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PCN 662A Topic 6 Lecture


Reprising Ethics



Introduction

The overall objectives of counseling ethics are to maintain client welfare foremost, to do no harm (physical, emotional, or financial), and to maintain standards of responsibility, integrity, and accountability. All counseling and treatment must be framed by professional codes of ethical standards such as those of ACA and NAADAC. These ethical standards supersede all other treatment considerations.


Key Components of Counseling Ethics

Some key areas of professional counseling ethics that GCU students have learned about include:

Maintenance of proper professional boundaries. When both client and counselor are members of the same recovery fellowship, this can present a quandary as to which “hat” is being worn. Secondly, there are gray areas such as whether hugging a client is permissible, which varies from agency to agency.

Maintenance of privacy and confidentiality is a legal as well as an ethical imperative, as spelled out in federal and state regulations, and the relatively new HIPAA regulations. Exceptions to confidentiality were spelled out in your Professional Counseling Ethics course, and as you perform your practicum, you should review these mandates.

Complaints about counseling practice often cite financial ethics. Kickbacks, fee-splitting, promoting personal business or that of a relative or friend, are but a few examples.

Counselors must be adequately trained and competent to perform their functions, they must not be impaired, and they must maintain professional growth. Services cannot be denied because of client gender, race, ethnicity, disability, or sexual orientation. This is the principle of nondiscrimination

Counselors must strive to be objective and not to promote their own ideological agenda or belief system. This is the principle of objectivity.

Representation of services must be honest, realistic, and straightforward. Credentials can be easily exaggerated to clients who are not system-savvy; to print “John Smith, S.A.C.” on a card or stationary for an in-house title of Substance Abuse Counselor falsely implies certification or licensure (Myers & Salt, 2007).

An issue of relevance to the counseling profession and one that frequently comes up in class discussion is that of unethical diagnoses. The following phenomena are included:

Diagnostic Creep or Upcoding

Diagnostic creep or upcoding is exaggerating or inventing symptoms, or simply changing a diagnosis to the highest treatment category possible. This maximizes reimbursement for the treatment agency and is considered fraudulent. Sometimes there are grey areas on this topic. Sometimes clients do not have insurance coverage for a legitimate complaint and the counselor assigns clients a billable diagnosis so they can be treated.

So-Called Criterion Creep:

So-called criterion creep is when syndrome categories are somewhat carelessly widened to include characteristics formerly thought within range of normality. Critics have pointed to disorders du jour, including PTSD, ADHD, and conduct disorder as over-diagnosed by clinicians who are very loose with diagnostic criteria. Some motives include the desire to maximize the number of patients in treatment, maximize reimbursement, or dramatize research claims to get published, and because of the tendency to take advantage of a cultural fad. For example, a couple of decades ago, persons who nowadays would be diagnosed with various mood disorders were sent into treatment for codependency.

Current science does recognize spectrum disorders with mild forms of schizophrenia (schizotypal and schizoid personality disorders have a small amount of schizophrenia symptoms, often occurring in families with schizophrenic members) and autistic spectrum disorders (including Asperger’s syndrome), so it is a tricky research area. But spectrum researchers are being very careful about the diagnostic criteria, and are rearranging existing diagnoses onto dimensions and spectra rather than diagnosing otherwise unremarkable people off the street and haphazardly throwing them into disease and pathological categories.

Diagnostic Slamming

Diagnostic slamming describes counselors who give clients unfair, severe diagnoses and predicted outcomes in response to criticism of their therapeutic practice to keep patients in treatment to ensure continuity of income.


Case Vignette

Below is an example of ethical lapses as described in a fictional case:

Scenario

Mr. and Mrs. Tarasoff took their 9-year-old daughter, Tatyana, to therapy after her school complained that she was disruptive in class, argued with teachers, and did not hand in assignments. They were referred to child psychologist, Dr. Joan Moore.

Dr. Moore found the child to be quite a handful. She would dart about the office and refuse to focus on her play therapy activities. Very frustrated with her inability to manage her client, the doctor experienced out of control countertransference through anger at the child and frustration at the father who was disturbed at what he sensed in the interaction, but who the doctor thought let the child get away with too much. As an example of her interpretations of behavior influenced by countertransference, when Tatyana called from a sleepover in a scary high-rise urban project to say that the parents were gone and she wanted to be picked up, Dr. Moore said that Tatyana was being manipulative and controlling. To make matters worse, Dr. Moore experienced a stroke which left her labile, somewhat aphasic when under stress, and thus even less in control of her countertransferential reaction. Tatyana hid in the restroom and was forbidden to use it, resulting in a humiliating accident.

As these struggles ensued, the client pleaded to be relieved of this therapeutic relationship. Knowing all too well of the child’s difficult behaviors, the parents uneasily went along with the expert. However, the situation finally came to a head when the therapist administered a couple of spanks to the client supposedly to focus the client, and not part of any sanctioned or known intervention, and certainly not part of any treatment technique that was conveyed to the parents with informed consent. The parents confronted the therapist and expressed their desire to immediately terminate the treatment. Dr. Propriatt countered that Tatyana “has a thought disorder,” and “will decompensate if terminated” from this therapist. To multiply this ethical lapse, the therapist brought in a post-hoc “consultation” with an eminent psychologist to justify these events. Readers are probably not surprised to learn that the child did a lot better when rid of this therapist, and she was subsequently diagnosed with attention-deficit hyperactivity disorder (ADHD), although by this time had suffered a great deal of shame, guilt, and loss of self-esteem from her school and therapy experiences.

Ethical Lapses

Incompetency; inability to properly diagnose and treat ADHD.

Harmful countertransferential reaction, not properly monitored or supervised.

Gross impairment due to neurological event (stroke).

Harmful application of force.

No informed consent on utilization of unorthodox treatment technique.

Unethical use of diagnoses (diagnostic slamming).

Improper post hoc use of supervision.


Conclusion

Other courses within the program discuss ethical issues in depth. Now that the practicum course is in full swing, there is an opportunity to be presented with ethical dilemmas firsthand. Draw upon previous training and interact with supervisors and mentors when in doubt about how to proceed in specific circumstances.


References

Myers, P. L., & Salt, N. (2007). Becoming an addictions counselor: A comprehensive text (2nd ed.). Sudbury, MA: Jones and Bartlett.