report child abuse in all 50 states and the laws governing duty to warn.

Counselors should be aware that 2013 brought important changes to HIPAA and that September 23, 2013, was the compliance deadline for many of these regulatory requirements. Any counselor or therapist who is not sure if they are considered a "covered entity" under HIPAA should immediately access the online decision-making tool available at the website of the Centers for Medicare and Medicaid Services. All counselors who are covered entities should move quickly to come into compliance or risk very stiff monetary penalties [10].

With more than 800 pages, the entire HIPAA document and Privacy Rule is extensive. Covered entities regulated by the rule are obligated to comply with all of its requirements and should not rely on this summary as the source of legal information or advice. Professionals should receive specialized training and continuing education on HIPAA regulations related to their practice. To view the entire rule, and for other information about how it applies, review the website at https://www.hhs.gov/hipaa/for-professionals/privacy/index.html.

17. GLOSSARY

Professional counseling and marriage and family therapist associations, such as the NBCC, ACA, and AAMFT, have terms and definitions in common that are seen throughout their ethical codes. Some of the most commonly used terms and their definitions are as follows:

Abandonment: The ending or termination of a counseling or therapeutic relationship that harms a client or puts the client at risk.

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.

Assent: Actions that indicate or demonstrate agreement when a person is not capable or competent to give informed consent.

Bartering: Goods or services that are accepted from clients in exchange for counseling or therapy services.

Client: Individuals or groups at the point where they make contact and ask for services.

Client record: The paper or electronic system containing all information gathered and stored throughout service delivery. This may include written, electronic audio, and video records.

Clinical supervision: Guidance, mentoring, education, coaching, and monitoring by a practicing professional to enable the development of professional skills and facilitate learning in application of skills to practice settings.

Competency: Therapists and counselors provide services only within the boundaries of their expertise based on education, training, license, certification, and experience.

Confidentiality: The ethical duty of counselors to protect client identity, communications, or any information related to the relationship with clients.

Consultation: A professional collaboration that includes advice, information, assistance, support, or testimony. The codes promote professional consultation.

Counseling: A professional relationship that aids diverse individuals, families, and groups of all ages to enhance mental health, wellness, education, and career goals.

Counselor educator: A professional counselor engaged in developing, implementing, supervising, monitoring, and evaluating the educational preparation of professional counselors.

Counselor services agreement: Written document that informs the client of the terms and conditions of the counseling or therapeutic service. It includes potential benefits and risks.

Counselor supervisor: A licensed, practicing counselor in a formal professional relationship with a student counselor or a counselor-in-training to oversee the individual's counseling work or clinical skill development.

Culture: The customary beliefs, social norms, institutions, behavior patterns, values, and lifestyles of a particular community or group.

Deceptive methods: Any methods used in which clients are unaware, misinformed, or denied informed consent.

Digital technology: Digitized information recorded in a binary code of combinations of the digits 0 and 1, called bits, which represent words and images. Digital technology enables immense amounts of information to be compressed on small storage devices that can be easily preserved and transported including the Internet, digital mobile devices, and systems used in communication and social media.

Discrimination: To make distinctions or to differentiate based on preference or prejudicial views of an individual or group.

Distance counseling: The therapeutic or counseling services delivered without physical proximity to the client by using technology as the point of access.

Diversity: The differences and distinct qualities within cultures and social groups.

Documents: Written, digital, or audio/visual records of client information within the counseling or therapeutic relationship with clients.

Encryption: Process of encoding information to protect identity and to block access by unauthorized parties.

Examinee: The client who is being assessed for the purpose of determining psychological, educational, or developmental levels to inform the counseling or therapeutic process.

Exploitation: Unethical actions for one's own advantage.

Fee splitting: The division of payment for referrals or services.

Forensic evaluation: An assessment to inform professional knowledge to prepare for testimony legal proceedings. These reports do not fall under HIPAA guidelines and may cover evaluations for determining child custody decisions, competency to stand trial, and criminal culpability.

Harmful multiple relationships: Relationships developed outside of the professional relationship that do not protect the welfare of the client and erode the ethical practice of counseling and therapy.

Implicit bias: Also called implicit prejudice, is a negative attitude, of which one is not consciously aware, against a specific social group [32].

Impairment: Diminished strength, value, fitness, and quality that renders the professional incapable of delivering ethical services to clients.

Informed consent: A process of advising clients on all aspects of the counseling or therapeutic process prior to services. This includes all benefits, risks, rights and responsibilities, and explanations required by the client to understand all phases of the treatment and decide to consent or to decline the service. Adjustments may be required as the service progresses so consent must be revisited.

Intellectual property: An original work, invention, or creation to which one has the rights of ownership.

Interdisciplinary teams: Teams of professionals who collaborate to serve clients from a variety of applicable areas of expertise. The team should agree with the counselor and therapist regarding confidentiality.

Marriage and family therapist: Marriage and family therapists (MFTs) are mental health professionals trained in psychotherapy and family systems and licensed to diagnose and treat mental and emotional disorders within the context of marriage, couples, and family systems.

Minors: Individuals younger than 18 years of age; however, this age will vary according to state statutes. In some jurisdictions, minors may have the right to consent to counseling or therapy independent of a parent or a guardian.

Multicultural/diversity competence: An approach to counseling or therapy from the context of the personal culture of the client.

Multicultural/diversity counseling: Professional services that accommodate differences in religion, spirituality, sexual orientation, gender, age and maturity, socioeconomic class, and family history and emphasize the worth, dignity, potential, and uniqueness of individuals.

Non-counseling relationships: All relationships that exist outside of the context of the professional counseling practice.

Personal virtual relationship: A relationship that exists through technology or social media that is outside the professional boundaries for therapy or counseling. These relationships should be avoided as they may lead to unethical practices.

Privacy: The right of an individual to control their personal information to avoid unauthorized disclosure.

Privilege: A legal term denoting the protection of confidential client information in a legal proceeding, including subpoena, deposition, and testimony.

Pro bono publico: Contributing professional services without regard for financial gain.

Professional virtual relationship: Using technology and/or social media in the delivery of professional, ethical services to clients.

Psychosocial: Interrelation of social factors with individual thoughts and behaviors.

Records custodian: The person responsible for keeping records in an ordinary course of practice. In some organizations, the custodian is responsible for the accuracy and the security of records, as well as adherence to all ethical guidelines and legal requirements.

Self-growth: A process of self-examination and professional development to enhance professional competence.

Serious and foreseeable: A concept used in negligence tort law to limit the liability of a party to those acts that carry a risk of foreseeable harm, meaning a reasonable person would be able to predict or anticipate the harmful consequence of their actions.

Sexual harassment: Unwanted and offensive physical, verbal, or nonverbal sexual conducts in a workplace, professional, or social situation.

Social justice: Equity for all people, including the distribution of wealth, opportunities, and privileges within a society to end oppression and to provide access to communities, schools, workplaces, governments, and other social or institutional systems.

Social media: Websites and applications that enable users to create and share content, communicate, or participate in social networking.

Subpoena duces tecum: A writ ordering a person to appear before the court and bring relevant documents and other tangible evidence for use at a hearing or trial.

Telemental health: Counseling and therapy services delivered through two-way electronic communication including but not limited to telephone, videoconferencing, email, text, and instant messaging.

18. RESOURCES

American Association of Marriage and Family

https://www.aamft.org/AAMFT/Legal_Ethics/Code_of_Ethics.aspx

American Counseling Association

https://www.counseling.org/docs/default-source/default-document-library/ethics/2014-aca-code-of-ethics.pdf

American Mental Health Counselors Association

https://www.amhca.org

American Psychological Association

https://www.apa.org/ethics/code

Association for Child and Adolescent Counseling (ACAC)

https://acachild.org

Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC)

https://www.counseling.org/about-us/governance-bylaws/candidate-profiles/divisions-and-regions/association-for-lesbian-gay-bisexual-and-transgender-issues-in-counseling

Association for Multi-Cultural Counseling and Development

https://www.multiculturalcounselingdevelopment.org

HIPAA Privacy Rule

https://www.hhs.gov/hipaa/for-professionals/privacy/index.html

International Association of Marriage and Family Counselors (IAMFC)

https://www.iamfconline.org

National Board for Certified Counselors

https://www.nbcc.org

19. CONCLUSION

Clearly the major counseling and therapy associations and regulatory divisions agree on the standards, principles, and guidelines that dictate and govern ethical practice.

Today, ethical practice requires competence that goes beyond basic professional foundational standards and involves knowledge of ethical decision making, multicultural awareness and sensitivity, self-awareness to address implicit bias including microaggressions, telemental health practices, ethics codes, and state and federal laws that are continuously evolving.

It is the counselors' and therapists' obligation to stay current with research and revisions in the knowledge, guidelines, and laws that govern their profession.

Many resources are available, and the professional must rely on colleagues, supervisors, associations, and state and local agencies for collaboration on decisions to address complicated ethical dilemmas that may arise. There are no codes or guidelines to address every ethical issue a professional may face, and no decision-making model will apply to all cases. The practitioner must be familiar with the procedures of decision making and include the client when possible to build rapport and participation in the counseling or therapy process.

In addition to collaboration with other professionals, there are case studies, legal statutes, state administrative codes, and considerable research to consider when making ethical decisions. Always apply tests to evaluate the decision before putting the plan into action.

Best practice to ensure the delivery of ethical service relies on the professional acquiring competencies to deliver new methods of telemental health services, continuing self-awareness, knowledge of changing cultures and family dynamics, and culture-fair assessment to inform practice. The professional must continually evaluate their services to ensure they are delivering ethical practice. Every action must be based on the primary focus of client welfare that includes identification of foreseeable harm and taking appropriate measures for prevention.

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