Ethical Standards Go Viral
COVID-19 and Ethical Behavior for Counselors
This Musing summarizes material originally presented as part of the IMHCA Webinar on COVID-19, March 24, 2020.
On March 20, 2020, Governor Pritzker of Illinois issued an Executive Order in response to the spread of the COVID-19 virus. That order, “Staying at Home; Social Distancing Requirements and Essential Businesses and Operations,” designated counseling services an essential medical service, allowing them to remain open. However, many counselors and counseling services have increased or shifted entirely to telehealth services. This is partly a short-term response to the virus, but more importantly it represents the ongoing trend of offering clients remote and other technology-based services, as such services become more accessible and reliable. As a result, many counselors are working with their clients using remote technology, often for the first time.
These new circumstances bring up a lot of questions in the counseling community, among them how to apply ACA ethical standards.
In many professional responses to the COVID-19 situation, I have seen a lot of good advice, especially around managing anxiety; I have also seen a lot strongly expressed opinions, and plenty of rather dubious declarative statements. Ethics and appropriate ethical behaviors are vitally important to our profession; they are too important to neglect - especially in any sort of crisis. Based on my background as an ethics consultant and expert, I think I have some good advice to offer about ethics, and I’ll try to avoid too much opinion or issuing any dubious statements of my own. This Musing is about sharing my perspective on appropriate ethical behaviors, and how to sustain them in our current situation, and into the future.
Before we get into the details regarding the standards, here are some general principles to keep in mind about ethics and ethical standards:
It is important for counselors to remember how ethical standards apply to practice. Ethical standards drive our professional conduct. They are a guide to maintaining proper professional relationships among counselors, clients, supervisors, counselor educators and others affected by our work. In Illinois, ACA ethical standards are the same as the professional conduct standards for your counseling license, and the same as the laws that govern professional conduct. (Note that this may vary in other states.) On the other hand, insurance providers create their own policies regarding legibility requirements for reimbursement. Understanding and following insurance policy is not the same as maintaining ethical standards.
Ethical standards are about good practice. You are required to know the ethical standards of your profession and make a good-faith effort to follow them. This includes identifying and ethical resolving ethical dilemmas using a sound decision-making model. Nothing about our current situation, or any other personal or social crisis, changes any of these important principles.
There is no need to over-react. Public or private discussion of liability and ethical standards should not make us afraid to practice. It is natural that our current situation will raise your anxiety and increase the fear of making “ethical mistakes,” but if you follow ethical practice to the best of your ability, and document your decision-making process when dilemmas arise, you will be fine. Do it right, and with a “No Fear” attitude!
Remember that ethics are discipline-specific. Social workers, MFTs, and psychologists all have their own ethical standards, and each varies a bit from the others. Everyone is entitled to their own opinion, and anxiety can make people strident in their opinions about what others should do. When you hear someone loudly announce what’s ‘ethical’ or ‘unethical,’ check that someone’s opinions against your own counseling professional practice standards.
Now let’s get to the specifics. In general, counselors must maintain all the ACA ethical standards. However, our current situation may affect some standards more than others. The following are my opinions on the relevant standards and how to apply them, in other words, how to maintain appropriate professional conduct under each standard.
All of Section H: Distance Counseling, Technology and Social Media:
All standards in Section H apply to offering counseling services using remote technology, and include other online issues. They represent our professional conduct standard for telehealth counseling, and you are required to understand and follow them to the best of your ability. These standards are all directly relevant to telehealth services. For all these reasons, telehealth training with a strong ethics component is a critical professional experience.
Clinical Practice Standards:
A.2 a: Informed Consent: A specific consent for telehealth must be created, provided to, and signed by clients.
A.4.a: Avoiding Harm and A.4.b: Personal Values: These standards suggest that counselors keep their personal opinions and values out of the counseling relationship. We must be careful not to judge our clients and/or impose our values on them. Even if a client’s behaviors are illegal or unethical, such as violating quarantine or curfew restrictions, we do not judge. (Note that there are certain specific exceptions to these standards, including ‘danger to self or others,’ and certain legally-mandated reporting requirements.)
A.6. Managing and Maintaining Boundaries and Professional Relationships: Related to the issue above, we may feel tempted to develop a non-therapeutic relationship with our clients. You might begin telling yourself that an extreme or unfamiliar situation calls for different responses, outside the therapeutic. That might even be true - but crossing the line into becoming a client’s friend, parent, doctor or coach is never ethically appropriate. Crossing these boundaries may feel especially easy when the public or political situation is highly stressful; an unethically close relationship can feel comforting to us, or the client may push for a more comforting relationship.
A.10.a: Self-Referral: This standard requires us to be careful about referring a client to ourselves, specifically from one employment situation to another. The most common example is school, community or agency counselors referring clients from these venues to their own private practices. The standard suggests that, even when this is allowed by explicit policy, we must give the client referral options. I think it becomes easier to violate this standard the more clients are seen remotely, regardless of employment setting. You might also be worried about losing clients and thus cross this line by inappropriately encouraging a school or agency client to see you in your private practice setting. And, the high levels of public anxiety we are currently experiencing can make anything feel like an emergency requiring a rapid response – don’t fall into the trap of thinking that response has to be you.
A.12.Abandonment and Client Neglect: From the other side, we must also be careful not to abandon or neglect our clients. When you can’t see clients in the office, and telehealth is unavailable or awkward, it can be tempting to tell them “I’ll see you when this situation is over.” Another danger is losing track of, or not following up with, clients who don’t reach out to you. These issues might be especially problematic for those with large caseloads in schools or agencies. Many in these settings already have unmanageably large caseloads, which the current situation has made worse. Worry about our own families, friends and coworkers adds to the problem. This standard suggests the need to develop strategies to address crises, even a makeshift strategy.
C.2.a: Boundaries of Competence: This standard suggests we should not treat clients that we are not competent to treat. Typically, ‘competence’ is defined by specific licensing, education, experience, training and supervision. Along with the push for ‘social distancing,’ many of us are ‘pushing the boundaries’ of our competence by offering telehealth with limited training and experience. In the current situation, I believe offering telehealth near the boundaries of competence can be defended as the resolution of an ethical dilemma. You can’t abandon your clients, so when you can’t treat them in your office you are obliged to find another way. But this one special case doesn’t mean that you can ignore any competence boundary and treat any client who comes to you.
C.2.g: Impairment: Feeling freaked out? Ungrounded? Annoyed? Be sure to monitor your own impairment level. A wide range of emotional reactions to this current situation is understandable. It is also understandable that our own mental health can be disrupted by it. Don’t allow yourself to become an impediment or even a danger to yourself or your clients. Under these circumstances, it is usually advantageous to check in more often with your supervisor, case consultation group, colleagues or your own therapist. Ask them specifically about any signs of your own possible impairment.
C.3.f Promoting to Those Served: This standard is related to Self-Referral, A.10.a. It suggests that we not promote ourselves to clients who are vulnerable. The classic example of this is bringing your cards to a car accident, passing them out to any survivors and saying, “You’re probably traumatized, I can help you, here’s my card!” That’s pretty crass, and most of us would never do it - but how about offering counseling to those who are traumatized by the news? To those struggling to make sense of their changing world? This is a fine line, and it needs to be carefully monitored. Try the ‘60 Minutes Test’: Ask yourself, “Would I be comfortable making a public statement about how I got this client?” You might also consult with your supervisor, case consultation group, or colleagues before promoting yourself and/or accepting a client.
C.6.c: Media Presentations: Many of us have been called on to publicly address issues related to the virus, such as the effects of social distancing or isolation to our mental health. This situation has certainly increased the requests for media presentations from mental health professions. I recommend that you review this standard C.6.c carefully. It gives clear guidance for media presentations, including making sure that your presentations are based on professional counseling knowledge, and do not assume ongoing therapeutic relationships. We need to be careful not to overuse therapeutic “jargon” when speaking to the public. And we must be especially careful about crossing the boundary into offering medical advice.
C.6.e: Contributing to the Public Good (Pro Bono Work): As counselors, we sometimes are asked to contribute to the public good by working for little or no money. This volunteer or ‘pro bono’ work must be conducted according to the same ethical practice standards as any other professional counseling, paid or unpaid. It is important to balance paid and pro bono work, to maintain our livelihood while also feeling that we are contributing to the public good. As professionals, each of us must determine this balance in our own way.
C.8.a Personal Public Statements: This standard is similar to C.6.c: Media Presentations. We sometime find ourselves making personal statements in a public context. Our community connections make this an important activity, social media has amplified it, and the current situation has supercharged it, with many people desperate for information or reassurance. All these factors increase the frequency and impact of our public statements. We must careful and clear when expressing our personal opinions, and not allow or encourage the impression that we are speaking for all counselors or the profession.
D.2.a: Consultation Competency: This last standard is just a reminder not to consult in areas outside our competency. Our boundary of competence for consultation is often the same boundary as our therapeutic competence. Outside our competence boundary, our professional advice is actually personal opinion.
I hope this short musing will help answer some of your ethical questions, and perhaps bring up some additional issues for you to think more about. In this current crisis, ethical decision-making isn’t some abstract concept or debate topic; it’s a practical process that we need to apply right now. Who could ask for a better challenge?
Written by Dr. Francesca Giordano, LCPC