What’s Behind Ethical Decisions and Responses

Throughout the topics below, any reference to “counselors” can also be related to pastors, students and lay leaders. You can also infer, the ethical standards are consistent with Biblical standards and God’s virtues for all people. Yet not all of God’s standards and virtues are in code of ethics, including the condition of a person’s heart is not listed in a professional code of conduct. As Christ followers, called to counsel, both ethical conduct and the condition of the heart are a part of being surrendered to Him as a counselor. Second, professional codes of ethics do not encompass the full scope of Biblical character and conduct. Yet for Christ followers who counsel, being transformed into the likeness of Jesus (synonymous with Agape love) through the Holy Spirit provides the ability for ethical decision making and conduct. Applying God’s Agape love to one’s life and counseling practice is ultimately the goal, along with a willingness for accountability. Jesus said in Matthew 6:22-23a, “The eye is the lamp of the body. So, if your eye is healthy, your whole body will be full of light, but if your eye is bad, your whole body will be full of darkness.” Agape love is not only a standard, but a condition of our eyes, mind , character and heart!

So then, modeling Agape love in the counseling setting is based upon the counselor’s surrendered condition to God’s unconditional love, above any human ethical code. Agape love problem solving in counseling ethical dilemmas is the means for determining the counselor’s next step. Human ethical decision matrices are limited by the bounds of ethical codes, human wisdom and experience, especially when the dilemma is not black or white, right or wrong, win or lose. Here’s a subtle example of a client who becomes frustrated by the counselor comparing the client’s conditional behavior from pride with the Biblical norm of patience. When the client reacts in a defensive, prideful manner, the counselor can take a deep breath, ask the Holy Spirit for help and insight. From a surrendered heart, the counselor will find a non-reactive response that may sound like, “I could be wrong, I don’t have to be right. Why don’t you think and pray about it, then get back to me.”

When the counselor models Agape love, the client has the responsibility and the choice to see it, hear it and receive it. Some counselors may not accept the responsibility to model or respond with Agape love. Instead, they may place the problem on the client’s resistance. Introducing the concept of thinking and praying about a client’s problem with the counselor reduces a potential power struggle, focuses the client on their relationship with God and the freedom to chose their next step. In this situation, the counselor followed the Holy Spirit’s lead and the professional code of giving the client the right to choose. Love wins!

A more serious dilemma can be when a counselor notices a particular client’s persona, appearance or demeanor is triggering their own past unresolved memory or emotional need. You can fill in the missing details and may imagine various scenarios that may or may not happen. Yet, modeling and relying of Agape love first, the counselor can choose to step away after the session with a humble approach to process with the Lord and with another trusted peer to sort out the internal reaction. Though, in the midst of back to back sessions, with uncomfortable emotions and intrusive thoughts swirling, the counselor eventually has the choice to face their reality. There are many possible scenarios here, though let’s say the counselor chooses to ignore the trigger and discomfort, continues to see the client and is influenced by their internal, compromising thoughts and feelings. The counselor is depending upon their own strength to monitor and control their internal storm till they make an outward, conditional decision and reaction that harms the client and themself. As you can see, ethical decisions and responses are more than just following the professional code of ethical conduct.

Duals Relationships

A dual relationship describes a counselor’s relationship with someone in a personal, work, church or community setting who reaches out for your professional services. A counselor is often perceived as caring and a source of help, a friend in a time of need. Many counselors differ in their response to help or provide wise counsel that often happens in family, social, and church settings. Ethical standards at times will be very clear for the counselor to deny or accept someone’s request, while other times exceptions can be allowed. Before giving an answer, consider two potential risks. First, will your objectivity be neutral or biased? Second, will your relationship change, the person be harmed or shift the power dynamic in the relationship? Depending on the situation, the answer could be “yes” to one or both of these questions, yet you may still have ethical reasons to fulfill the request. While in many relationships, answering “yes” will also lead the person to consider various alternatives.

Even though ethical decisions appear to be “black or white”, a personal request may also consist of “gray areas” in both the situation (request) and in your response. Generally, listening to a person’s dilemma with compassion and support is always the best kind of response before discussing ethical boundaries. Helping the person to sort out their concerns in a confidential manner promotes problem solve for therapeutic options, is the best course of action. In these types of conversations, notice any red flags such as their pressure on you, obligation to help, or fear that leads to believing there is only one solution with no alternatives. Taking a deep breath and seeking the Spirit’s sense of direction often brings alternatives to mind. The same process can apply with holding boundaries in your professional interactions with colleagues, employers, supervisors and trainees. These conversations of ethical decisions are often the place for disagreement, proving a point, and a hotbed for right or wrong opinions. Boundaries are often violated in the crossover of professional roles; peers/supervisors feel disrespected or unheard, unspoken question of who is in charge and who is the expert in the room.

Informed Consent

Next, let’s look at how ethical standards affect counseling policies. One policy is “informed consent”, which is both an ethical and legal process of explaining the treatment details, risks, benefits, and client rights, so the client can make an informed decision before he/she starts sharing personal information. It is wise for a counselor to share an informed consent form with the client prior to the client’s arrival to the counseling session. Many providers who have a website will post their documents on their site for the client to obtain. Other providers email this form to the client once they have scheduled their initial session. CBT counselors will include the Initial Session Information form (ISI) along with the informed consent form(s).

Best practice informed consent forms contain detailed statements about the nature of the counseling, along with goals and responsibilities. The provider usually provides their credentials, limits to confidentiality, fees and payment policies and the client rights to ask questions, view their records or stop attend therapy at any point without penalty. The counselor’s goal in providing this information is an ethical act of transparency, collaboration and compliance to professional codes.

Several CBT handout examples are provided, such as the Fee and Payment Schedule form which is a written policy given to the client to inform them of the cost for counseling, and appointment cancellations. A second up to date form that covers similar information, along with confidentiality and other office procedures is a public form, the Therapist-Client Agreement. The limits of confidentiality (page 2) including release of information (counselor’s notes, test results and completed forms on page 3). Be sure to review your state’s regulations for proper storage of your counseling records and digital access. Never leave a hard copy file/notes unattended on your desks, open on your PC or laptop in your office. Same goes at your home office.

Client Privacy and Record Storage

All practitioners’ codes of ethic take a client or patient’s right to privacy as a serious matter. You may have heard a counselor use this phrase in the past when asked about a professional relationship with a potential client, “I can neither confirm or deny whether Mr. Smith is my client.” Verbal communication with or about a client, whether knowingly or unknowingly, open to the public, does not ensure the privacy of a client’s personal and health information. Ensure conversations with clients are behind closed doors and notify a client of the limits of their confidentiality when outside of a secure location. Same goes for public electronic communication.

Historically, all hard copy counseling files containing all hand written or typed notes, evaluations, reports, letters and demographic forms, were kept in a file folder, that was locked into a file cabinet that was behind a locked door. For the majority of all state licensing boards, this record storage standard was and still is legally mandated. Even though there is no legal authority who goes to counseling offices to enforce legal compliance, if or when a breach of information is reported, investigators will pursue how the confidential information was found. No matter if the breach of private information is reported or not, it is an ethical violation even if no one finds out, no matter if it is an accidental breach. The client can be harmed whether they know about it or not. Notification of a breach of information to a client and/or partnering organization, is expected for ethical and legal accountability. If or when a breach or privacy violation occurs, seek legal counsel for the next best step.

Secondary to public safety, is the offense and risk for loss or suspension of a practitioner’s state license, if found guilty. Two types of violations can occur: 1) Breach of confidentiality and/or data - when a counselor fails to lock or secure physical files or electronic records and/or a third party acquires or views confidential records. 2) HIPAA Privacy Violation - federal mandate to secure all Protected Health Information by the U.S. Department of Health and Human Services Office for Civil Rights. A report of a violation can also impact a practitioner’s ability for future malpractice insurance.

Virtual or Teletherapy

Online counseling (telehealth) or virtual counseling offers a convenient and effective way to receive care while maintaining the same professional, ethical, and legal standards as in-person counseling. All online counseling services are conducted in accordance with state laws and the ethical guidelines governing licensed professional counselors. In all states, licensed professional counselors, pastors and counseling students are required to uphold rigorous expectations to ensure that clients receive safe, confidential, and clinically appropriate care in a virtual setting.

Telehealth is not considered a lesser form of care; rather, it must meet the same standard of care as face-to-face counseling. This means that every session involves appropriate clinical assessment, thoughtful treatment planning, and ongoing evaluation of a client’s needs and progress. Counselors are responsible for determining whether online counseling is appropriate for each individual, not based upon the provider’s preferences. Not all concerns are best addressed remotely, and when necessary, referrals or alternative services may be recommended to ensure the highest level of care.

A counselor will also need to consider the following concerns:

1. State license regulations when counseling someone in a different state than the location of their office.

2. Evaluation and treatment limitations, differences in face-to-face counseling.

3. Crisis and emergency response resources in the client’s area of residence.

4. Payment processes and insurance/EAP billing, including form signatures.

5. Limits of confidential communication with clients, such as electronic access, texting, emailing and online encryption services that is HIPAA compliant.

6. Client’s technology limitations related to personal knowledge of use, adequate equipment, Wifi access and communication limitations.

7. Counselor’s experience and online presence, presentation and etiquette.

8. Malpractice insurance expectations and limitations.

Policies and forms need to be created in light of online concerns as a means of informed consent and the best interest of the client. Expectations for the clients to have their camera turned, ability to see their face with eye contact and audio clarity should be a part of the virtual counseling agreement. Other expectations are the client’s context for confidentiality, ability to openly express themself, client’s ability to feel connected to the counselor and engaged in therapeutic dialogue.

Roles & Responsibilities

Whether during the initial session or after several counseling sessions, counselors continually assess a client's level of engagement, motivation, and ownership of the counseling process. The counselor intentional or unintentional influence on the client can impact a client’s choice to engage in counseling or not. Balancing compassionate support and encouragement with the responsibility to speak the truth in love can be challenging, especially if the client is ambivalent about receiving help. Ultimately, the counselor’s desire is the client’s best interest, ethically and spiritually, not taking the client’s responsibility to sustain counseling.

A subtle, but effective routine for the counselor is closing each session in prayer, which is seen as a potential sticky wicket in secular settings. Yet, this can be an effective way to release the client into God’s hands (transference) and responsibility for the client to then choose their next step. Such as, what is their takeaway from the session? What is their focus? When do they want to schedule their next appointment? See Role of the Counselor and Responsibility of the Client.

Termination of Services

Clients and counselors do not enter into a counseling relationship knowing they will terminate their relationship. Some clients hit a wall of resistance or motivation, then leave therapy. Some find enough relief and hope after the first session and do not return to counseling. It is the responsibility of the counselor to graciously surrender them into God’s hands by giving them the choice to return or not. In one case, after three counseling sessions, the married couple reported to the counselor, they are going to take a family vacation which will heal their marriage and not return to counseling.

Then there are times when the client determines Biblical counseling is not a good fit for them, or the counselor-client relationship is not conducive for their betterment, or the client states they want to see a different therapist. This is clear, a referral is in the best interest of the client. Generally, the counselor is responsible to provide contact information for three counselors, who are reasonably accessible for the client.

In other circumstances, when a client is actively engaging in counseling, though struggling to connect with God in the change process, Course 3, Chapter 9 provided extensive descriptions physical, psychological or spiritual challenges. The When to Refer document provides more basis and application for these challenges. Though the goal is for the client to continue in Biblical counseling in faith that God will lead the client to healing and maturity.

More difficult counseling situations can find the client displaying an ongoing resistance to receiving help or become unresponsive in attending counseling sessions or showing ambivalence in the ownership phase of counseling. The counselor now becomes responsible to patiently take incremental steps in providing the client options towards consistent growth. Accepting the client’s lack of motivation, lack of readiness for change and/or choosing other priorities in place of counseling is again, both ethical and an act of love. This leaves the counselor responsible to document each step and client’s responses that lead to a letter of termination with three referrals.

Consultation and Self-Care

In the day-to-day counseling setting, an ethical focus of “do no harm” and “the best interest of the client” provide the right attitude and motive in the helping professions. When situations rise to a higher risk for potential harm or questionable interest, consulting with a peer or seasoned counselor is generally helpful while maintaining a client’s privacy. Consultation and referral applications are discussed in Course 4, Chapters 6 & 25 and widely covered in Course 6.

Seeking your own care is a form of ethical practice and Agape love. The culmination of daily stressors and pressures build up and are usually not noticed by many therapist. It has been said by female providers, they can forget to take time to use the restroom or hydrate themself which can cause a urinary tract infection. Or the male therapist that ignores the tension or pressure in his chest, that eventually leaks out at home. Just like client awareness and ownership is key in their health, the same goes for the counselors’ health. Paying attention to your body and emotional signals is the first step in self care. Accepting these signals, taking time to respond helps yourself, your clients and your family. See the Counselor’s Self Care Inventory.