Frequently Asked Questions on Ethics

Question: If a client refuses to sign my treatment contract, can I then provide services to that individual?

Answer: In general, no. Counselors must respect client rights, and as stated in the AMHCA Code of Ethics (Code), Principle I.B.7,i, a basic right of clients is “to refuse any recommended services, techniques or approaches and to be advised of the consequences of this action.”   Clients may, of course, give informed consent to treatment if they choose to do so.  Code section I.B.2 provides excellent guidance regarding the informed consent process, and the disclosures that should be made to clients.


Question: When do I have the duty to warn of a threat by my client or a duty to protect against violence that may be committed by a client?

Answer: The Tarasoff duty to warn and protect against serious threats of imminent violence by a client has been adopted in various forms in state laws and licensing board Rules. Counselors need to comply with their state law or licensing board Rules regarding the duty to hospitalize a client who is dangerous to others, in order to prevent threatened violence and to protect the potential victim.  By doing this, you comply with Code Principle I.A.2.c which contains an exception to confidentiality “for the protection of life” and provides:  “mental health counselors are required to comply with state… statutes regarding mandated reporting.”



Question: I have been seeing a Mom and her children in counseling to deal with issues concerning parent-adolescent problems and divorce issues. Mom and Dad are separated. Mom’s attorney wants me to testify in court that Mom should have custody of her children. I have never met the husband, and know little about him, except for information provided by Mom concerning his drug problems and his acts of domestic violence. Can I testify as an expert witness for Mom in the divorce case?

Answer: No, a counselor who is serving in a clinical role, providing treatment to a Mom and her children in family counseling, cannot also take on the role of forensic expert. To do so would violate Code principle I.D.4.g which prohibits counselors from evaluating for “forensic purposes, individuals whom they are currently counseling or have counseled in the past.” To express an opinion on custody, which Mom’s attorney has requested, would also result in a violation of Code section I.A.3 which prohibits counselors from having dual relationships in serving clients.  A dual relationship would result if a counselor served the same client in both a clinical and forensic role. 

Mom’s attorney should ask the court to appoint an unbiased, objective, forensic evaluator; or the attorney can retain a forensic expert to evaluate custody issues and make recommendations to the court in the best interests of the parties’ children.

 


Question: Part of my practice as a counselor involves providing clinical supervision to people who are seeking licensure. What should I do to protect myself from liability, in case I am sued for the actions of a supervisee? For example, how could I defend myself if a therapist that I was supervising was having a personal relationship with a client—without my knowledge?

Answer: The best defense against any potential risk in a situation such as this is for the clinical supervisor to have a thorough Clinical Supervision Contract with the supervisee in compliance with Code section III.B.2. The Contract needs to have a requirement that the supervisee will comply with the AMHCA Code of Ethics; and the supervisor should provide the supervisee with a copy of the Code as stated in Principle III.B.2.b. Exploitative relationships, such as an intimate relationship between the supervisee and client are “strictly prohibited” according to Code section I.A.4. Thus, the AMHCA Code of Ethics is an excellent learning device in the clinical supervision process, and the supervisee’s commitment to comply with the Code assures that the clinical supervisor in not responsible if the supervisee crosses boundaries with the client without the supervisor’s knowledge, after the supervisee has promised to comply with the Code of Ethics.

 


Question: I have a client who is being seen in couples counseling. His unwillingness to make a serious attempt to cooperate with counseling has been an obstacle to the process of therapy. His flirtatious remarks to me make me very uncomfortable. I feel that I should refer this couple to another therapist, but I do not want to be seen as abandoning these clients. Can I terminate my services and refer the couple out?

Answer: Trust your judgment and refer the client couple to another counselor. By doing this, you are not abandoning the couple, you are complying with Code section I.A.3.a which provides that “mental health counselors make every effort to avoid dual/multiple relationships with clients”.  Flirtatious clients can create any number of problems, even when the counselor is not crossing boundaries.  By terminating treatment and referring the couple to another counselor, no abandonment occurs.

 


Question: In disclosing my fee to clients, am I required to inform them concerning my sliding scale or withhold that information until a client asks for it?

Answer: Informed consent is intended to be a transparent process in which information about treatment is disclosed to clients. Accordingly, counselors should disclose billing practices including a sliding scale fee in compliance with I.B.2.a of the Code, which requires disclosure of information to clients including “counselor credentials, issues of confidentiality, the use of tests and inventories, diagnosis, reports billing, and the therapeutic process.”  Similarly, counselors need to comply with section I.E.2, which provides that counselors “clearly explain to clients, early in the counseling relationship, all financial  arrangements related to counseling.”

 

 


Question: I am a devoutly religious person, and I do not believe in divorce. When working with couples who have marital problems, I make every effort to preserve the marriage, and counsel my clients not to seek a divorce because of the guilt and emotional problems that this will cause the couple and their children. Is this permissible?

Answer: Counselors cannot impose their values on others. The Code, section I.A.4.d, cautions counselors to be “aware of their own values, attitudes, beliefs, and behaviors, as well as how these apply in a society with clients from diverse ethnic, social, cultural, religious and economic backgrounds.”  Then, of course, you must respect the client and be mindful that you are not imposing your attitudes, beliefs, or values on them.



Question: How do I handle confidentiality in conducting group therapy, and what do I tell group members will be the consequences if confidentiality is breached?

Answer: The Code provides that “in working with…groups, the right to confidentiality of each member should be safeguarded” according to section I.A.2.l. Inform each group member in the treatment contract or disclosure statement that group counseling is confidential, disclose the exceptions that apply, and also disclose that what is said in group stays in group, because the information is personal, private and confidential.  Then, at the beginning of each group session, remind the members again that all information shared in sessions is confidential, and stays in group.  If a member talks outside of group about what someone else had said in a ssession, then often the consequences are left up to the group to decide what should be done.  However,  the counselor should reserve the right to determine if group counseling should be terminated for the member who violated another’s confidentiality, in order to prevent a repetition of the breach of confidentiality.

 

 


Question: When I engage in couples counseling, can I share information with the husband that is confided to me by the wife in order to facilitate communication between them?

Answer: The Code provides in section I.A.2.l: “In working with families…,the right to confidentiality of each member should be safeguarded.”  When you meet with a member of a couple individually to obtain information for purposes of couples counseling, get an agreement immediately at the end of the session regarding what information can be shared to the other member of the couple, and what information may not be shared.   Note this agreement in the session note for that meeting. 

 

 


Question: I am counseling a man who is experiencing marital problems. His wife is having an affair, and he is devastated. He wants to preserve his marriage, but his wife is not willing to seek counseling. He wants for me to meet with her, and she has agreed to do so. Will she be my client, too?

Answer: No, the wife is unwilling to take part in counseling, so she would be a “collateral”, not a client, in the husband’s individual counseling process. The Code states in section I.B.3.b: “Collateral consent informs family members or others… of the parameters and limitations of confidentiality.”  The client husband needs to sign a Release (ROI) authorizing his wife to attend a session and to receive treatment information.   Any collateral in a situation such as this should receive a Collateral Disclosure informing that the collateral is not a client and will not be receiving treatment; and that any treatment information shared with her will be part of the client husband’s confidential treatment record, and is not confidential information  belonging to her.   This clarifies the roles of the 2 spouses in the treatment process.  So, any notes or records regarding the wife/collateral’s involvement in the husband’s individual counseling are part of the husband’s treatment record, and he can use the information or authorize its release since it is his confidential treatment information.                              

 


Question: I am providing services online through e-mail with clients. Is this practice ethical? Are there any special disclosures that I need to give these clients?

Answer: Yes, at a minimum, two disclosures are needed regarding the security of email communication. First, in compliance with Code principle I.A.2.o, disclose that only encrypted email is secure in communicating online and conducting treatment sessions; and that unencrypted e-mail is not secure because it can be hacked more easily.  Section I.A.2.o states;  “Mental health counselors take necessary precautions to ensure client confidentiality of information transmitted electronically through the use of a computer, e-mail, fax, telephone, voicemail, answering machines,” or other media such as video conferencing platforms.  The second disclosure that should be made pursuant to I.B.6.c concerns “the benefits and risks of entering into distance counseling” including “e-mail contact with a client.”  The risk that a breach of confidentiality may occur if unencrypted e-mail is used is well known to most e-mail users, but should still be discussed in making this disclosure.

 


Question: For years, I have been asking whether I am required to report a client who is HIV-positive and who is having unprotected sex with his partner. Recently this issue arose, and my client refused to allow me to disclose to his partner that he is HIV-positive. We have treated this as a clinical issue. Do I have a duty to report this situation, or am I required to maintain my client’s privacy and the confidentiality of this information?

Answer: Comply with state law in determining whether you are required to report information regarding a client in treatment who has been tested and found to be HIV-positive, or whether, on the other hand, state law requires that such information be kept confidential. The Code addresses this issue in section I.A.2.n which provides:  “Mental health counselors may justify disclosing information to identifiable third parties if clients disclose that they have a communicable life-threatening illness.  However, prior to disclosing such information, mental health counselors must confirm the diagnosis with a medical provider.  The intent of clients to inform a third party about their illness and to engage in possible behaviors that could be harmful to an identifiable third party must be assessed as part of the process of determining whether a disclosure should be made to  identifiable third parties.”  In view of the legal risks of informing the client’s partner that he is HIV-positive without his written consent, a counselor would be well advised to seek legal counsel before taking any such action.

 


Question: How should I disclose to clients the limitations on confidentiality, such as the mandatory reporting of suspected child abuse or neglect, and other exceptions to confidentiality?

Answer:The Code requires in section I.B.2 that counselors obtain informed consent for treatment by providing disclosures to clients, which include “issues of confidentiality”. These disclosures may be made in the “counselor’s professional disclosure statement” which should list the basic exceptions to confidentiality and any special exceptions that may apply in a particular client’s situation.

 

 


Question: Am I required to report another counselor if I know that the counselor cannot practice competently or if I know of an ethical violation that a professional has committed?

Answer: The Code addresses this problem in II.A.7, which provides: “When mental health counselors have knowledge of the impairment, incompetence, or unethical conduct of a mental health professional, they are obliged to attempt to rectify the situation.  Failing an informal solution, mental health counselors should bring such unethical activities to the attention of the appropriate state licensure board and/or the ethics committee of the professional association.”  If the information about the unethical conduct of another professional comes from a client and constitutes confidential treatment information, obtain consent in writing in a release by the client before disclosing it.

 


Question: What am I required to do when I receive a subpoena for my records?

Answer: The Code provides excellent guidance in this situation in section I.A.2.d  which states:  “Mental health counselors are advised to seek legal advice upon receiving a subpoena in order to respond appropriately.”   A counselor should check with their professional liability insurer to determine if their insurance policy contains coverage for the counselor to retain an attorney to handle the subpoena, and provides that the insurer will pay the attorney fees involved.  An attorney may need to file a motion to quash if the subpoena was not properly served, or to file a motion for protective order if the subpoena seeks confidential treatment information or records, and the client does not consent to these disclosures.  A subpoena does not compel the production of counseling records and does not compel testimony by a counselor:  client consent is needed, in writing, in order to disclose confidential treatment information.  A subpoena, properly served, does compel a counselor to appear at the time and place indicated in it.  Legal advice can assist a counselor to determine if the subpoena was properly served, and should assure that the counselor’s response to the subpoena is proper, in order to avoid a breach of confidentiality through the disclosure of confidential information without client consent.

 

 


Question: My client has sent me a letter containing a written request for a copy of her treatment records. This client’s diagnosis is paranoid schizophrenia. I am afraid that she will feel stigmatized by this label, and that she will be confused not only by the diagnosis in her file, but also by the test data contained in it. Am I required to turn over to this client a copy of her chart?

Answer: Code section I.A.2.b apples in this instance. It states:  “The information in client records belongs to the client and shall not be shared without permission granted through a formal release of information.   In the event that a client requests that information in his or her record be shared, mental health counselors educate clients to the implications of sharing the materials.”  Some state laws require that health care providers and counselors give a copy of their treatment records to clients, upon request; however, many state laws agree with HIPAA standards which provide that the counselor’s “psychotherapy notes” need not be shared with clients, who are entitled to a progress report, which is a treatment summary.  Disclosure to this client of her treatment notes and records could be harmful to her, due to the client’s inability to process diagnoses, labels or discussions of her history. Thus, if state law allows a counselor to provide the client with a treatment summary in this instance, it would undoubtedly be an appropriate judgment on the part of the counselor to do that. 


Question: I have several clients in my drug and alcohol agency who are indigent and cannot afford to pay me. Can I put them to work for me in my agency, and trade services with them?

Answer: No, this would not be advisable, due to the dual relationship that would result in violation of principle I.A.3.a, which prohibits multiple relationships arising out of “familial, social, financial, business, or close personal relationships with the clients”.   Putting these clients to work in the agency would create dual relationships between the counselor-client and employer-employee.  Supervising the client in the workplace would lead to foreseeable problems.  Code provision I.E.2.b states that “counselors usually refrain from accepting goods or services from clients in return for counseling services, because such arrangements may create the potential for conflicts, exploitation and distortion of the professional relationship.”  Bartering is problematic because it can only occur “if there is no exploitation”, and whenever a client complains to a licensing board that they were exploited in such a situation, the client will be believed, and the counselor may be punished for engaging in a dual relationship.

 


Question: I have a client who continues to schedule appointments with me every week, even though I have suggested that she does not need counseling any longer. She says that it makes her feel better and that she enjoys our interaction. What should I do?

Answer: Code section I.B.5.b applies in this analysis: “Mental health counselors terminate a counseling relationship when it is reasonably clear that the client is no longer benefiting,” or “when services are no longer required”.  Clients can become dependent on counselors and counseling, which is not healthy as it does not promote client autonomy.  Schedule a termination session with this client, thank the client for her excellent work which resulted in treatment goals being reached, discuss her progress in treatment, and suggest that she can return if she should need additional services.


Question: I have a client who has not been paying for his sessions. I know that he can afford to pay, because he has a good job, drives an expensive car, and is always well-dressed. What can I do?


Answer: The AMHCA Code provides that “counselors may terminate a counseling relationship when clients do not pay fees charged” according to section I.B,5.c. “In such cases referrals are offered to the clients” in order to prevent abandonment of the client.  If the counselor intends to use a collection agency to obtain payment of treatment invoices, the counselor must first disclose the intention to use a collection agency, and try to work out a payment plan, an approach that can be used prior to terminating the professional relationship with the client.


Question: I know that doctors carry pagers, and that they have other physicians to take calls for them after hours when the doctor is not available. Are counselors required to do the same? Many of my colleagues have messages on their answering machines that direct callers to go to the nearest hospital emergency room or call 911 if they are in crisis. Do counselors have to be available to their clients 24/7?


Answer: The Code does provide that assistance be “given in making appropriate arrangements for the continuation of treatment, when necessary, during interruptions such as vacations and following treatment”, according to section I.B.5.a. Regarding after hours calls or texts from clients, be aware that some managed health care companies enter into fee for service contracts with counselors which require them to be available to respond to calls from the insured/client after hours in case of a crisis or emergency.  Check any provider contract carefully to see if it has such a requirement, and comply with the contract if it does. 

 It is a generally accepted practice, however, in the absence of such a contract, for counselors to inform clients to call 911 or to go the nearest hospital Emergency Room for treatment in the event of a crisis.  In general that is the safest approach, since counselors  are not available on a 24/7 basis to triage client’s problems and emergencies after hours, and clients need to know what to expect in these situations.

Code of Ethics

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