Law and Ethics in Counseling (addiction)

This training is informational only and does not constitute legal advice.

Most of the Ethical Standards are generally written to apply to counselors in the many roles that they play. The application of an Ethical Standard may vary depending on the situation. The Ethical Standards are not extensive. The fact that a given conduct is not specifically addressed by an Ethical Standard does not mean that it is necessarily either ethical or unethical.

Ethic Codes apply only to counselors' activities that are part of their scientific, educational, or professional roles as counselors. Areas covered include but are not limited to the clinical, counseling, school practice of psychology; research; teaching; supervision of trainees; public service; policy development; social intervention; development of assessment instruments; conducting assessments; educational counseling; organizational consulting; forensic activities; program design and evaluation; and administration. Ethics Codes apply to these activities across a variety of contexts, such as in person, via mail, telephone, internet, and other electronic transmissions.

The Ethic Codes are intended to provide guidance for counselors and standards of professional conduct that can be applied by the ethics committee and by other bodies that choose to adopt them. The Ethics Code is not intended to be a basis of civil liability. Whether a counselor has violated the Ethics Code standards does not by itself determine whether the counselor is legally liable in a court action, whether a contract is enforceable, or whether other legal consequences occur.

Counselors establish relationships of trust with those with whom they work. They are aware of their professional responsibilities to society and to the specific communities in which they work. Counselors uphold professional standards of conduct, clarify their professional roles and obligations, accept appropriate responsibility for their behavior, and seek to manage conflicts of interest that could lead to exploitation or harm. Counselors consult with, refer to, or cooperate with other professionals and institutions to the extent needed to serve the best interests of those with whom they work. They are concerned about the ethical compliance of their colleagues' scientific and professional conduct. Counselors strive to contribute a portion of their professional time for little or no compensation or personal advantage.

Both law and ethics govern the practice of therapy. When making decisions regarding professional behavior, counselors must consider the Code of Ethics and applicable laws and regulations for the state in which they practice therapy. If the Code of Ethics maintains a standard higher than that required by law, counselors must meet the higher standard of the Code of Ethics. Counselors comply with the mandates of law, but make known their commitment to the Code of Ethics and must take steps to resolve the conflict in a responsible manner.

Counselors have an obligation to be familiar with the Code of Ethics and its application to their professional services. Lack of awareness or misunderstanding of an ethical standard is not a defense to a charge of unethical conduct.



Principle 1: Non-discrimination
The Certified Alcoholism and Drug Counselor Associate should not discriminate against clients or professionals based upon race, religion, age, sex, handicaps, national ancestry, sexual orientation or economic condition.

Principle 2: Responsibility
The Certified Alcoholism and Drug Counselor Associate should espouse objectivity and integrity, and maintain the highest standards in the services the counselor offers.

The Certified Alcoholism and Drug Counselor Associate as teacher, should recognize the counselor's primary obligation to help others acquire knowledge and skill in dealing with the disease of chemical dependency.

The Certified Alcoholism and Drug Counselor Associate, as practitioner, should accept the professional challenge and responsibility deriving from the counselor's work.

The Certified Alcoholism and Drug Counselor Associate, who supervises others, accepts the obligation to facilitate further professional development of these individuals by providing accurate and current information, timely evaluations and constructive consultation.

Principle 3: Competence
The Certified Alcoholism and Drug Counselor Associate should recognize that the profession is founded on national standards of competence which promote the best interests of society, of the client, of the counselor and of the profession as a whole. The counselor associate should recognize the need for ongoing education as a component of professional competency.

The Certified Alcohol and Drug Counselor Associate should prevent the practice of alcoholism and drug abuse counseling by unqualified and unauthorized persons.

The Certified Alcohol and Drug Counselor Associate who is aware of unethical conduct or of unprofessional modes of practice should report such violations to the appropriate certifying authority.

The Certified Alcohol and Drug Counselor Associate should recognize boundaries and limitations of counselor's competencies and not offer services or use techniques outside of these professional competencies.

d. The Certified Alcohol and Drug Counselor Associate should recognize the effect of professional impairment on professional performance and should be willing to seek appropriate treatment for oneself or for a colleague. The counselor should support peer assistance programs in this respect.

Principle 4: Legal Standards and Moral Standards
The Certified Alcohol and Drug Counselor Associate should uphold the legal and accepted moral codes, which pertain to professional conduct.

The Certified Alcohol and Drug Counselor Associate should not claim directly or by implication, professional qualifications/affiliations that the counselor does not possess.

The Certified Alcohol and Drug Counselor Associate should not use the affiliation with the California Association of Certified Alcohol and Drug Counselor Associates for purposes that are not consistent with the stated purposes of the Association.

The Certified Alcohol and Drug Counselor Associate should not associate with or permit the counselor's name to be used in connection with any services or products in a way that is incorrect or misleading.

d. The Certified Alcohol and Drug Counselor Associate associated with the development or promotion of books or other products offered for commercial sale should be responsible for ensuring that such books or products are presented in a professional and factual way.

Principle 5: Public Statements
The Certified Alcohol and Drug Counselor Associate should respect the limits of present knowledge in public statements concerning alcoholism and other forms of drug addiction.

The Certified Alcohol and Drug Counselor Associate who represents the field of alcoholism counseling to clients, other professionals, or to the general public should report fairly and accurately the appropriate information.

The Certified Alcohol and Drug Counselor Associate should acknowledge and document materials and techniques used.

c. The Certified Alcohol and Drug Counselor Associate who conducts training in alcoholism or drug abuse counseling skills or techniques should indicate to the audience the requisite training/qualifications required to properly perform these skills and techniques.

Principle 6: Publication Credit
The Certified Alcohol and Drug Counselor Associate should assign credit to all who have contributed to the published material and for the work upon which the publication is based.

The Certified Alcohol and Drug Counselor Associate should recognize joint authorship, major contributions of a professional character, made by several persons to a common project. The author who has made the principle contribution to a publication should be identified as a first listed.

b. The Certified Alcohol and Drug Counselor Associate should acknowledge in footnotes or an introductory statement minor contributions of a professional character, extensive clerical or similar assistance and other minor contributions.

The Certified Alcohol and Drug Counselor Associate should acknowledge, through specific citations, unpublished, as well as published material, that has directly influences the research or writing.

d. The Certified Alcohol and Drug Counselor Associate who complies and edits for publication the contributions of others should list oneself as editor, along with the names of those who have contributed.

Principle 7: Client Welfare
The Certified Alcohol and Drug Counselor Associate should respect the integrity and protect the welfare of the person or group with whom the counselor is working.

The Certified Alcohol and Drug Counselor Associate should define for self and others the nature and direction of loyalties and responsibilities and keep all parties concerned informed of these commitments.

The Certified Alcohol and Drug Counselor Associate, in the presence of professional conflict should be concerned primarily with the welfare of the client.

The Certified Alcohol and Drug Counselor Associate should terminate a counseling or consulting relationship when it is reasonably clear that the client is not benefiting from it.

d. The Certified Alcohol and Drug Counselor Associate, in referral cases, should assume the responsibility for the client's welfare either by termination by mutual agreement and/or by the client becoming engaged with another professional. In situations when a client refuses treatment, referral or recommendations, the alcohol and drug abuse counselor should carefully consider the welfare of the client by weighing the benefits of continued treatment or termination and should act in the best interest of the client.
e. The Certified Alcohol and Drug Counselor Associate who asks a client to reveal personal information from other professionals or allows information to be divulged should inform the client of the nature of such transactions. The information released or obtained with informed consent should be used for expressed purposes only.
f. The Certified Alcohol and Drug Counselor Associate should not use a client in a demonstration role in a workshop setting where such participation would potentially harm the client.
g. The Certified Alcohol and Drug Counselor Associate should ensure the presence of an appropriate setting for clinical work to protect the client from harm and the counselor and the profession from censure. h. The Certified Alcohol and Drug Counselor Associate should collaborate with other health care professional(s) in providing a supportive environment for the client who is receiving prescribed medications

Principle 8: Confidentiality


The Certified Alcohol and Drug Counselor Associate should embrace, as a primary obligation, the duty of protecting the privacy of clients and should not disclose confidential information acquired, in teaching, practice or investigation.
a. The Certified Alcohol and Drug Counselor Associate should inform the client and obtain agreement in areas likely to affect the client's participation including the recording of an interview, the use of interview material for training purposes, and observation of an interview by another person.
b. The Certified Alcohol and Drug Counselor Associate should make provisions for the maintenance of confidentiality and the ultimate disposition of confidential records.
c. The Certified Alcohol and Drug Counselor Associate should reveal information received in confidence only when there is clear and imminent danger to the client or to other persons, and then only to appropriate professional workers or public authorities.
d. The Certified Alcohol and Drug Counselor Associate should discuss the information obtained in clinical or consulting relationships only in appropriate settings, and only for professional purposes clearly concerned with the case. Written and oral reports should present only data germane to the purpose of the evaluation and every effort should be made to avoid undue invasion of privacy.
e. The Certified Alcohol and Drug Counselor Associate should use clinical and other material in classroom teaching and writing only when the identity of the persons involved is adequately disguised.

Principle 9: Client Relationships
The Certified Alcohol and Drug Counselor Associate should inform the prospective client of the important aspects of the potential relationship.
a. The Certified Alcohol and Drug Counselor Associate should inform the client and obtain the client's agreement in areas likely to affect the client's participation including the recording of an interview, the use of interview material for training purposes, and/or observation of an interview by another person.
b. The Certified Alcohol and Drug Counselor Associate should inform the designated guardian or responsible person of the circumstances, which may influence the relationship, when the client is a minor or incompetent.
c. The Certified Alcohol and Drug Counselor Associate should not enter into a professional relationship with members of one's own family, intimate friends or close associates, or others whose welfare might be jeopardized by such a dual relationship.

The Certified Alcohol and Drug Counselor Associate should not engage in any type of sexual activity with a client.

The Certified Alcohol and Drug Counselor Associate shall not accept as clients anyone with whom they have engaged in sexual behavior.

Principle 10: Interprofessional Relationships
The Certified Alcohol and Drug Counselor Associate should treat colleagues with respect, courtesy and fairness, and should afford the same professional courtesy to other professionals. a. The Certified Alcohol and Drug Counselor Associate should not offer professional services to a client in counseling with another professional except with the knowledge of the other professional or after the termination of the client's relationship with the other professional.

The Certified Alcohol and Drug Counselor Associate should cooperate with duly constituted professional ethics committees and promptly supply necessary information unless constrained by the demands of confidentiality.

The Certified Alcohol and Drug Counselor Associate shall not in any way exploit relationships with supervisees, employees, students, research participants or volunteers.

Principle 11: Remuneration
The Certified Alcohol and Drug Counselor Associate should establish financial arrangements in professional practice and in accordance with the professional standards that safeguard the best interests of the client, of the counselor and of the profession.
a. The Certified Alcohol and Drug Counselor Associate shall inform the client of all financial policies. In circumstances where an agency dictates explicit provisions with its staff for private consultations, clients shall be made fully aware of these policies.
b. The Certified Alcohol and Drug Counselor Associate should not send or receive any commission or rebate or any other form of remuneration for referral of clients for professional services. The counselor should not engage in fee splitting.
c. The Certified Alcohol and Drug Counselor Associate in clinical or counseling practice should not use one's relationship with clients to promote personal gain or the profit of an agency or commercial enterprise of any kind.
d. The Certified Alcohol and Drug Counselor Associate should not accept a private fee or any other gift or gratuity for professional work with a person who is entitled to such services though an institution or agency. The policy of a particular agency may make explicit provisions for private work with its client by members of its staff, and in such instances the client must be fully apprised of all policies affecting the client.

Principle 12: Societal Obligations
The Certified Alcohol and Drug Counselor Associate should advocate changes in public policy and legislation to afford opportunity and choice for all persons whose lives are impaired by the disease of alcoholism and other forms of drug addiction. The counselors should inform the public through active civic and professional participation in community affairs of the effects of alcoholism and drug addiction and should act to guarantee that all persons, especially the needy and disadvantaged, have access to the necessary resources and services. The Certified Alcohol and Drug Counselor Associate should adopt a personal and professional stance, which promotes the well being of all human beings.

The CCBADC is comprised of certified counselors who, as responsible health care professionals, believe in the dignity and worth of human beings. In practice of their profession they assert that the ethical principles of autonomy, beneficence and justice must guide their professional conduct. As professionals dedicated to the treatment of alcohol and drug dependent clients and their families, they believe that they can effectively treat its individual and families manifestations. CCBADC certified counselors dedicate themselves to promote the best interest of their society, of their clients, of their profession, and of their colleagues.

NAADAC Code of Ethics

Principle 1: Non-Discrimination
I shall affirm diversity among colleagues or clients regardless of age gender, sexual orientation, ethnic/racial background, religious/spiritual beliefs, marital status, political beliefs, or mental/physical disability and veteran status.

• I shall strive to treat all individuals with impartiality and objectivity relating to all based solely on their personal merits and mindful of the dignity of all human persons. As such, I shall not impose my personal values on my clients.
• I shall avoid bringing personal or professional issues into the counseling relationship. Through an awareness of the impact of stereotyping and discrimination, I shall guard the individual rights and personal dignity of my clients.
• I shall relate to all clients with empathy and understanding no matter what their diagnosis or personal history.

Principle 2: Client Welfare
I understand that the ability to do good is based on an underlying concern for the well being of others. I shall act for the good of others and exercise respect, sensitivity, and insight. I understand that my primary professional responsibility and loyalty is to the welfare of my clients, and I shall work for the client irrespective of who actually pays his/her fees.

• I shall do everything possible to safeguard the privacy and confidentiality of client information except where the client has given specific, written, informed, and limited consent or when the client poses a risk to himself or others.
• I shall provide the client his/her rights regarding confidentiality, in writing, as part of informing the client of any areas likely to affect the client's confidentiality.
• I understand and support all that will assist clients to a better quality of life, greater freedom, and true independence.
• I shall not do for others what they can readily do for themselves but rather, facilitate and support the doing. Likewise, I shall not insist on doing what I perceive as good without reference to what the client perceives as good and necessary.
• I understand that suffering is unique to a specific individual and not of some generalized or abstract suffering, such as might be found in the understanding of the disorder. I also understand that the action taken to relieve suffering must be uniquely suited to the suffering individual and not simply some universal prescription.
• I shall provide services without regard to the compensation provided by the client or by a third party and shall render equally appropriate services to individuals whether they are paying a reduced fee or a full fee.

Principle 3: Client Relationship
I understand and respect the fundamental human right of all individuals to self-determination and to make decisions that they consider in their own best interest. I shall be open and clear about the nature, extent, probable effectiveness, and cost of those services to allow each individual to make an informed decision of their care.

• I shall provide the client and/or guardian with accurate and complete information regarding the extent of the potential professional relationship, such as the Code of Ethics and professional loyalties and responsibilities.
• I shall inform the client and obtain the client's participation including the recording of the interview, the use of interview material for training purposes, and/or observation of an interview by another person.

Principle 4: Trustworthiness
I understand that effectiveness in my profession is largely based on the ability to be worthy of trust, and I shall work to the best of my ability to act consistently within the bounds of a known moral universe, to faithfully fulfill the terms of both personal and professional commitments, to safeguard fiduciary relationships consistently, and to speak the truth as it is known to me.

• I shall never misrepresent my credentials or experience.
• I shall make no unsubstantiated claims for the efficacy of the services I provide and make no statements about the nature and course of addictive disorders that have not been verified by scientific inquiry.
• I shall constantly strive for a better understanding of addictive disorders and refuse to accept supposition and prejudice as if it were the truth.
• I understand that ignorance in those matters that should be known does not excuse me from the ethical fault of misinforming others.
• I understand the effect of impairment on professional performance and shall be willing to seek appropriate treatment for myself or for a colleague. I shall support peer assistance programs in this respect.
• I understand that most property in the healing professions is intellectual property and shall not present the ideas or formulations of others as if they were my own. Rather, I shall give appropriate credit to their originators both in written and spoken communication.
• I regard the use of any copyrighted material without permission or the payment of royalty to be theft.

Principle 5: Compliance with Law
I understand that laws and regulations exist for the good ordering of society and for the restraint of harm and evil, and I am aware of those laws and regulations that are relevant both personally and professionally and follow them, while reserving the right to commit civil disobedience.

• I understand that the determination that a law or regulation is unjust is not a matter of preference or opinion but a matter of rational investigation, deliberation, and dispute.
• I willingly accept that there may be a penalty for justified civil disobedience, and I must weigh the personal harm of that penalty against the good done by civil protest.

Principle 6: Rights and Duties
I understand that personal and professional commitments and relationships create a network of rights and corresponding duties. I shall work to the best of my ability to safeguard the natural and consensual rights of each individual and fulfill those duties required of me.

• I understand that justice extends beyond individual relationships to the community and society; therefore, I shall participate in activities that promote the health of my community and profession.
• I shall, to the best of my ability, actively engage in the legislative processes, educational institutions, and the general public to change public policy and legislation to make possible opportunities and choice of service for all human beings of any ethnic or social background whose lives are impaired by alcoholism and drug abuse.
• I understand that the right of confidentiality cannot always be maintained if it serves to protect abuse, neglect, or exploitation of any person or leaves another at risk of bodily harm.

Principle 7: Dual Relationships
I understand that I must seek to nurture and support the development of a relationship of equals rather than to take unfair advantage of individuals who are vulnerable and exploitable.

• I shall not engage in professional relationships or commitments that conflict with family members, friends, close associates, or others whose welfare might be jeopardized by such a dual relationship.
• Because a relationship begins with a power differential, I shall not exploit relationships with current or former clients for personal gain, including social or business relationships.
• I shall not under any circumstances engage in sexual behavior with current or former clients.
• I shall not accept substantial gifts from clients, other treatment organizations, or the providers of materials or services used in my practice.

Principle 8: Preventing Harm
I understand that every decision and action has ethical implication leading either to benefit or harm, and I shall carefully consider whether any of my decisions or actions has the potential to produce harm of a physical, psychological, financial, legal, or spiritual nature before implementing them.

• I shall refrain from using any methods that could be considered coercive such as threats, negative labeling, and attempts to provoke shame or humiliation.
• I shall make no requests of clients that are not necessary as part of the agreed treatment plan.
• I shall terminate a counseling or consulting relationship when it is reasonably clear that the client is not benefiting from the relationship.
• I understand an obligation to protect individuals, institutions, and the profession from harm that might be done by others. Consequently, I am aware that the conduct of another individual is an actual or likely source of harm to clients, colleagues, institutions, or the profession, and that I have an ethical obligation to report such conduct to competent authorities.

Principle 9: Duty of Care
I shall operate under the principle of Duty of Care and shall maintain a working/therapeutic environment in which clients, colleagues, and employees can be safe from the threat of physical, emotional or intellectual harm.

• I respect the right of others to hold spiritual opinions, beliefs, and values different from my own.
• I shall strive for understanding and the establishment of common ground rather than for the ascendancy of one opinion over another.
• I shall maintain competence in the area of my practice through continuing education, constantly improving my knowledge and skills in those approaches most effective with my specific clients.
• I shall scrupulously avoid practicing in any area outside of my competence.

Updated August 18, 2008

The Confidentiality Of Alcohol And Drug Abuse Patient Records Regulation and the HIPAA Privacy Rule: Implications For Alcohol and Substance Abuse Programs
http://www.hipaa.samhsa.gov/Part2privacyrule.htm
II. How the Privacy Rule affects disclosures of information
A. The General Rule

The "general rules" established by Part 2 and the Privacy Rule regarding uses and disclosures of patient health information are very different.¹⁰

Substance abuse treatment programs must comply with both rules. Generally, this will mean that they will continue to follow Part 2's general rule and not disclose information unless they can obtain consent or point to an exception to that rule that specifically permits the disclosure. Programs must then make sure that the disclosure is also permissible under the Privacy Rule.

B. When disclosures are permitted
1. Part 2 Consent11 and Privacy Rule Authorization

42 CFR Part 2 Programs may not use or disclose any information about any patient unless the patient has consented in writing (on a form that meets the requirements established by the regulations) or unless another very limited exception specified in the regulations applies. Any disclosure must be limited to the information necessary to carry out the purpose of the disclosure.

The Privacy Rule The Privacy Rule permits uses and disclosures for "treatment, payment and health care operations" as well as certain other disclosures without the individual's prior written authorization. Disclosures not otherwise specifically permitted or required by the Privacy Rule must have an authorization that meets certain requirements. With certain exceptions, the Privacy Rule generally requires that uses and disclosures of PHI be the minimum necessary for the intended purpose of the use or disclosure.

Substance abuse treatment programs most often make disclosures after a patient has signed a consent form that meets the requirements of 42 CFR ?2.31. Note that a disclosure under Part 2 includes the acknowledgment that someone has applied to or is enrolled in the program, and thus is only permitted if the patient has signed a consent form (or another of the regulations' narrow exceptions applies). See 42 CFR ??2.11 and 2.13. A Part 2 consent form must include the following elements:

• Name or general designation of the program or person permitted to make the disclosure;
• Name or title of the individual or name of the organization to which disclosure is to be made;
• Name of the patient;
• Purpose of the disclosure;
• How much and what kind of information is to be disclosed;
• Signature of patient (and, in some States, a parent or guardian);
• Date on which consent is signed;
• Statement that the consent is subject to revocation at any time except to the extent that the program has already acted on it; and
• Date, event, or condition upon which consent will expire if not previously revoked.

When programs operating under Part 2 disclose information pursuant to a consent form, they must include a written statement that the information cannot be redisclosed. See 42 CFR ?2.32.

The core required elements for the Privacy Rule written authorization are similar to those of Part 2. However, to comply with the Privacy Rule authorization requirements, the Part 2 consent must also contain a statement reflecting the ability or inability of the substance abuse treatment program to condition treatment on whether the patient signs the form as described in 45 CFR ?164.508(c)(2)(ii). In addition, the consent may be signed by a personal representative, and if so, must include a description of such representative's authority to act for the patient. See 45 CFR ?164.508(c)(1)(vi). Finally, the consent must be written in plain language. See 45 CFR ?164.508(c)(3).

The requirements above must be met with respect to the Part 2 consent form when the purpose of the disclosure is not for "treatment, payment or health care operations" or for any other permitted or required disclosure under the Privacy Rule. See 45 CFR ?164.502(a).12 The statements would have to be added when the consent form authorizes a program to make a disclosure for which an authorization is required under the Privacy Rule, e.g., those disclosures addressed by 45 CFR ?164.508.

The Privacy Rule imposes three additional steps programs must take when disclosing information pursuant to a patient's written consent:

• Programs must ensure that the consent complies with the applicable requirements of 45 CFR ?164.508.
• Programs must give patients a copy of the signed form (45 CFR ?164.508(c)(4)).
• Programs must keep a copy of each signed form for six (6) years from its expiration date (45 CFR ?164.508(b)(6)).

Therefore, substance abuse treatment programs should generally continue to use the consent form for disclosures subject to Part 2. If the Privacy Rule requires authorization for the disclosures, the substance abuse treatment program may use the Part 2 consent form with additional elements required by the Privacy Rule as listed above. ?

Client Welfare
The primary responsibility of counselors is to respect the dignity and to promote the welfare of their clients. Counselors encourage client growth and development in ways that foster the client's interest and welfare; Counselors avoid fostering dependent counseling relationships.

Counselors and their clients work jointly in devising integrated, individual counseling plans that offer reasonable promise of success and are consistent with abilities and circumstances of clients. Counselors and clients regularly review counseling plans to ensure their continued viability and effectiveness, respecting client's freedom of choice.

Counselors recognize that families are usually important in client's lives and strive to enlist family understanding and involvement as a positive resource, when appropriate. Counselors work with their clients in considering employment in jobs and circumstances that are consistent with the clients overall abilities, vocational limitations, physical restrictions, general temperament, interest and aptitude patterns, social skills, education, general qualifications, and other relevant characteristics and needs. Counselors neither place nor participate in placing clients in positions that will result in damaging the interest and the welfare of clients, employers, or the public.

Competence
Counselors cannot practice outside of their scope of practice. This means that they must only practice in areas in which they have been trained. Scope of practice is defined for the entire profession, whereas scope of competence is different for each individual counselor.

Respecting Diversity
Counselors do not condone or engage in discrimination based on age, color, culture, disability, ethnic group, gender, race, religion, sexual orientation, marital status, or socioeconomic status. Counselors will actively attempt to understand the diverse cultural backgrounds of the clients with whom they work. This includes, but is not limited to; learning how the Counselors own cultural/ethnic/racial identity impacts her or his values and beliefs about the counseling process.

Client Rights
When counseling is initiated, and throughout the counseling process as necessary, counselors informs their clients of the purposes, goals, techniques, procedures, limitations, potential risks, and benefits of services to be performed, and other pertinent information. Counselors take steps to ensure that clients understand the implications of diagnosis, the intended use of tests and reports, fees, and billing arrangements.

A counselor must disclose their fee prior to the beginning of the first session, preferably prior to the first session. A counselor working for an organization must disclose the name of the owner of any fictitious business name.

Clients have the right to expect confidentiality and to be provided with an explanation of its limitations, including supervision and/or treatment team professionals; to obtain clear information about their case records; to participate in the ongoing counseling plans; and to refuse any recommended services and be advised of the consequences of such refusal.

Counselors offer clients the freedom to choose whether to enter into a counseling relationship and to determine which professionals will provide counseling. Restrictions that limit choices of clients are fully explained. When counseling minors or persons unable to give voluntary informed consent, counselors act in the clients best interests.

Confidentiality
Counselors respect their client's right to privacy and avoid illegal and unwarranted disclosures of confidential information. The right to privacy may be waived by the client or his or her legally recognized representative. The general requirement that counselors keep information confidential does not apply when disclosure is required to prevent clear and imminent danger to the client or others or when legal requirements demand that confidential information be revealed. Counselors consult with other professionals when in doubt as to the validity of an exception.
When court ordered to release confidential information without the client's permission, counselors request to the court that the disclosure not be required due to potential harm to the client or counseling relationship.
When circumstances require the disclosure of confidential information, only essential information is revealed. To the extent possible, clients are informed before confidential information is disclosed. When counseling is initiated and throughout the counseling process as necessary, counselors need to inform their clients of the limitations of confidentiality and identify foreseeable situations in which confidentiality must be breached. Counselors make every effort to ensure that privacy and confidentiality of clients are maintained by subordinates including employees, supervisees, clerical assistants, and volunteers. If client treatment will involve a continued review by a treatment team, the client will be informed of the team's existence and composition.
Groups and Families
In group work, counselors clearly define confidentiality for the specific group, explain its importance, and discuss the difficulties related to confidentiality involved in group work. The fact that confidentiality cannot be guaranteed is clearly communicated to group members. In family counseling, information about one family member cannot be disclosed to another member without permission. Counselors protect the privacy rights of each family member.
Minor or Incompetent Clients
When counseling clients who are minors or individuals who are unable to give informed consent voluntary, parents or guardians may be included in the counseling process if appropriate. Counselors act in the best interests of the clients and take care to safeguard their confidentiality.
Records
Counselors maintain records necessary for rendering professional services to their clients and as required by laws, regulations, or agency or institution procedures.
Counselors are responsible for securing the safety and confidentiality of any counseling records they create, maintain, transfer, or destroy whether the records are written, taped, computerized, or stored in any other medium.
Counselors obtain permission from clients prior to electronically recording or observing sessions. Counselors recognize that counseling records are kept for the benefit of clients, and therefore provide access to records and copies of records when requested by competent clients, unless the records contain information that may be misleading and detrimental to the client. In situations involving multiple clients, access to records is limited to those parts of records that do not include confidential information related to another client.
Counselors must obtain written permission from clients to disclose or transfer records to legitimate third parties unless exceptions to confidentiality exist. Steps are taken to ensure that receivers of counseling records are sensitive to their confidential nature.
Parents, generally have access to their child's records, unless:

• Minor has access to the records
• It would have a detrimental effect on the relationship
• It would have a detrimental effect on the child's safety or psychological wellness.

If a patient asks to see his records you can refuse, offer a treatment summary or let them see your records. If you choose to release a summary to the client, court or any other request, you should include: Chief complaints, Pertinent history, diagnosis, referrals, treatment plan, prognosis, tests, and progress.

When releasing records or summaries you should always have the client's permission in writing. You can only refuse to let your client see your records only if you think it would be detrimental to your client. If you refuse to show your client their records you must document the date of refusal, the reason for the refusal and that you chose to refuse your client access to the records.

Clients Served by Others
If a client is receiving services from another mental health professional, counselors, with client consent, inform the professional persons already involved and develop clear agreements to avoid confusion and conflict for the client.
Personal Needs and Values
In the counseling relationship, Counselors are aware of the intimacy and responsibilities in the counseling relationship, maintain respect for clients, and avoid actions that seek to meet their personal needs at the expense of clients.

Counselors are aware of their own values, attitudes, beliefs, and behaviors and how these apply in a diverse society, and avoid imposing their values on clients.

Dual Relationships
Counselors are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of clients. Counselors make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of harm to clients. Examples of such relationships include, but are not limited to, familial, social, financial, business, or close personal relationships with clients. When a dual relationship cannot be avoided, Counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs.

Counselors do not accept superiors or subordinates with whom they have administrative, supervisory, or evaluative relationships as clients.

Sexual Intimacies with Clients
Counselors do not have any type of sexual intimacies with clients and do not counsel persons with whom they have had a sexual relationship.

Multiple Clients
When counselors agree to provide counseling services to two or more persons who have a relationship, such as husband and wife, or parents and children, counselors clarify at the outset which person or persons are clients and the nature of the relationships they will have with each involved person. If it becomes apparent that counselors may be called upon to perform potentially conflicting roles, they clarify, adjust, or withdraw from roles appropriately.
Group Work
Counselors screen prospective group counseling/therapy participants. To the extent possible, counselors select members whose needs and goals are compatible with goals of the group, who will not impede the group process, and whose well-being will not be jeopardized by the group experience. In a group setting, counselors take reasonable precautions to protect clients from physical or psychological trauma.

Fees and Bartering
Counselors clearly explain to clients, prior to entering the counseling relationship, all financial arrangements related to professional services including the use of collection agencies or legal measures for nonpayment.

In establishing fees for professional counseling services, counselors consider the financial status of clients and locality. In the event that the established fee structure is inappropriate for a client, assistance is provided in attempting to find comparable services of acceptable cost.

Counselors ordinarily refrain from accepting goods or services from clients in return for counseling services because such arrangements create inherent potential for conflicts, exploitation, and distortion of the professional relationship. Counselors may participate in bartering only if the relationship is not exploitative, if the client requests it, if a clear written contract is established, and if such arrangements are an accepted practice among professionals in the community. However, bartering can be complicated and therefore may become unethical.

Counselors contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return (pro bono).

Termination and Referral
Counselors do not abandon or neglect clients in counseling. Counselors assist in making appropriate arrangements for the continuation of treatment, when necessary, during interruptions such as vacations, and following termination.

If counselors determine an inability to be of professional assistance to clients, they avoid entering or immediately terminate a counseling relationship. Counselors are knowledgeable about referral resources and suggest appropriate alternatives. If clients decline the suggested referral, Counselors should discontinue the relationship.

Counselors terminate a counseling relationship (securing client agreement when possible), when it is reasonably clear that the client is no longer benefiting, when services are no longer required, when counseling no longer serves the clients needs or interests, when clients do not pay fees charged, or when agency or institution limits do not allow provision of further counseling services.

Computer Technology
When computer applications are used in counseling services, counselors ensure that: the client is intellectually, emotionally, and physically capable of using the computer application; the computer application is appropriate for the needs of the client; the client understands the purpose and operation of the computer applications; and a follow-up of client use of a computer application is provided to correct possible misconceptions, discover inappropriate use, and assess subsequent needs.
Research and Training
Use of data derived from counseling relationships for purposes of training, research, or publication is confined to content that is disguised to ensure the anonymity of the individuals involved. Identification of a client in a presentation or publication is permissible only when the client has reviewed the material and has agreed to its presentation or publication.
Professional Responsibility
Counselors have a responsibility to read, understand, and follow the Code of Ethics and the Standards of Practice.
Professional Competence
Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Counselors will demonstrate a commitment to gain knowledge, personal awareness, sensitivity, and skills pertinent to working with a diverse client population.

Counselors practice in specialty areas new to them only after appropriate education, training, and supervised experience. While developing skills in new specialty areas, Counselors take steps to ensure the competence of their work and to protect others from possible harm.

Counselors accept employment only for positions for which they are qualified by education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Counselors hire for professional counseling positions only individuals who are qualified and competent.

Counselors continually monitor their effectiveness as professionals and take steps to improve when necessary. Counselors in private practice take reasonable steps to seek out peer supervision to evaluate their effectiveness as counselors. Counselors take reasonable steps to consult with other counselors or related professionals when they have questions regarding their ethical obligations or professional practice. Counselors recognize the need for continuing education to maintain a reasonable level of awareness of current scientific and professional information. They take steps to maintain competence in the skills they use, are open to new interventions, and keep current with the diverse populations that they work with.

Counselors refrain from offering or accepting professional services when their physical, mental, or emotional problems are likely to harm a client or others. They are alert to the signs of impairment, seek assistance for problems, and, if necessary, limit, suspend, or terminate their professional responsibilities.

Advertising and Soliciting Clients
There are no restrictions on advertising by counselors except those that can be specifically justified to protect the public from deceptive practices. Counselors advertise or represent their services to the public by identifying their credentials in an accurate manner that is not false, misleading, deceptive, or fraudulent. Counselors may only advertise the highest degree earned which is in counseling or a closely related field from a college or university that was accredited when the degree was awarded.

Counselors who develop products related to their profession or conduct workshops or training events ensure that the advertisements concerning these products or events are accurate and disclose adequate information for consumers to make informed choices.

Counselors do not use counseling, teaching, training, or supervisory relationships to promote their products or training events in a manner that is deceptive or would exert undue influence on individuals who may be vulnerable. Counselors may utilize textbooks they have authored for instruction purposes.

Credentials
Counselors claim or imply only professional credentials possessed and are responsible for correcting any known misrepresentations of their credentials by others. Professional credentials include graduate degrees in counseling or closely related mental health fields, accreditation of graduate programs, national voluntary certifications, government-issued certifications or licenses, or any other credential that might indicate to the public specialized knowledge or expertise in counseling. Counselors follow the guidelines for use of credentials that have been established by the entities that issue the credentials. Counselors do not attribute more to their credentials than the credentials represent, and do not imply that other counselors are not qualified because they do not possess certain credentials. Counselors who hold a master's degree in counseling or a closely related mental health field, but hold a doctoral degree from other than counseling or a closely related field, can not use the title "Dr." in their practices and do not announce to the public in relation to their practice or status as a counselor that they hold a doctorate.
Public Responsibility
Counselors do not discriminate against clients, students, or supervisees in a manner that has a negative impact based on their age, color, culture, disability, ethnic group, gender, race, religion, sexual orientation, or socioeconomic status, or for any other reason. Counselors do not engage in sexual harassment. Sexual harassment is defined as sexual solicitation, physical advances, or verbal or nonverbal conduct that is sexual in nature, that occurs in connection with professional activities or roles, and that either is unwelcome, is offensive, or creates a hostile workplace environment, and counselors know or are told this; or is sufficiently severe or intense to be perceived as harassment to a reasonable person in the context. Sexual harassment can consist of a single intense or severe act or multiple persistent or pervasive acts.

Counselors are accurate, honest, and unbiased in reporting their professional activities and judgments to appropriate third parties including courts, health insurance companies, those who are the recipients of evaluation reports, and others.

When Counselors provide advice or comment by means of public lectures, demonstrations, radio or television programs, prerecorded tapes, printed articles, mailed material, or other media, they take reasonable precautions to ensure that: the statements are based on appropriate professional counseling literature and practice; the statements are otherwise consistent with the Code of Ethics and the Standards of Practice; and the recipients of the information are not encouraged to infer that a professional counseling relationship has been established.

Counselors do not use their professional positions to seek or receive unjustified personal gains, sexual favors, unfair advantage, or unearned goods or services.

Responsibility to Other Professionals
Counselors are respectful of approaches to professional counseling that differ from their own. Counselors know and take into account the traditions and practices of other professional groups with which they work.

When making personal statements in a public context, Counselors clarify that they are speaking from their personal perspectives and that they are not speaking on behalf of all counselors or the profession. When Counselors learn that their clients are in a professional relationship with another mental health professional, they request release from clients to inform the other professionals and strive to establish positive and collaborative professional relationships.

Relationships with Employers and Employees
Counselors define and describe for their employers and employees their job description and the levels of their professional roles.

Counselors establish working agreements with supervisors, colleagues, and subordinates regarding counseling or clinical relationships, confidentiality, and adherence to professional standards, distinction between public and private material, maintenance and dissemination of recorded information, work load, and accountability. Working agreements in each instance are specified and made known to those concerned.

Counselors alert their employers to conditions that may be potentially disruptive or damaging to the counselor's professional responsibilities or that may limit their effectiveness. Counselors submit regularly to professional review and evaluation by their supervisor or the appropriate representative of the employer. Counselors are responsible for in-service development of self and staff. Counselors inform their staff of goals and programs. Counselors provide personnel and agency practices that respect and enhance the rights and welfare of each employee and recipient of agency services. Counselors strive to maintain the highest levels of professional services.

Counselors select competent staff and assign responsibilities compatible with their skills and experiences. Counselors, as either employers or employees, do not engage in or condone practices that are inhumane, illegal, or unjustifiable (such as considerations based on age, color, culture, disability, ethnic group, gender, race, religion, sexual orientation, or socioeconomic status) in hiring, promotion, or training. Counselors have a responsibility both to clients and to the agency or institution within which services are performed to maintain high standards of professional conduct. Counselors do not engage in exploitative relationships with individuals over whom they have supervisory, evaluative, or instructional control or authority. The acceptance of employment in an agency or institution implies that counselors are in agreement with its general policies and principles. Counselors strive to reach agreement with employers as to acceptable standards of conduct that allow for changes in institutional policy conducive to the growth and development of clients.

Consultation
Counselors may choose to consult with any other professionally competent persons about their clients. In choosing consultants, counselors avoid placing the consultant in a conflict of interest situation that would exclude the consultant being a proper party to the counselor's efforts to help the client. Should Counselors be engaged in a work setting that compromises this consultation standard, they consult with other professionals whenever possible to consider justifiable alternatives. Counselors are reasonably certain that they have or the organization represented has the necessary competencies and resources for giving the kind of consulting services needed and that appropriate referral resources are available.

When providing consultation, counselors attempt to develop with their clients a clear understanding of problem definition, goals for change, and predicted consequences of interventions selected. The consulting relationship is one in which client adaptability and growth toward self-direction are consistently encouraged and cultivated.
Fees for Referral
Counselors refuse a private fee or other remuneration for rendering services to persons who are entitled to such services through the counselor's employing agency or institution. The policies of a particular agency may make explicit provisions for agency clients to receive counseling services from members of its staff in private practice. In such instances, the clients must be informed of other options open to them should they seek private counseling services. Counselors do not accept a referral fees from other professionals.

Subcontractor Arrangements
When counselors work as subcontractors for counseling services for a third party, they have a duty to inform clients of the limitations of confidentiality that the organization may place on counselors in providing counseling services to clients. The limits of such confidentiality ordinarily are discussed as part of the intake session.

Evaluation, Assessment, and Interpretation
The primary purpose of educational and psychological assessment is to provide measures that are objective and interpretable in either comparative or absolute terms. Counselors recognize the need to interpret the statements in this section as applying to the whole range of appraisal techniques, including test and non-test data.

Counselors promote the welfare and best interests of the client in the development, publication, and utilization of educational and psychological assessment techniques. They do not misuse assessment results and interpretations and take reasonable steps to prevent others from misusing the information these techniques provide. They respect the client's right to know the results, the interpretations made, and the bases for their conclusions and recommendations.

Competence to Use and Interpret Tests
Counselors recognize the limits of their competence and perform only those testing and assessment services for which they have been trained. They are familiar with reliability, validity, related standardization, error of measurement, and proper application of any technique utilized. Counselors using computer-based test interpretations are trained in the test being measured and the specific instrument being used prior to using this type of computer application. Counselors take reasonable measures to ensure the proper use of psychological assessment techniques by persons under their supervision.

Counselors are responsible for the appropriate application, scoring, interpretation, and uses of assessment instruments, whether they score and interpret such tests themselves or use computerized or other services.

Counselors responsible for decisions involving individuals or policies that are based on assessment results have a thorough understanding of educational and psychological measurement, including validation criteria, test research, and guidelines for test development and use.

Counselors provide accurate information and avoid false claims or misconceptions when making statements about assessment instruments or techniques. Special efforts are made to avoid unwarranted connotations of such terms as IQ and grade equivalent scores.

Informed Consent
Prior to assessment, Counselors explain the nature and purposes of assessment and the specific use of results in language the client (or other legally authorized person on behalf of the client) can understand, unless an explicit exception to this right has been agreed upon in advance. Regardless of whether scoring and interpretation are completed by counselors, by assistants, or by computer or other outside services, counselors take reasonable steps to ensure that appropriate explanations are given to the client.

The examinee's welfare, explicit understanding, and prior agreement determine the recipients of test results. Counselors include accurate and appropriate interpretations with any release of individual or group test results.

Release of Information to Competent Professionals
Counselors do not misuse assessment results, including test results, and interpretations, and take reasonable steps to prevent the misuse of such by others.

Counselors ordinarily release data (e.g., protocols, counseling or interview notes, or questionnaires) in which the client is identified only with the consent of the client or the clients legal representative. Such data are usually released only to persons recognized by Counselors as competent to interpret the data.

Proper Diagnosis of Mental Disorders
Counselors take special care to provide proper diagnosis of mental disorders. Assessment techniques (including personal interview) used to determine client care (e.g., locus of treatment, type of treatment, or recommended follow-up) are carefully selected and appropriately used. Counselors recognize that culture affects the manner in which clients' problems are defined. Clients' socioeconomic and cultural experience is considered when diagnosing mental disorders.

Test Selection
Counselors carefully consider the validity, reliability, psychometric limitations, and appropriateness of instruments when selecting tests for use in a given situation or with a particular client. Counselors are cautious when selecting tests for culturally diverse populations to avoid inappropriateness of testing that may be outside of socialized behavioral or cognitive patterns.
Conditions of Test Administration
Counselors administer tests under the same conditions that were established in their standardization. When tests are not administered under standard conditions or when unusual behavior or irregularities occur during the testing session, those conditions are noted in interpretation, and the results may be designated as invalid or of questionable validity.

Counselors are responsible for ensuring that administration programs function properly to provide clients with accurate results when a computer or other electronic methods are used for test administration. Counselors do not permit unsupervised or inadequately supervised use of tests or assessments unless the tests or assessments are designed, intended, and validated for self-administration and/or scoring. Prior to test administration, conditions that produce most favorable test results are made known to the examinee.

Diversity in Testing
Counselors are cautious in using assessment techniques, making evaluations, and interpreting the performance of populations not represented in the norm group on which an instrument was standardized. They recognize the effects of age, color, culture, disability, ethnic group, gender, race, religion, sexual orientation, and socioeconomic status on test administration and interpretation and place test results in proper perspective with other relevant factors.

Test Scoring and Interpretation
In reporting assessment results, Counselors indicate any reservations that exist regarding validity or reliability because of the circumstances of the assessment or the inappropriateness of the norms for the person tested. Counselors exercise caution when interpreting the results of research instruments possessing insufficient technical data to support respondent results. The specific purposes for the use of such instruments are stated explicitly to the examinee. Counselors who provide test scoring and test interpretation services to support the assessment process confirm the validity of such interpretations. They accurately describe the purpose, norms, validity, reliability, and applications of the procedures and any special qualifications applicable to their use. The public offering of an automated test interpretations service is considered a professional-to-professional consultation. The formal responsibility of the consultant is to the consultee, but the ultimate and overriding responsibility is to the client.

Counselors maintain the integrity and security of tests and other assessment techniques consistent with legal and contractual obligations. Counselors do not appropriate, reproduce, or modify published tests or parts thereof without acknowledgment and permission from the publisher.

Counselors do not use data or test results that are obsolete or outdated for the current purpose. Counselors make every effort to prevent the misuse of obsolete measures and test data by others. Teaching, Training, and Supervision

Counselor Educators and Trainers
Counselors who are responsible for developing, implementing, and supervising educational programs are skilled as teachers and practitioners. They are knowledgeable regarding the ethical, legal, and regulatory aspects of the profession, are skilled in applying that knowledge, and make students and supervisees aware of their responsibilities. Counselors conduct counselor education and training programs in an ethical manner and serve as role models for professional behavior. Counselor educators should make an effort to infuse material related to human diversity into all courses and/or workshops that are designed to promote the development of counselors.

Counselors clearly define and maintain ethical, professional, and social relationship boundaries with their students and supervisees. They are aware of the differential in power that exists and the student's or supervisee's possible incomprehension of that power differential. Counselors explain to students and supervisees the potential for the relationship to become exploitive. Counselors do not engage in sexual relationships with students or supervisees and do not subject them to sexual harassment.

Counselors do not accept close relatives as students or supervisees. Counselors who offer clinical supervision services are adequately prepared in supervision methods and techniques. Counselors who are doctoral students serving as practicum or internship supervisors to master's level students are adequately prepared and supervised by the training program. Counselors who supervise the counseling services of others take reasonable measures to ensure that counseling services provided to clients are professional. Counselors do not endorse students or supervisees for certification, licensure, employment, or completion of an academic or training program if they believe students or supervisees are not qualified for the endorsement. Counselors take reasonable steps to assist students or supervisees who are not qualified for endorsement to become qualified.

Research Responsibilities
Counselors plan, design, conduct, and report research in a manner consistent with pertinent ethical principles, federal and state laws, host institutional regulations, and scientific standards governing research with human subjects. Counselors design and conduct research that reflects cultural sensitivity appropriateness.

Counselors seek consultation and observe safeguards to protect the rights of research participants when a research problem suggests a deviation from standard acceptable practices. Counselors who conduct research with human subjects are responsible for the subjects' welfare throughout the experiment and take reasonable precautions to avoid causing injurious psychological, physical, or social effects to their subjects. The ultimate responsibility for ethical research practice lies with the principal researcher. All others involved in the research activities share ethical obligations and full responsibility for their own actions.

Counselors take reasonable precautions to avoid causing disruptions in subjects' lives due to participation in research. Counselors are sensitive to diversity and research issues with special populations. They seek consultation when appropriate.

Informed Consent
In obtaining informed consent for research, Counselors use language that is understandable to research participants and that: accurately explains the purpose and procedures to be followed; identifies any procedures that are experimental or relatively untried; describes the attendant discomforts and risks; describes the benefits or changes in individuals or organizations that might be reasonably expected; discloses appropriate alternative procedures that would be advantageous for subjects; offers to answer any inquiries concerning the procedures; describes any limitations on confidentiality; and instructs that subjects are free to withdraw their consent and to discontinue participation in the project at any time.

Counselors do not conduct research involving deception unless alternative procedures are not feasible and the prospective value of the research justifies the deception. When the methodological requirements of a study necessitate concealment or deception, the investigator is required to explain clearly the reasons for this action as soon as possible. Participation in research is typically voluntary and without any penalty for refusal to participate. Involuntary participation is appropriate only when it can be demonstrated that participation will have no harmful effects on subjects and is essential to the investigation.

Information obtained about research participants during the course of an investigation is confidential. When the possibility exists that others may obtain access to such information, ethical research practice requires that the possibility, together with the plans for protecting confidentiality, be explained to participants as a part of the procedure for obtaining informed consent.

When a person is incapable of giving informed consent, Counselors provide an appropriate explanation, obtain agreement for participation, and obtain appropriate consent from a legally authorized person. Counselors take reasonable measures to honor all commitments to research participants.

After data are collected, Counselors provide participants with full clarification of the nature of the study to remove any misconceptions. Where scientific or human values justify delaying or withholding information, Counselors take reasonable measures to avoid causing harm.

Counselors who agree to cooperate with another individual in research or publication incur an obligation to cooperate as promised in terms of punctuality of performance and with regard to the completeness and accuracy of the information required.

In the pursuit of research, Counselors give sponsors, institutions, and publication channels the same respect and opportunity for giving informed consent that they give to individual research participants. Counselors are aware of their obligation to future research workers and ensure that host institutions are given feedback information and proper acknowledgment.

Reporting Results
When reporting research results, Counselors explicitly mention all variables and conditions known to the investigator that may have affected the outcome of a study or the interpretation of data. Counselors plan, conduct, and report research accurately and in a manner that minimizes the possibility that results will be misleading. They provide thorough discussions of the limitations of their data and alternative hypotheses. Counselors do not engage in fraudulent research, distort data, misrepresent data, or deliberately bias their results.

Counselors communicate to other counselors the results of any research judged to be of professional value. Results that reflect unfavorably on institutions, programs, services, prevailing opinions, or vested interests are not withheld.

Counselors who supply data, aid in the research of another person, report research results, or make original data available take due care to disguise the identity of respective subjects in the absence of specific authorization from the subjects to do otherwise.

Counselors are obligated to make available sufficient original research data to qualified professionals who may wish to replicate the study.

Resolving Ethical Issues
Knowledge of Standards
Counselors are familiar with the Code of Ethics and the Standards of Practice and other applicable ethics codes from other professional organizations of which they are a member, or from certification and licensure boards. Lack of knowledge or misunderstanding of an ethical responsibility is not a defense against a charge of unethical conduct.

Suspected Violations
Counselors expect professional associates to adhere to the Code of Ethics. When Counselors possess reasonable cause that raises doubts as to whether a counselor is acting in an ethical manner, they take appropriate action.

When uncertain as to whether a particular situation or course of action may be in violation of the Code of Ethics, counselors consult with other counselors who are knowledgeable about ethics, with colleagues, or with appropriate authorities

Organization Conflicts
If the demands of an organization with which counselors are affiliated pose a conflict with the Code of Ethics, counselors specify the nature of such conflicts and express to their supervisors or other responsible officials their commitment to the Code of Ethics. When possible, counselors work toward change within the organization to allow full adherence to the Code of Ethics.

When counselors have reasonable cause to believe that another counselor is violating an ethical standard, they attempt to first resolve the issue informally with the other counselor if feasible, providing that such action does not violate confidentiality rights that may be involved.

When an informal resolution is not appropriate or feasible, counselors, upon reasonable cause, take action such as reporting the suspected ethical violation to state or national ethics committees, unless this action conflicts with confidentiality rights that cannot be resolved.

Counselors do not initiate, participate in, or encourage the filing of ethics complaints that are unwarranted or intend to harm a counselor rather than to protect clients or the public.

Consent for Medical Care for Minors (August 07, 2001)

Parents and their teenage children often have questions concerning their rights to consent, or refuse to consent, to medical care for a child. The parent(s) or guardian of a minor child (that is, anyone under the age of eighteen years) is generally required to give informed consent for most medical decisions on behalf of that child. However, there are exceptions, and there are certain types of medical care for which minors may themselves consent. The following discusses who may consent to medical care for a minor child. The first section covers the laws which allow minors to consent to their own medical care. The second section discusses the laws which allow parents, including divorced parents and foster parents, guardians and others to consent to medical care for minors.

Laws Authorizing Minors to Consent to Treatment
Minors authorized to consent because of their status

There are two types of laws which authorize minors to consent to medical treatment. First, there are laws which authorize minors who have attained a certain status to consent to virtually all types of health care except certain irreversible and highly invasive. Minors authorized to give legal consent to medical treatment under these laws include:

Married (or divorced) minors (Family Code ??7002 and 7050(e)(1)).

Minors on active duty with the U.S. Armed Forces (Family Code ??7002 and 7050(e)(1)).

Minors emancipated by a court order (Family Code ?7120).

Self-sufficient minors (minors fifteen years or older living away from home and managing their own financial affairs) (Family Code ?6922). These minors will generally be asked to complete a form which provides information demonstrating that they fall within the statute.

Types of treatment to which minors can consent

Second, there are a number of laws which authorize minors to consent to certain types of medical treatment. Medical treatment covered by these statutes includes:

Pregnancy, Contraception and Abortion. Care for the prevention or treatment of pregnancy (including contraception and abortion, but not sterilization) for minors of any age (Family Code ?6925). (The law which would have established a parental or court approval requirement for abortion is NOT IN EFFECT.) The right of a minor to consent to pregnancy related services includes genetic counseling and testing services which, under the law, must be offered to all pregnant women. (Health & Safety Code ?125000.)

Contagious Diseases. Care of any infectious, contagious, or communicable disease of the type which must be reported to the local health officer if the minor is twelve or older. (Family Code ?6926.)

Sexually Transmitted Diseases. Care of a sexually transmitted disease if the minor is twelve or older. (Family Code ?6926.)

Rape. Care related to the diagnosis or treatment of rape if the minor is twelve or older. (Family Code ?6927.)

Sexual Assault. Care related to the diagnosis or treatment of sexual assault for a minor of any age (but the treating physician must attempt to contact the child's parents or legal guardian unless the physician "reasonably believes" that the parent or guardian committed the sexual assault). (Family Code ?6928.)

Mental Health. Mental health treatment or counseling on an out-patient basis (not including convulsive therapy, psychosurgery or psychotropic drugs), or residential shelter services, if the minor is twelve or older and mature enough to participate intelligently and either (1) the minor is an alleged victim of incest or child abuse or (2) there is danger of serious physical or mental harm to the minor or others without such treatment. (The treating physician must contact and involve the parents unless the physician believes such contact would be inappropriate.) (Family Code ?6924.) "Residential shelter services" are defined to mean the provision of residential and other support services to minors on a temporary or emergency basis in a facility which services only minors by a governmental agency or other specified entities or individuals. Minor's parent or guardian should be included in the treatment of a minor unless, it is the opinion of the treating professional, that it would be detrimental to the minor. If the treating professional does not involve the parent of guardian then they must document the reasoning in the minor's records.

Drug or Alcohol Abuse. Care related to the diagnosis or treatment of drug or alcohol-related problems (not including methadone or LAAM treatment) if the minor is twelve or older. (The treating physician must contact the parents or guardian and give them an opportunity to participate unless the physician believes such contact would be inappropriate.) Moreover, parents have the right to seek such care and obtain the resulting medical information over the child's objection. (Family Code ?6929) Federal laws prohibiting the disclosure of certain substance abuse records may control over this state law.

HIV Tests. The performance of an HIV test for minors twelve or older. (Health & Safety Code ?121020)

Confidentiality of minor's medical records
Except as otherwise provided by law or if the minor authorizes it in writing, physicians are prohibited from telling the minor's parents or legal guardian about medical care the minor was legally able to authorize. When a minor seeks medical treatment for which the minor has the legal power to consent, for example, treatment for the prevention and care of pregnancy, and the minor's parents have no knowledge of the proposed care, the physician will generally discuss with the minor the advantages of disclosing the proposed treatment to the minor's parents or guardian before services are rendered. The physician and minor should reach an understanding concerning 1) the extent to which the parents or guardians will be informed, 2) who is responsible for paying the cost of the medical treatment and 3) to whom the physician can disclose the medical information that is necessary to obtain payment for the treatment. Minors should understand that it may be impossible to keep the information from their parents if the minor expects the parents' health plan to pay for the services.

Consent of parents and others
Adoptive Parents
If a child has been legally adopted, the adoptive parents have the same authority to consent to medical treatment as do biological parents. A stepparent has legal power to make medical treatment decisions for a minor only if he or she has legally adopted the minor.

Minors Born to Unmarried Parents
The biological mother has the legal right to make medical treatment decisions for a minor, whether or not she is married. If there is no question of the identity of the natural father, then he also has the legal right to make medical treatment decisions for the minor. In cases of uncertainty about the biological father's identity, or if the biological parents disagree about the appropriate treatment, court resolution may be necessary.

Minors Born to Minor Parents
A minor natural parent has the legal right to make medical treatment decisions for his or her minor child. It is important to make sure that the minor parent understands the nature of the treatment and the possible consequences of the treatment in order to give informed consent.

Parents Who Disagree
For most common medical procedures, it is sufficient to obtain the consent of one parent (in an intact married couple). However, if the treatment poses a significant risk to the minor, or implicates special personal or religious concerns, for example, a blood transfusion if one or both of the parents are Jehovah's Witnesses, the consent of both parents would be advisable. If the parents disagree about the advisability of the procedure, and the dispute cannot be resolved, it may be necessary for a juvenile court to intervene.

Parents Who Have Divorced
If the parents have joint legal custody, the parents must "share" the right to make health care decisions for their child. This means that either parent acting alone may consent to a recommended medical procedure, unless the court issuing the order of joint legal custody has specified that the consent of both parents is required for certain, or all, medical decisions (Family Code ??3003 and 3083.) If the parents with joint legal custody are unable to agree about the treatment that should be provided, it may be necessary to obtain a court order resolving the matter before treatment is provided, unless there is an emergency.

If a parent has sole legal custody of the child, that parent has the right to make health care decisions for the child. It should be noted that a court may award joint legal custody without awarding joint physical custody. Therefore, the fact that a child lives with one parent only does not mean that the other parent does not have the legal right to make a medical decision for the child. A parent with legal custody cannot be denied access to his or her child's medical record and information merely because the parent is not the child's custodial parent. (Family Code ?3025.)

If a custodial parent has been diagnosed with a terminal condition, as evidenced by a physician's declaration, a court may appoint the custodial parent and a person nominated by the custodial parent as joint guardians of the minor. However, such an appointment cannot be made over the objection of a non-custodial parent unless a finding has been made that the non-custodial parent's custody would be detrimental to the minor. (Probate Code ??1419.5 and 2105.)

Parents with Children under the Jurisdiction of the Juvenile Court but Living at Home It is usually assumed that parents retain the right to make health care decisions for their children even when the court has taken jurisdiction due to child abuse or neglect unless the court specifically orders otherwise.

Legal Guardians
A legal guardian has, for the most part, the same authority to consent to medical treatment for a minor as a parent would have. However, if the minor is fourteen years of age or older, no surgery may be performed upon the minor without either 1) the consent of both the minor and the guardian or 2) a court order specifically authorizing the treatment. However, if the guardian determines in good faith, based upon medical advice, that there is an emergency in which the minor faces loss of life or serious bodily injury if the surgery is not performed, the guardian's consent alone is sufficient for the surgery. (Probate Code ?2353) In addition, a guardian cannot authorize sterilization, convulsive treatment, experimental drugs or placement in a mental health treatment facility over the minor's objection. (Probate Code ?2356)

Caregivers
Certain categories of caregivers have the same rights to authorize medical or dental care as a guardian has under Probate Code ?2353. (Family Code ?6550.) The caregiver must meet the requirements of ?6550 and complete and sign an affidavit form as set out in Family Code ?6552.

A caregiver who is a relative may consent to mental health treatment (subject to the limitations imposed on a conservator by Probate Code ?2356). (Family Code ?6550(a))

Stepparents
A stepparent does not have the authority to give legal consent to medical treatment for a minor stepchild, unless the stepparent has legally adopted the child or been designated a legal guardian. If the stepparent becomes the child's adoptive parent, the stepparent takes over the rights and responsibilities of the parent who loses parental rights.

Foster Parents
A person who is licensed to provide residential foster care to a child placed with him or her either 1) by order of the juvenile court or 2) voluntarily by the person or persons having legal custody of the child, may legally give consent to ordinary medical and dental treatment for the child, including, but not limited to, immunizations, physical examinations, and x-rays. A foster parent may not give consent for other types of medical or dental treatments, e.g., surgical or experimental/controversial treatments. However, if the parent or parents have voluntarily placed the child with the foster parent(s), the parties may agree in writing to permit the foster parent(s) to consent to other types of medical treatment. Moreover, with respect to court placements, the juvenile court may expressly reserve the right to consent to medical treatment to itself. (Health & Safety Code ?1530.6.)

Foster parents who have only temporary custody of a child before a dependency hearing do not have the legal right to give consent to medical treatment for the child.

Minors Whose Parents are Unavailable
As discussed previously, consent of a parent or guardian is not necessary when the minor is authorized to consent him or herself as provided with respect to 1) certain categories of minors or 2) certain types of care. There are other exceptions to the general rule which allow children to receive necessary medical care even in the absence of a parent or guardian.
Minors 16 or Older
If a minor is sixteen years or older, and the minor has no parent or guardian available to give legal consent, the minor may apply to the superior court for consent to medical treatment. No fee may be charged for such a proceeding. (Family Code ?6911.) The California Medical Association has provided this information. For a legal opinion concerning your specific situation, consult your personal attorney.

© California Medical Association 2001

The California Child Abuse and Neglect Reporting Law
Requirements of the Child Abuse and Neglect Reporting Act (as amended effective January 1, 1999)
What is child abuse?
Physical injury which is inflicted by other than accidental means on a child by another person. (This does not include a "mutual affray between minors.")

Sexual abuse, including sexual assault (rape, incest, sodomy, lewd or lascivious acts upon a child under 14, oral copulation, penetration of a genital or anal opening by a foreign object, child molestation, any penetration of the vagina or anal opening of one person by the penis of another, any sexual contact between the mouth or tongue of one and the vagina or anal opening of another, any intrusion by one person into the vagina or anal opening of another including the use of any object for that purpose, intentional touching of a child's genitals or intimate parts or the clothing covering them for sexual gratification, intentional masturbation of the perpetrator's genitals in the presence of a child) and sexual exploitation (using a minor in obscene matter, using a child to engage in or assist in prostitution or to model in obscene materials).

Effective January 1, 1998: Sexual abuse includes situations where there is sexual intercourse between a person over 21 years and a child under the age of 16 and also when a person commits lewd or lascivious acts with a child of 14 or 15 years where the person committing the act is at least 10 years older than the child/victim.

Lewd and lascivious acts are generally defined as causing any touching of a child by the perpetrator or by the child at the direction of the perpetrator which is for the purpose of arousing, appealing to or gratifying the lusts, passions or sexual desires of the person or the child. These actions when done with a minor under 14 have been and continue to be reportable. Under the new provisions, such conduct with a 14 or 15 year old, even if supposedly consensual, by someone ten years older or more is reportable.

Neglect: negligent treatment or maltreatment or maltreatment under circumstances indicating harm or threatened harm to the child's health or welfare. This includes both acts and omissions.

Severe neglect: negligent failure to protect the child from severe malnutrition or non-organic failure to thrive; willfully causing or permitting the person or health of a child to be endangered, including failure to provide adequate food, clothing, shelter or medical care.

General neglect: negligent failure to provide adequate food, clothing, shelter, medical care or supervision where no physical injury to the child has occurred.

Physical abuse: any physical injury which is inflicted on a child by other than accidental means; any act or omission constituting willful cruelty or unjustifiable punishment of a child or unlawful corporal punishment or injury.

Willful cruelty or unjustifiable punishment of a child: willfully causing or permitting any child to suffer, or inflicting upon a child, unjustifiable physical pain or mental suffering, or while having the care or custody of any child, willfully causing or permitting the person or health of the child to be placed in a situation so that the child's health is endangered.

Unlawful corporal punishment or injury: willfully inflicting upon any child any cruel or inhuman corporal punishment or injury resulting is a traumatic condition.

Note: Unlawful corporal punishment or injury specifically does not include an amount of force that is reasonable and necessary for a person employed by or engaged in a public school to quell a disturbance threatening physical injury to person(s) or damage to property, for purposes of self-defense, or to obtain possession of weapons or other dangerous objects within the control of a pupil.

Who Must Report?
Child care custodians:
Teachers
An instructional aide, teacher's aide or teacher's assistant who has been trained in the duties of the Child Abuse and Neglect Reporting Act
Classified employees who have been trained in the duties of the Child Abuse and Neglect Reporting Act
An administrative officer
Supervisor of child welfare and attendance
Certificated pupil personnel employees
Employees of child day care or Headstart programs
An employee of a school district police or security department
Administrator or presenter of, or a counselor in, a child abuse prevention program in any school

Health care practitioners:
Physicians, dentists, podiatrists, chiropractors, licensed nurses, optometrists, dental hygienists and residents and interns
Psychiatrists
Counselors and psychological assistants
Marriage, Family and Child Counselors, registered interns and trainees
Licensed clinical social workers, interns and trainees

Others:
Clergy
Firefighters, animal control officers, humane society officers if trained in child abuse assessment and reporting
Employees of any child protective agency, including police or sheriff's departments, county probation and county welfare offices
Commercial film and photographic print processors who discover films, videos, etc., depicting children under the age of 14 engaged in sexual conduct.

Who May Report?
"Any other person who has knowledge of or observes a child whom he or she knows or reasonably suspects has been a victim of child abuse may report the known or suspected instance of child abuse to a child protective agency." [Cal. Penal Code ?11166, subd.(d).]
Conditions Necessary for Reporting
Before you must report, each of the following conditions are required:
You have knowledge of or observe a child
In your professional capacity or scope of employment
Whom you know or reasonably suspect to be a victim of child abuse.
"Reasonable suspicion" means that "... it is objectively reasonable for a person to entertain a suspicion, based upon facts that could cause a reasonable person in a like position, drawing when appropriate on his or her training and experience, to suspect child abuse.... The pregnancy of a minor does not, in and of itself, constitute a basis of reasonable suspicion of sexual abuse." [Cal. Penal Code, ?11166, subd. (a).]

When and How to Report
Mandatory child abuse reporters must do the following:
Notify a child protective agency immediately or as soon as practically possible by telephone;
AND
Prepare and send a written report within 36 hours of receiving information concerning the incident.
The "36-hour" requirement means 36 clock hours. There is no grace period for weekends or holidays. No later than 36 hours after you have received the information on which you have based your report, you must have the appropriate Department of Justice form (#SS 8572) in the mail.

When two or more mandatory reporters are present and jointly have knowledge of a known or suspected instance of child abuse, they may agree that one of them shall make the telephone report and a single report may be made and signed by the designated individual. However, if one learns that the designated individual has failed to comply, he or she must then make the report.

Reporting Duties Are Individual
No supervisor or administrator may impede or inhibit the reporting duties and no person making a report shall be subject to any sanction for making the report.

Internal procedures to facilitate reporting and apprise supervisors and administrators of reports may be established as long as they are not inconsistent with the terms of this act. The internal procedures shall not require any employee who is a mandated reporter to disclose his/her identity to the employer.

Liability for Failure to Report The mandated reporter who fails to report faces direct liability. First, failure to report can subject one to criminal charges. The penalty is up to six months in jail, a fine of not more than one thousand dollars, or by both. [Cal. Penal Code ?11172, subd. (e).] Of equal concern is that the immunity from civil liability (lawsuits!) exists only once one has fulfilled his or her reporting duty. [See Penal Code ?11172, subd. (a).]

The other risk for failing to report is that the counselor's licensing board can -- and probably will -- bring charges for unprofessional conduct for failing to report the abuse. In such instances, one's license will be subject to discipline, including suspension or revocation.

Elder Abuse
Any mandated reporter who in their professional capacity learns of physical abuse, financial abuse, isolation, abandonment, or neglect towards an elderly or dependent adult must report the abuse immediately or as practically possible. A written report must be completed within two working days.

Physical Abuse
Any physical pain or injury which is willfully inflicted upon an elder by a person who has care or custody of, or who stands in a position of trust with that elder, constitutes physical abuse. This includes, but is not limited to, direct beatings, sexual assault. unreasonable physical restraint, and prolonged deprivation of food or water.

Financial Abuse
Any theft or misuse of an elder's money or property, by a person in a position of trust with an elder, constitutes financial abuse.

Neglect
The failure of any person having the care or custody of an elder to provide that degree of care which a reasonable person in a like position would provide constitutes neglect. This includes, but is not limited to: Failure to assist in personal hygiene or the provision of clothing for an elder.

Failure to provide medical care for the physical and mental health needs of an elder. This does not include instances in which an elder refuses treatment.

Failure to protect an elder from health and safety hazards.

Self-Neglect
Failure to provide for self through inattention or dissipation. The identification of this type of case depends on assessing the elder's ability to choose a life-style versus a recent change in the elder's ability to manage.

Psychological/Emotional Abuse
The willful infliction of mental suffereing, by a person in a position of trust with an elder, constitutes psychological/emotional abuses. Examples of such abuse are: verbal assaults, threats, instilling fear, humiliation, intimidation, or isolation of an elder.

Abandonment
Abandonment constitutes the desertion or willful forsaking of an elder by any person having the care and custody of that elder, under circumstances in which a reasonable person would continue to provide care of custody.

Duty to Warn

Duty to warn refers to the responsibility of a counselor or counselor to breach confidentiality if a client or other identifiable person is in clear or imminent danger. In situations where there is clear evidence of danger to the client or other persons, the counselor must determine the degree of seriousness of the threat and notify the person in danger and others who are in a position to protect that person from harm (police).

Professional Ethics and Suicide

The conduct of clinicians is guided by ethics codes that provide nominal protection to suicidal clients. The codes draw on these principles:
Autonomy - Respect for the individual self-determination
Doing the greatest good possible
Minimizing or preventing harm
Justice - Fairness and equal access to care.
Respect for person - The basis of client rights
Telling the truth and giving all the facts - Disclosure
Confidentiality - Maintaining client privacy
Fidelity - Doing the job" and "being there" for the client.

Ethics for Counselors
a) Do you use a waiver of confidentiality?
b) Do you use a "no suicide contract"?
c) How do you deal with psychological pain?
d) What would you do if I became suicidal while in your care?

Legal and Ethical issues - Questions and Answers

Many counselors will work their whole careers without ever being called to testify in court, but that isn't likely. Child welfare issues, divorce, abuse, neglect and other issues can land the counselor/counselor with a subpoena or court order. Here are some common legal and ethical questions asked by practitioners, but every counselor can benefit from the answers.

Q. I have been seeing this couple for several months and they have decided on a divorce. The wife wants me to testify for her in the hearing, but the husband doesn't. What should I do?
A. If you do not have prior written permission from both parties, you should refuse to testify and explain your reasons. Check your state law to ascertain your legal position. If you are subpoenaed to testify and bring your documents, show up at the specified time with all documentation and ask for the judge to rule on the issue. If the court orders you to testify, then you are legally required to do so. Legal consultation is advised for all situations involving subpoenas. To avoid both legal and ethical dilemmas, it is important to explain that as a counselor the couple or the family is considered to be your client, rather than any individual within the unit. To reduce any later confusion, this should be in writing in your disclosure form and given to your client(s) before counseling begins.

Q. I am interested in assisting the divorcing couples that I counsel in the best possible manner. I know my state law, and I think I could save them unnecessary expense by working with them on settlement, custody, and visitation issues. Is this legal?
A. Your client's best interest is always of importance to you as an ethical counselor. You may best assist your clients through mediation with their negotiation of these matters, thus allowing less time to be spent with the legal process. Remember always that giving legal advice is illegal.

Q. In my practice, I see many couples who are divorcing. When the attorney calls, what should I say? A. If you do not have prior written permission to talk with the attorney, simply state that if this person were your client, without written permission you would not be able to talk with the attorney. If the attorney persists, be polite but give no further information or indication of your relationship with the person in question.

Q. Why do attorneys "attack" counselors when they cross-examine them on the stand?
A. Whether you are called to testify in a case or choose to be a witness or child custody evaluator, it is important to understand the nature of the legal system. The legal system is an adversarial one, set up to discover the facts in a given situation. It is not based upon the assumption of furthering anyone's mental health or growth. The opposing attorney is merely "doing his or her job" in search of the facts, and none of the questions should be taken as being personal.

Q. What is the difference between a subpoena and a court order?
A. A subpoena is an order by an attorney for information or testimony. The order to appear in a subpoena must be followed. A court order is a directive by the court to comply and must be followed.

Q. Several of my colleagues have become "expert witnesses." Are there educational or training requirements for being an expert witness? How can I become one?
A. Your educational background and clinical expertise in a given area may qualify you to be an expert witness. Some states specify requirements for particular types of issues that must be met to qualify to testify. You may contact colleagues who are presently giving expert witness testimony or local attorneys in your area. Above all, if you decide to become an "expert" be sure that you have sufficient knowledge in that area.

Q. I have been requested to complete a child custody evaluation for a district court. The parents are paying for the evaluation. Whom do I represent?
A. A court-appointed child custody evaluator is responsible for representing the child and the court. The evaluator is asked to determine the best interests of the children.

Q. In my marriage and family training program I learned the technique of using paradox. However, I still feel somewhat uncomfortable with this method. Are there any legal restrictions on using paradoxical interventions? A. There are no legal restraints differing from those applying to other forms of practice. The authors caution you, however, to indicate in your disclosure statement that paradoxical interventions are part of your therapeutic technique and to be certain you are adequately trained and have sufficient facts. It may be difficult to explain harm caused to clients by asking them to do the activity that you did not want them to do. Extreme caution is advised in the use of paradoxical interventions.

Q. What do I tell my clients who are stepparents concerning their legal rights and responsibilities toward their stepchildren?
A. Stepparents in today's society have few legal rights or responsibilities toward their stepchildren. However, some states now have a provision that recognizes the "psychological/extended family of children" and may address stepparent issues. Families should check with an attorney to understand fully their rights and responsibilities.

Q. When I am seeing a couple or a family is it illegal to receive insurance reimbursement for an individual client within the family?
A. It may be considered insurance fraud to submit an individual diagnosis for third-party payment when you are actually seeing a couple or family. Report honestly to the insurance company even if the result is denial of reimbursement. Fraud could result in ethical censure and/or civil and criminal liability.

10 ways practitioners can avoid frequent ethical pitfalls
Boost your ethical know-how with these practical tips on avoiding common ethical quandaries.
BY DEBORAH SMITH Monitor Staff
January

2003
Volume 34

Number 1
Talk to the ethics experts, and they'll tell you the best defense against ethical problems is a good offense. By looking out for foreseeable conflicts and discussing them frankly with colleagues and clients, practitioners can evade the misunderstandings, hurt feelings and sticky situations that lead to hearings before ethics boards, lawsuits, loss of license or professional membership, or even more dire consequences.

However, being vigilant doesn't mean psychologists should spend their days worrying about where the next pitfall could be, says Robert Kinscherff, JD, PhD, former chair of APA's Ethics Committee, which adjudicates ethics complaints. "Instead of worrying about the ways [they] can get in trouble, psychologists should think about ethics as a way of asking 'How can I be even better in my practice?'" he explains. "Good ethical practice is good professional practice, which is good risk management practice."

When psychologists do end up in ethical quandaries, it's often because they unwittingly slid too far down a slippery slope--a result of ignorance about their ethical obligations or thinking they could handle a situation that spiraled out of control.

Many problems are what Ethics Committee member Anne Hess, PhD, calls "stealth" dilemmas: situations that develop gradually, moving step by small step beyond once-firm professional boundaries. Although each step seemed harmless at the time, many practitioners later realize that they have landed themselves in deep trouble.

The Monitor interviewed some of psychology's leading ethics experts to talk about how practitioners can avert common ethical dilemmas, from multiple relationships to whether to breach confidentiality, to terminating treatment. Here's their advice, boiled down to 10 ways to help avoid ethical pitfalls.

1. Understand what constitutes a multiple relationship

Is it ethical to volunteer at your daughter's softball team fund-raiser if you know a client is going to be there? Can you buy a car from a client who owns the only dealership in your small, rural town? Can you ask an intern to drive you to the airport? "A central question in any multiple relationship situation is whose needs are being met here?" says Stephen Behnke, JD, PhD, director of APA's Ethics Office, which advises psychologists on ethical dilemmas. "Whenever the answer is the needs of the psychologist, that's a time when the psychologist needs to take great care and get a consultation."

According to the Ethics Code, psychologists should avoid relationships that could reasonably impair their professional performance, or could exploit or harm the other party. Behnke emphasizes, however, that multiple relationships that are not reasonably expected to have such effects are not unethical.

That's because sometimes it's impossible for psychologists to completely avoid multiple relationships, explains Steven Sparta, PhD, immediate past-chair of APA's Ethics Committee. For example, the psychologist in a rural town may decide to buy a car from his client because going elsewhere could signal that the car dealer was in therapy.

How do you weigh the pros and cons in such situations? APA Ethics Committee member Michael Gottlieb, PhD, suggests in a Psychotherapy (Vol. 30, No. 1) article that psychologists think about three factors:

• Power. How much of a power differential is there between the psychologist and the other person? Since you also supervise the intern, it might be better to ask a colleague to drive you to the airport.
• Duration. Will it be brief contact or will it be continuous or episodic contact over a long time? "We usually don't know how long professional contact will last except in very specific circumstances," says Gottlieb. Before entering into a dual relationship, psychologists should consider whether, for example, a client could return for additional services.
• Termination. Has the therapeutic relationship been permanently terminated, and does the client understand that as well? If a psychologist sees patients with chronic illnesses, they should keep in mind that treatment could stop and start for years, precluding some relationships that might be all right otherwise.

"It's only an ethical problem when there's a reasonable basis to see a foreseeable risk, and the psychologist fails to see it or ignores it and goes forth anyway," Sparta explains.

Moreover, one type of multiple relationship is never acceptable: "Sexual relationships with current clients are never permissible," says Behnke.

While sexual relationships with previous clients are not automatic violations of the Ethics Code if they occur more than two years after therapy's termination, "psychologists need to be mindful of the harm that can come from a sexual involvement with a client no matter when it occurs," Behnke adds.

Lastly, if psychologists find that, despite their efforts, a potentially harmful multiple relationship has arisen, they are ethically mandated to take steps to resolve it in the best interest of the person or group while complying with the Ethics Code.

2. Protect confidentiality

Psychologists are often asked to provide information about their clients to employers, spouses, school administrators, insurance companies and others. While such requests may be well-intentioned, psychologists need to carefully balance the disclosure with their ethical obligations to protect their patients' confidentiality.

Indeed, because the public puts their trust in psychologists' promises of confidentiality, it's essential for psychologists to be clear on whether and why they are releasing information. "Ask yourself, 'On what basis am I making this disclosure?'" advises Behnke. "Is there a law that mandates the disclosure? Is there a law that permits me to disclose? Has my client consented to the disclosure?'" APA's 2002 Ethics Code stipulates that psychologists may only disclose the minimum information necessary to provide needed services, obtain appropriate consultations, protect the client, psychologist or others from harm, or obtain payment for services from a client.

To help prevent confidentiality problems, psychologists can:

• Discuss the limits of confidentiality, including their uses of electronic transmission and the foreseeable uses of confidential information, as soon as possible.
• Ensure the safe storage of confidential records. At the outset, notify people what will be done with case materials, photos and audio and video recordings, and secure their consent. Also, make sure rooms where confidential conversations occur are soundproof.
• Know federal and state law. Know the ins and outs of your state's laws that relate to your practice. And keep in mind how the recently implemented Health Insurance Portability and Accountability Act affects your practice.
• Obey mandatory reporting laws. Even if a psychologist believes that reporting abuse could make the situation even worse, "these laws are mandatory reporting laws, not discretionary reporting laws," says lawyer Mathew D. Cohen, who specializes in representing human-service providers. Mandatory reporting laws were not created to have clinicians decide whether abuse or neglect is happening, says Cohen, but to have them bring the facts to the attention of authorities, who will decide.

"If you wait and nothing bad happens, you've still violated the law," he says. "[But] if you wait and something bad happens, not only have you violated the law, but you have injured a potential victim who could have been protected."

3. Respect people's autonomy

Psychologists need to provide clients with information they need to give their informed consent right at the start.

When they fail to give details, sticky situations can arise. For example, when psychologists fail to explain their duty to report abuse and neglect to an adolescent client before therapy begins, they may be unsure what to do if abuse is later revealed that the client doesn't want reported.

For psychologists providing services, the experts suggest they discuss:

• Limits of confidentiality, such as mandatory reporting.
• Nature and extent of the clinician's record-keeping.
• The clinician's expertise, experience and training as well as areas where the counselor lacks training.
• Estimated length of therapy.
• Alternative treatment or service approaches.
• The clinician's fees and billing practices.
• Whom to contact in case of emergency.
• Client's right to terminate sessions and any financial obligations if that occurs.
• * Not only what services the psychologist will provide, but what they can't or won't do.

If individuals are not competent to make decisions for themselves, then the person who's giving permission must have access to that same information. Moreover, a signed consent form does not substitute for the informing process, which should occur first, say ethics experts--and that includes situations where informed consent is implied, such as in an employee evaluation.

4. Know your supervisory responsibilities

Psychologists may be responsible for the acts of those who perform work under their watch, whether it's interns providing therapy or administrative assistants helping with record-keeping and billing.

That means supervising psychologists should continually assess their supervisees' competence and make sure they are managing them appropriately, say experts. Such supervision should cover everything from ensuring that supervisees conduct the informed-consent process correctly to prohibiting them from using the supervisor's signature stamp on any bill or letter that the supervisor hasn't reviewed.

"If it goes out under your name, you're responsible," says APA Ethics Committee Chair Michael D. Roberts, PhD. "If they release medical files without proper consent, they're not going to sue the receptionist, they're going to sue you."

According to the experts, supervisors should also:

Establish timely and specific processes for providing feedback--and provide information about these processes at the beginning of supervision.
• Outline the nature and structure of the supervisory relationship in writing before supervision begins. Supervisors should include both parties' responsibilities as well as intensity of the supervision and other key aspects of the job.
• Document their experience with the supervisees, including supervision dates, discussions they've had and other relevant facts. Such information will help if ethical dilemmas arise later.
• Explain to patients that the counselor is in training and give clients the name of the supervisor. Note that billing may be under a supervisor's name, not the supervisee's, so that clients don't accidentally report billing problems when there are none.
• Avoid delegating work to people who have multiple relationships with the client that would likely lead to harm or the supervisee's loss of objectivity--for example, avoid using a non-English-speaking person's spouse as a translator.

5. Identify your client and role

When practicing psychologists work with organizations or groups of individuals, they should understand from the start who they were hired to help and what is expected of them. Dilemmas crop up in a variety of settings:

• In couples therapy. For example, when one partner wants a better marriage but the other wants a "painless" divorce, psychologists should clarify at the beginning that they cannot decide whether the couple should stay together or offer expert opinions later on during a divorce suit.
• In court, when it's not clear whether the psychologist is serving as an expert witness or advocate for one side. Court-appointed evaluators should express well-balanced, objective opinions, says Ethics Committee member Linda F. Campbell, PhD, while advocates are often counselors for one party who have had little direct contact with the other. Because they can't provide an objective evaluation, psychologists who are counselors for one of the parties shouldn't serve as expert witnesses.
• When psychologists provide services to a person or entity at the request of a third party, such as a parent requesting therapy for their child or a police department requesting an evaluation of an officer. "You may have one legal client, but several ethical clients," cautions Kinscherff. "In each case it's important to know who it is that you're serving and what your role is in providing that service."

How can psychologists avoid role-related dilemmas?

"Knowing who your client is, what your role is and being transparent about what it is that you do and mindful about the professional boundaries that arise are good guideposts to effective practice," says Kinscherff. That means psychologists should, at the outset, have frank discussions with all parties involved about the relationship they will have with each person or organization--for example, are they hired by a business to enhance worker productivity or are they there to help individual workers with mental health problems?

Other things to cover include confidentiality limits, what specific services will be provided to which people and how the psychologist and others could use the services or information obtained. "If you're reasonable and straightforward with people, treat them the way you would want to be treated in a similar situation, find out what their expectations are, and clarify those expectations, you'll be in good shape most of the time," adds Kinscherff.

6. Document, document, document

Documentation can be psychologists' best ally if they ever face ethical charges, says Ed Nottingham, PhD, an associate member of APA's Ethics Committee. However, lack of documentation--or the wrong kind of documentation--can be detrimental.

Some specifics to include in documenting therapeutic interactions, according to the guidelines and ethics experts such as Nottingham:

• Identifying information and first contact.
• Relevant history and risk factors, medical status and attempts to get prior treatment records.
• Dates of service and fees.
• Diagnostic impressions, assessments, treatment plans, consultation, summary and testing reports and supporting data, and progress notes. Include not only the treatments chosen, but treatments considered and rejected.
• Informed-consent documentation, consent to audiotape or videotape, and release of information documentation.
• Relevant telephone calls and out-of-office contacts.
• Follow-up efforts when clients "drop out of sight."
• Details necessary, including those listed above, so that another psychologist could take over delivery of service, such as in the event of a psychologist's death or retirement.

A few other tips:

• Only include germane information. APA's Record Keeping Guidelines advise practitioners to take into account the nature of the services, the source of the information recorded, the intended use of the records and the psychologist's professional obligation.
• Never alter a record after the fact. "It's illegal, and it gets you into trouble, and more times than not you get caught," says lawyer Joseph T. Monahan. You can append additional information to records, adds Behnke, but when doing so, the record should clearly indicate that the information was added later on.
• Use documentation to your advantage. "The process of writing helps [psychologists] crystallize in their own mind what they are saying about the problem," says Sparta. "It helps pinpoint when things don't make sense or where they need to get more information."

7. Practice only where you have expertise

Every psychologist knows they are obligated by the Ethics Code to practice only where they are competent. But sometimes difficulties arise when, for example, they practice in emerging areas where there aren't clear standards.

"The problem is that, many times, how does the psychologist know when there's something they don't know?" says Sparta. "If you don't know from the professional literature that there are certain guidelines...you may be well-intentioned, but not realize you're going beyond the boundaries of your competence."

Competence issues also come into a play in child-custody ethics, when psychologists are unfamiliar with the nuances of working with courts. Take the case of a psychologist who is asked to write a letter to a judge about the relationship of a boy in treatment to his parents. If she has little forensic training, the psychologist could land in ethical hot water if, for example, she failed to include the limitations of her opinion, such as that she's never met one of the boy's parents.

Another area to keep in mind is assessment, says Campbell: "If you find yourself falling back on instruments because you feel confident with them and you don't know which others to use, that means you haven't kept up with the advances in that particular area and need to re-examine what needs to be done to be proficient."

One of the best ways to address competence issues is to stay in touch with the profession through conferences, continuing education, consulting with colleagues, and reading journals, guidelines and other publications, says Sparta. For example, if you begin seeing an adolescent with anorexia, but infrequently treat eating disorders, read up on the professional literature and arrange for supervision or consultation to ensure that the treatment is adequate.

"In the age of long-distance telephone, teleconference and the Internet, it's hard to argue that you couldn't have gotten the right kinds of information," says Kinscherff.

The 2002 Ethics Code does make exceptions for psychologists in extraordinary circumstances: Psychologists with closely related experience can provide services if there's no one else who can--as long as they make a reasonable effort to obtain the competence required. See Standard 2.01 for the details.

8. Know the difference between abandonment and termination

Every year, APA's Ethics Office field's calls from psychologists who want to end treatment with a patient, but are anxious because they fear they're abandoning their client.

"Abandonment is not the same as treatment termination," Behnke tells them, pointing to the 2002 Ethics Code, which says in Standard 10.10 that psychologists can discontinue treatment when clients:

• Aren't benefiting from therapy.
• May be harmed by the treatment.
• No longer need therapy.
• Threaten the counselor, themselves or others.

Psychologists should provide pre-termination counseling and suggest alternative service providers, says the Ethics Code, noting that this may not be possible in all cases, such as if a patient abruptly stops attending therapy. Such pre-termination counseling could include explaining the benefits of the new services and why the current treatment is no longer helpful, addressing feelings of separation by emphasizing the transfer is not a personal rejection, and identifying practical issues in transferring the client, such as resolving financial arrangements with the new provider before ending treatment.

"Involve the client in the plan," advises Sparta. "Empower them to feel confident and competent. Help the client understand that the transition is a constructive step toward achieving their goals."

By contrast, abandonment occurs when a psychologist inappropriately ends treatment, such as halting needed therapy with no notice.

In his tenure on various ethics groups, Sparta says he has seen as many cases when psychologists continued treatment beyond the point necessary as when they precipitously stopped treatment. While dependent clients can make it difficult to end treatment appropriately, the blurred multiple roles that can result from prolonged relationships--giving a client a job, for example--are too risky, says Sparta.

Psychologists can often head off termination dilemmas by thinking ahead, say ethics experts. For example, a psychologist treats a woman until her insurance coverage expires, but when she can't pay out of pocket, he explains that the relationship must end and facilitates her care to another provider. To avoid the misperception that the psychologist "dumped" the client, the psychologist discusses the treatment timeline at their first session, including the differences between short- and long-term therapy and what could happen if therapy was needed beyond what the woman's insurance covered.

If there are cases in which it's apparent that a patient may have financial troubles at therapy's start, give consideration before you take the case, say ethics experts. And make sure you are aware of clients for whom financial hardship is developing.

9. Stick to the evidence

When you give your expert opinion or conduct an assessment, base your evaluation only on the data available. For example, psychologists in child-custody cases should be sure they aren't being biased in favor of the parent who is more financially secure.

"The best approach is to stay mindful about what you know, what you don't know and what your sources of information have been," says Kinscherff.

Ethics experts recommend that psychologists:

• Know what the referral question is and choose assessment tools that can validly answer that question. That means psychologists need to read and understand test manuals, says Sparta. For example, personality tests appropriate for clinical use are not necessarily appropriate for employment selection.
• Don't rely on third-party reports to formulate assessments and avoid giving an opinion of any person they haven't directly evaluated. According to the Ethics Code, when psychologists can't evaluate a person directly, they should document the efforts they made and the result of those efforts. They also need to discuss the limited information's impact on the accuracy and certainty of their opinion, and appropriately limit their conclusions or recommendations.
• Make sure the assessment is thorough. Psychologists can find themselves in hot water when they give an expert opinion without consulting all of the sources available. For example, a psychologist conducting a custody evaluation fails to check with child protection services and therefore does not learn that one parent is being investigated for child neglect--a fact that might have changed the psychologist's opinion.
• Discuss the limitations of their work and make statements about the certainty of their findings. If no interview is possible, note those limitations in the report. "It's equally important to offer any plausible alternative hypotheses that would account for the data," adds Kinscherff. In fact, in court cases where the facts are disputed, Kinscherff lays out the contradictions between the two parties and then makes a set of recommendations based on each party's side of the story, leaving it up to the court to decide which party is truthful.
• Ensure that tests were developed for the target population and that they are culturally appropriate, says Sparta. If the test isn't, make the proper adjustments and note the limitations of those adaptations in your findings. New text in APA's 2002 Ethics Code specifies that psychologists take such measures.

10. Be accurate in billing

There's nothing more important than accuracy when it comes to billing patients and insurers for psychological services, say ethics experts.

While sloppy bookkeeping can land some psychologists in hot water, others find themselves in predicaments because they've worked the system to get clients more benefits than a third-party payor entitles them to.

To avoid such ethical problems, a psychologist should:

• Bill only for services you have provided using correct procedure codes. Never bill an insurer for a service that is covered instead of the treatment actually provided. For example, it's improper to bill for individual therapy instead of couples therapy, for therapy instead of psychological testing or for psycho educational tests as if they were health-related. Moreover, don't bill the insurance company when clients miss appointments; bill the client. "Be accurate, conservative, and consult when in doubt," advises Ethics Committee associate Peter Mayfield, PhD.
• Only list the dates you treated the patient. While it may be tempting to tell an insurer that only pays for one session a week that you saw a client two Mondays in a row instead of the Monday and Friday you actually met, psychologists should never "fudge" a treatment date.
• Call it as you see it. Occasionally, a patient might ask for a less damaging diagnosis for fear that employers or others might find out. Or psychologists may consider exaggerating diagnoses to justify more visits to insurers. No matter what, don't do it: "Honesty is the best policy," says Mayfield.
• Discuss billing practices up front. "All of the financial policies need to be told to the client at the beginning of therapy," says Eric Harris, JD, EdD, a risk management consultant for the APA Insurance Trust. In fact, Harris recommends that psychologists ask clients to sign informed-consent contracts that outline the financial arrangements, such as that clients will be billed for skipped sessions and they must pay for the services if the insurer refuses coverage.
• Be conscientious about collecting fees. "When a client isn't paying their fees, you need to raise it with them as early as possible," says Harris. "You need to set appropriate limits." Allowing clients to run large balances isn't good for either party's finances. One solution is to accept credit cards.
• Take caution in pursuing delinquent accounts. When psychologists use small claims court or a collection agency to pursue debtors, they are ethically obligated to first inform the client of their intent and give them the chance to pay. If the client does not pay, psychologists are ethically permitted to provide only the minimum information necessary to pursue their claim.
• Watch your paperwork. Because psychologists are accountable for everything that their offices bill, regardless of whether they ever saw the paperwork, Mayfield encourages psychologists to personally review any document that goes out under their name. Lastly, there's one, best strategy that psychologists can take to minimize their exposure to ethical and legal problems, says Behnke: "Be the best psychologist you can be."

Goals and Principles

The eight major goals of the certification system formulated by the Certification Board are as follows:

• Establish credibility, confidence and trust
• Clarify and define counselor duties and responsibilities
• Develop professional identity
• Enhance incentive for counselor professional growth
• Reduce alcohol/drug stigma
• Provide professional assistance to clients
• Increase potential of certification reciprocity
• Increase reimbursement potential

Principles of Certification:

• Certification is based on competence and knowledge about alcohol and drug problems rather than on academic achievement alone.
• Authority for this certification comes from IC&RC/AODA, a consortium of 60 member boards internationally representing professionals working in chemical dependency who share a common concern for standards of competence.
• The basic requirement for certification is the demonstration of competence in alcohol and drug counseling skills.
• Application for certification is entirely voluntary.
• Certification is offered to both members and non-members of the California Association of Alcohol and Drug Abuse Counselors.

NAADAC Code of Ethics

Principle 1: Non-Discrimination

I shall affirm diversity among colleagues or clients regardless of age gender, sexual orientation, ethnic/racial background, religious/spiritual beliefs, marital status, political beliefs, or mental/physical disability and veteran status.

• I shall strive to treat all individuals with impartiality and objectivity relating to all based solely on their personal merits and mindful of the dignity of all human persons. As such, I shall not impose my personal values on my clients.
• I shall avoid bringing personal or professional issues into the counseling relationship. Through an awareness of the impact of stereotyping and discrimination, I shall guard the individual rights and personal dignity of my clients.
• I shall relate to all clients with empathy and understanding no matter what their diagnosis or personal history.

Principle 2: Client Welfare

I understand that the ability to do good is based on an underlying concern for the well being of others. I shall act for the good of others and exercise respect, sensitivity, and insight. I understand that my primary professional responsibility and loyalty is to the welfare of my clients, and I shall work for the client irrespective of who actually pays his/her fees.

• I shall do everything possible to safeguard the privacy and confidentiality of client information except where the client has given specific, written, informed, and limited consent or when the client poses a risk to himself or others.
• I shall provide the client his/her rights regarding confidentiality, in writing, as part of informing the client of any areas likely to affect the client's confidentiality.
• I understand and support all that will assist clients to a better quality of life, greater freedom, and true independence.
• I shall not do for others what they can readily do for themselves but rather, facilitate and support the doing. Likewise, I shall not insist on doing what I perceive as good without reference to what the client perceives as good and necessary.
• I understand that suffering is unique to a specific individual and not of some generalized or abstract suffering, such as might be found in the understanding of the disorder. I also understand that the action taken to relieve suffering must be uniquely suited to the suffering individual and not simply some universal prescription.
• I shall provide services without regard to the compensation provided by the client or by a third party and shall render equally appropriate services to individuals whether they are paying a reduced fee or a full fee.

Principle 3: Client Relationship

I understand and respect the fundamental human right of all individuals to self-determination and to make decisions that they consider in their own best interest. I shall be open and clear about the nature, extent, probable effectiveness, and cost of those services to allow each individual to make an informed decision of their care.

• I shall provide the client and/or guardian with accurate and complete information regarding the extent of the potential professional relationship, such as the Code of Ethics and professional loyalties and responsibilities.
• I shall inform the client and obtain the client's participation including the recording of the interview, the use of interview material for training purposes, and/or observation of an interview by another person.

Principle 4: Trustworthiness
I understand that effectiveness in my profession is largely based on the ability to be worthy of trust, and I shall work to the best of my ability to act consistently within the bounds of a known moral universe, to faithfully fulfill the terms of both personal and professional commitments, to safeguard fiduciary relationships consistently, and to speak the truth as it is known to me.

• I shall never misrepresent my credentials or experience.
• I shall make no unsubstantiated claims for the efficacy of the services I provide and make no statements about the nature and course of addictive disorders that have not been verified by scientific inquiry.
• I shall constantly strive for a better understanding of addictive disorders and refuse to accept supposition and prejudice as if it were the truth.
• I understand that ignorance in those matters that should be known does not excuse me from the ethical fault of misinforming others.
• I understand the effect of impairment on professional performance and shall be willing to seek appropriate treatment for myself or for a colleague. I shall support peer assistance programs in this respect.
• I understand that most property in the healing professions is intellectual property and shall not present the ideas or formulations of others as if they were my own. Rather, I shall give appropriate credit to their originators both in written and spoken communication.
• I regard the use of any copyrighted material without permission or the payment of royalty to be theft.

Principle 5: Compliance with Law

I understand that laws and regulations exist for the good ordering of society and for the restraint of harm and evil, and I am aware of those laws and regulations that are relevant both personally and professionally and follow them, while reserving the right to commit civil disobedience.

• I understand that the determination that a law or regulation is unjust is not a matter of preference or opinion but a matter of rational investigation, deliberation, and dispute.
• I willingly accept that there may be a penalty for justified civil disobedience, and I must weigh the personal harm of that penalty against the good done by civil protest.

Principle 6: Rights and Duties

I understand that personal and professional commitments and relationships create a network of rights and corresponding duties. I shall work to the best of my ability to safeguard the natural and consensual rights of each individual and fulfill those duties required of me.

• I understand that justice extends beyond individual relationships to the community and society; therefore, I shall participate in activities that promote the health of my community and profession.
• I shall, to the best of my ability, actively engage in the legislative processes, educational institutions, and the general public to change public policy and legislation to make possible opportunities and choice of service for all human beings of any ethnic or social background whose lives are impaired by alcoholism and drug abuse.
• I understand that the right of confidentiality cannot always be maintained if it serves to protect abuse, neglect, or exploitation of any person or leaves another at risk of bodily harm.

Principle 7: Dual Relationships

I understand that I must seek to nurture and support the development of a relationship of equals rather than to take unfair advantage of individuals who are vulnerable and exploitable.

• I shall not engage in professional relationships or commitments that conflict with family members, friends, close associates, or others whose welfare might be jeopardized by such a dual relationship.
• Because a relationship begins with a power differential, I shall not exploit relationships with current or former clients for personal gain, including social or business relationships.
• I shall not under any circumstances engage in sexual behavior with current or former clients.
• I shall not accept substantial gifts from clients, other treatment organizations, or the providers of materials or services used in my practice.

Principle 8: Preventing Harm

I understand that every decision and action has ethical implication leading either to benefit or harm, and I shall carefully consider whether any of my decisions or actions has the potential to produce harm of a physical, psychological, financial, legal, or spiritual nature before implementing them.

• I shall refrain from using any methods that could be considered coercive such as threats, negative labeling, and attempts to provoke shame or humiliation.
• I shall make no requests of clients that are not necessary as part of the agreed treatment plan.
• I shall terminate a counseling or consulting relationship when it is reasonably clear that the client is not benefiting from the relationship.
• I understand an obligation to protect individuals, institutions, and the profession from harm that might be done by others. Consequently, I am aware that the conduct of another individual is an actual or likely source of harm to clients, colleagues, institutions, or the profession, and that I have an ethical obligation to report such conduct to competent authorities.

Principle 9: Duty of Care

I shall operate under the principle of Duty of Care and shall maintain a working/therapeutic environment in which clients, colleagues, and employees can be safe from the threat of physical, emotional or intellectual harm.

• I respect the right of others to hold spiritual opinions, beliefs, and values different from my own.
• I shall strive for understanding and the establishment of common ground rather than for the ascendancy of one opinion over another.
• I shall maintain competence in the area of my practice through continuing education, constantly improving my knowledge and skills in those approaches most effective with my specific clients.
• I shall scrupulously avoid practicing in any area outside of my competence.

Updated August 18, 2008

The Confidentiality Of Alcohol And Drug Abuse Patient Records Regulation and the HIPAA Privacy Rule: Implications For Alcohol and Substance Abuse Programs

http://www.hipaa.samhsa.gov/Part2privacyrule.htm

II. How the Privacy Rule affects disclosures of information

A. The General Rule

The "general rules" established by Part 2 and the Privacy Rule regarding uses and disclosures of patient health information are very different.10

Substance abuse treatment programs must comply with both rules. Generally, this will mean that they will continue to follow Part 2's general rule and not disclose information unless they can obtain consent or point to an exception to that rule that specifically permits the disclosure. Programs must then make sure that the disclosure is also permissible under the Privacy Rule.

B. When disclosures are permitted

1. Part 2 Consent11 and Privacy Rule Authorization

42 CFR Part 2

Programs may not use or disclose any information about any patient unless the patient has consented in writing (on a form that meets the requirements established by the regulations) or unless another very limited exception specified in the regulations applies. Any disclosure must be limited to the information necessary to carry out the purpose of the disclosure.

The Privacy Rule

The Privacy Rule permits uses and disclosures for "treatment, payment and health care operations" as well as certain other disclosures without the individual's prior written authorization. Disclosures not otherwise specifically permitted or required by the Privacy Rule must have an authorization that meets certain requirements. With certain exceptions, the Privacy Rule generally requires that uses and disclosures of PHI be the minimum necessary for the intended purpose of the use or disclosure.

Substance abuse treatment programs most often make disclosures after a patient has signed a consent form that meets the requirements of 42 CFR ?2.31. Note that a disclosure under Part 2 includes the acknowledgment that someone has applied to or is enrolled in the program, and thus is only permitted if the patient has signed a consent form (or another of the regulations' narrow exceptions applies). See 42 CFR ??2.11 and 2.13. A Part 2 consent form must include the following elements:

• Name or general designation of the program or person permitted to make the disclosure;
• Name or title of the individual or name of the organization to which disclosure is to be made;
• Name of the patient;
• Purpose of the disclosure;
• How much and what kind of information is to be disclosed;
• Signature of patient (and, in some States, a parent or guardian);
• Date on which consent is signed;
• Statement that the consent is subject to revocation at any time except to the extent that the program has already acted on it; and
• Date, event, or condition upon which consent will expire if not previously revoked.

When programs operating under Part 2 disclose information pursuant to a consent form, they must include a written statement that the information cannot be redisclosed. See 42 CFR ?2.32.

The core required elements for the Privacy Rule written authorization are similar to those of Part 2. However, to comply with the Privacy Rule authorization requirements, the Part 2 consent must also contain a statement reflecting the ability or inability of the substance abuse treatment program to condition treatment on whether the patient signs the form as described in 45 CFR ?164.508(c)(2)(ii). In addition, the consent may be signed by a personal representative, and if so, must include a description of such representative's authority to act for the patient. See 45 CFR ?164.508(c)(1)(vi). Finally, the consent must be written in plain language. See 45 CFR ?164.508(c)(3).

The requirements above must be met with respect to the Part 2 consent form when the purpose of the disclosure is not for "treatment, payment or health care operations" or for any other permitted or required disclosure under the Privacy Rule. See 45 CFR ?164.502(a).12 The statements would have to be added when the consent form authorizes a program to make a disclosure for which an authorization is required under the Privacy Rule, e.g., those disclosures addressed by 45 CFR ?164.508.

The Privacy Rule imposes three additional steps programs must take when disclosing information pursuant to a patient's written consent:

• Programs must ensure that the consent complies with the applicable requirements of 45 CFR ?164.508.
• Programs must give patients a copy of the signed form (45 CFR ?164.508(c)(4)).
• Programs must keep a copy of each signed form for six (6) years from its expiration date (45 CFR ?164.508(b)(6)).

Therefore, substance abuse treatment programs should generally continue to use the consent form for disclosures subject to Part 2. If the Privacy Rule requires authorization for the disclosures, the substance abuse treatment program may use the Part 2 consent form with additional elements required by the Privacy Rule as listed above. ?

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