Board notifying her of a lengthy complaint from a former client that they were investigating. As she outlined the various complaints and defenses, I told her it sounded as if she might have all but one of them dropped against her.
I told her that the dual relationship charge might be difficult to defend, and she was silent on the other end of the line. She knew she was in trouble here, but for all the wrong reasons. She had befriended the client early on in their relationship, taking her to lunch, inviting her to church, even inviting her into her home on occasion. My friend never imagined that the therapeutic relationship would turn sour, with her client accusing her of manipulation and taking control of her life. She complained that this is exactly what her client was doing to her, and when she resisted her demands to be available 24-7, the client got angry and filed a complaint.
Ethics can be understood as values in action. They are the practical rules and boundaries that guide our professional or ministerial behavior. Regulatory or statutory law can be distinguished by a set of codified ethics that are deemed so important by a particular state or the federal government, that civil and criminal penalties have been ascribed to them when these rules are broken. Various professional organizations such as the American Psychological Association, the American Counseling Association, the National Association of Social Workers, the National Association of Alcoholism and Drug Abuse Counselors, and the American Association of Marriage and Family Therapy, to name a few, have all established a comprehensive code of ethics to which members must strictly adhere.
Every year, licensing boards across the country investigate and process a number of different ethical and practice violations as complaints are filed against practitioners. Due to an upward trending of ethical misconduct, most states that now require Continuing Education Units for mental health practitioners specifically mandate that a certain number of contact hours be devoted to this critical area. Conducting oneself in an ethical manner, therefore, becomes an important task for any competent clinician. Christian leadership flows from core values such as compassion, sacrifice, stewardship, and servanthood, which when taken together, help define our moral and ethical compass.
Every year since 1991, the American Counseling Association has summarized and published the activities of their ethics committee. Many similar organizations, including state licensing boards, record and track ethical violations as well as the official rulings that are adjudicated from their investigative processes. Additionally, most boards that produce periodic newsletters to their constituencies frequently include a descriptive section on actual violations. This is often viewed as a potentially effective deterrent to practitioners since most founded violations eventually become a matter of public record.
Ethical violations typically fall into several general categories. These include, but are not limited to, sexual misconduct or other dual relationships, conflict and misuse of counselor influence, intentional harm or fraudulent practice, wrongful termination or abandonment of a client, failure to maintain confidentiality, improper documentation or handling of client records, and practicing outside the scope of ones education, training, or experience. The relatively recent HIPAA (Health Insurance Portability and Accountability Act) guidelines remind practitioners of the need to stay current with new laws and regulations. Nevertheless, the most common of these violations continue to occur in the area of dual relationships, especially sexual misconduct.
It has been estimated that somewhere between 5-10% of all psychotherapists in the United States have engaged in some form of sexual or erotic contact with their patients or clients (more than half of those have multiple incidents). Recently the American Association of Pastoral Counselors reported that malpractice claims against its insurance trust have significantly risen and subscribers now face major premium increases as a result (two thirds of the claims involved charges of sexual misconduct). Over 50% of all lawsuits and licensure revocation actions against counselors in the United States are for sexual misconduct. Plaintiffs routinely win over two thirds of the lawsuits that are subsequently filed.
Many states have criminalized sexual misconduct and it has become a major trend nationally. Nearly all insurance companies impose caps on damages and some are even refusing to cover these claims at all, leaving damage awards to be paid solely out of the personal or corporate assets of the violator or employer. This legal response is based on the reality that only one to five percent of victims typically report the misconduct and less than 10% of this small group will actually file suit and seek legal redress.
Consequences for serious violations can include any of the following sanctions by a regulatory agency: a revocation (the license or registration is canceled and the right to practice is ended); a suspension (the respondent is prohibited from practicing for a specified period of time); or a stay (revocation or suspension is postponed and the respondent is put on probation). Beyond these measures, criminal charges may be filed depending on the nature of the violation and clients sometimes also pursue available civil remedies. The counselor may be asked to complete additional coursework or training, enter into personal therapy, or maintain a certain level of clinical supervision before seeking reinstatement. The costs for reinstatement vary and can run into thousands of dollars with professional liability insurance rates usually increasing substantially as well.
While variation does exist between various state regulations and ethical codes of professional associations, there is nevertheless clear consistency on the inappropriateness of intimate or sexual relationships with current clients (American Counselors Association Code of Ethics, Section A.6; American Psychological Association Code of Ethics, Sections 4.05 and 4.07; National Board of Certified Counselors Code of Ethics, Section A.10; American Association of Marriage and Family Therapists Code of Ethics, Section 1.12; and National Association of Alcoholism and Drug Abuse Counselors Ethical Standards, Principle 9d).
There is much more variation in ethical standards with regard to sexual intimacies or dual relationships with former clients. Since sexual or romantic relationships are potentially manipulative, practitioners are expected to bear the burden of demonstrating that there has been no exploitation. A clients consent to the initiation of, or participation in, sexual behavior or involvement with a practitioner does not change the nature of the conduct nor necessarily lift any regulatory prohibition. Emotionally unhealthy individuals may enter into intimate relationships with a former therapist for inappropriate reasons and with unrealistic expectations.
Regulation and ethical codes addressing non-intimate dual relationship issues are less obvious and require even more careful examination by the therapist in assessing any potential for harm. The relationship between a counselor and a client (whether current or past) is very unique and by its nature, can lead to possible exploitation. While the therapy itself may progress well and be non-harmful, it is the potential for negative outcomes that must be kept in mind. When a counselor begins a therapy relationship with a client with whom they have another relationship, one of the two relationships is always in jeopardy of being compromised. Clearly the dynamics and expectations of the relationship will interfere with the critical need for therapeutic objectivity and honesty. The ACA Code of Ethics (Section A.6a) states: _œCounselors make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of harm to clients and that œwhen a dual relationship cannot be avoided, counselors should take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs_.
Many counselors live and work in the same communities as their client base. Obviously there are going to be situations that arise out of the office where they will come into contact with clients, former clients, and future clients. Assessing potential for harm does become more difficult, but nonetheless, it remains the responsibility of the therapist to examine carefully the œwhat-ifs. In some cases, it is also important to consider whether there may be potential for harm to other clients or even to the professions standing within the community. NBCC Ethical Code (Section A.13) states: _œCertified counselors are accountable at all times for their behavior. They must be aware that all actions and behaviors of the counselor reflect on professional integrity and, when inappropriate, can damage the public trust in the counseling profession._ Since the power differential inherent in the counselor-client relationship make clients more dependent and more vulnerable, the responsibility clearly lies with the counselor.
The following guidelines may be helpful when facing a dual relationship dilemma:
Define clearly the nature of the dual relationship from the onset.
Examine very carefully any potential risk of harm to the most vulnerable person.
Anticipate possible consequences, both positive and negative before proceeding.
Study both regulations and ethical codes for help and clarification.
Earnestly seek professional consultation to process through the issues.
The key area where discrepancies do exist are between client complaints and counselor-reported troubles. Psychologist Kenneth Pope (Pope & Vetter, 1992) surveyed over 1,300 APA members about the most common ethical dilemmas they faced in practice. Whereas sexual misconduct is by far the most complained about action by clients, it is only the eighth most troubling issue reported by psychologists.
On the other hand, while confidentiality accounted for only two percent of the primary category of active cases before the APA ethics committee in 1990 (œReport of the Ethics Committee,1991), participants in this research reported more struggles with confidentiality than any other category. Pope noted, œThis illustrates what the creators of the initial APA ethics code emphasizedthat there may be a significant discrepancy between the ethical dilemmas encountered by the membership and the complaints received by the ethics committee, and therefore revisions to the code should be informed by the former as well as the latter¦ [Yet] So difficult is the task of formulating clear, useful, practical, and generally acceptable ethical principles in this area that in the late 1970s, at the end of nine years of work revising the code, APA was unable to agree on a revision of the confidentiality section.
Respondents provided 703 ethically troubling incidents in 23 general categories, as presented in Table 1. Pope also noted that of these troubling confidentiality incidents, œ38 involved actual or potential risks to third parties, 23 involved child abuse reporting, eight involved individuals infected with human immunodeficiency virus (HIV) or suffering from acquired immunodeficiency syndrome (AIDS), six involved patients who threatened or had committed violence, and one involved elder abuse. An additional 79 dilemmas reveal that respondents are wrestling with agonizing questions about whether confidential information should be disclosed and, if so, to whom? Take help from telephone therapist.
In summary, we must see the helping profession, whether in a ministerial or professional clinical setting, for the high calling that it is and as an absolutely sacred trust. God, like any father, wants to place the lives of His hurting children into safe, competent, and ethical hands. As His Ambassadors of Reconciliation, we should endeavor at all times to faithfully represent His Kingdom, and in all things, to be above reproach, for œa trustworthy envoy brings healing (Proverbs 13:17).