Abstract
Counselors and other service providers face
daily ethical dilemmas that involve confidentiality, dual
relationships within the Deaf community, boundary issues and
questions related to self-disclosure. Most human services
professions have ethical guidelines or standards that focus
on various areas of professionalism. This article will provide
information on issues related to professional competence,
moral and legal standards, the use of professional codes of
ethics and guidelines, a decision making model, the power
differential and appropriate uses of supervision and peer
support.
Introduction
As a profession grows and changes, so do many
of its practices and standards. Professionals who work with
Deaf and hard of hearing individuals have grown from being
a relatively small group of service providers to a full complement
of specialists in a wide range of human service areas. No
longer is it good enough to be able to simply communicate
with consumers; it is essential that counselors, social workers,
psychologists, and others understand and accept the social
and cultural considerations that consumers who are Deaf bring
into the counseling setting. There is more demand for specialized
services than ever before as programs related to mental health
services, addictions treatment, independent living, education,
and recreation continue to emerge.
Through many of these changes, it is important
to consider how we as professionals view ourselves and what
practices we hold above all others. Most human services professions
have ethical guidelines or standards that focus on various
areas of professionalism including training, competence, duties,
research, community outreach, and moral and legal standards.
What do we perceive as our responsibility related to ethical
considerations when working within the field of Deafness?
Is there a different ethical code for those of us who work
with Deaf people? Why is the study of ethics in the provision
of services to individuals who are Deaf important?
Ethics comes from the Greek "ethos,"
meaning "character" or "custom." Plato
and Aristotle used this concept to describe their studies
of Greek values and ideals. One definition of ethics is,"Doing
the right thing because it is the right thing to do"
(Solomon, 1984). Aristotle believed that ethics provided
guidelines for virtuous action. In his Rule of the Golden
Mean, he defined the ethical choice as one that falls between
two extremes. For example, trust is the virtue that lies between
suspicion and foolish faith. Ethical issues revolve
around setting and maintaining professional boundaries. As
professionals, we deal with ethical issues and choices on
a daily basis. It is important to think about the role of
ethics in the human service setting and its implications for
both clients and counselors. Counselors and other service
providers face daily ethical dilemmas that involve confidentiality,
dual roles within the Deaf community, boundary issues and
questions related to self-disclosure. Professionals also need
to be knowledgeable about their professional code of ethics
and guidelines, agency guidelines, appropriate uses of supervision
and peer support.
Ethics and Values
Everyone has an internal set of standards of
behavior that reflects their own personal value system. The
acquisition of this value system is a product of living and
growing within a family, culture and society. Professionals
need to study the correlation between ethical standards and
personal values systems. Further, group and institutional
ethical standards must be compared to ones own personal
value system for congruency or conflict.
The terms profession and professional
may bring different images to mind. Profession is defined
as a group of people who share a common body of knowledge,
a code of ethics, and a concern for their peers(Bissell, 1994).
In athletics, for example, the major difference between the
amateur and the professional is that the professional is paid.
In contrast, the social and health services contain very few
professionals who are more interested in money than in helping
people. From another perspective, one major difference between
a business and a profession is that a business emphasizes
the importance of earning a profit, whereas a human service
profession is primarily aimed at rendering service. The Deaf
services professional does not work for a boss or for dollars,
but for the purpose of serving the client. Success is not
measured in profit, but in quality of service.
Legal and Ethical Conflicts
Whether or not a given behavior is legal does
not determine whether or not it is ethical. It is possible
for legal activities to be unethical, such as the situation
of a professional dating a client. The use of marijuana for
medicinal purposes in many places would be illegal, but may
be viewed as ethical. The potential for conflict between the
principles and practice guidelines of psychology and the law
is ever present. In some instances, laws are written in ways
that do not take into account the nuances or the complexities
of psychological practice. In other instances, the standards
that are incorporated into some laws may be more appropriate
for another profession or set of concerns.
Although adherence to professional ethics has
a deeper basis for right and wrong than fear of being arrested
or sued, there are times that legal concerns arise. Just because
we are threatened with a lawsuit does not mean we are wrong
or will lose, but even good people and their colleagues can
be successfully sued if they leave themselves liable. We need
to reduce liability by reasonably reducing the risk of accidents
or incompetent service, and by recording the remedies we adopt
so that evidence can be produced in court. There will be times
when we must do what we believe is honest and ethical, no
matter how it may appear in a court of law. In spite of their
best efforts, professionals may feel torn between the need
to protect themselves or their institution from litigation
and the desire to spare a client unneeded discomfort or expense.
Regardless of the circumstances surrounding
a suit, the laws that permit such suits are for the protection
of all who interact with the profession. Individuals must
conduct themselves in ways that will conform both to the ethical
and practical guidelines of the profession and the law, and
they must be prepared to defend their decisions if conflicts
arise. What should a psychologist do if a client who is diagnosed
as having AIDS or is tested positive for HIV reveals that
he is continuing to engage in sexual relations without concern
for safe sex practices and without telling his partners? If
the client gives the actual names of partners, does the psychologists
duty to protect others extend to those partners? Does case
law (decisions in actual cases) indicate that the psychologist
has a legal obligation to warn them even though there are
no federal or state laws requiring reporting such instances
at this time? Conversely, do laws governing confidentiality
prohibit the psychologist from warning the potential victims?
The professional must use his/her own sense
of judgment about the issues and concerns inherent in a particular
situation. The clinician may act in ways that appear to violate
a clients rights, as in the situation of warning a potential
victim of a clients violent intentions. They may also
place themselves in direct defiance of the law, as in the
situation of refusing to provide subpoenaed records in a divorce
case when asked for copies of personal notes about one partner
when both were treated during therapy.
Professionals are expected by the general public
and by members of other professions to have high standards,
to be responsible for their own colleagues, and to act with
integrity. Ethical accountability applies to all decisions
whether they are hard or easy to make, or personal or professional
in nature. Ethical responsibility starts with the self; if
one has good reasons for a specific decision, and is able
to justify that decision within ones self, one is ready
to justify and explain that decision to others. One is willing
to accept the consequences of his or her decisions. Professionals
must accept the consequences of their decisions and actions.
Dual Relationships
A frequent topic in the literature on ethics
for human service providers is dual relationships. Herlihy
and Corey (1992) addressed many of the issues relating to
dual relationships and provided a variety of insights and
perspectives on them. They defined a dual relationship as
"when professionals assume two roles simultaneously or
sequentially with a person seeking help" (p.3). The issue
of dual relationships is especially complicated when a Deaf
or hearing person who is actively involved in the Deaf community
is working in the profession. That person may be a therapist,
social worker, vocational counselor, teacher, substance abuse
counselor, administrator, etc. Many issues surface on a daily
basis for people working in this profession and living in
a community where they socialize with the same Deaf people
who are their clients. When dealing with a clinical situation,
the dual relationship may exist at the beginning, may develop
during treatment, or it may begin after the termination of
the clinical relationship with the client .
Although often perceived in only negative terms,
dual relationships are not necessarily problematic or unethical.
One variable in determining the ethical ramifications of a
potential dual relationship is its avoidability (Herlihy &
Corey, 1992). In small communities, for example, some form
of dual relationship may often be the rule rather than the
exception. Refusing to provide counseling to individuals with
whom one has another relationship would in these instances
prevent people in need from receiving assistance, which would
raise other ethical concerns. In the substance abuse field,
the recovering counselor may occasionally attend the same
Alcoholics Anonymous(A.A.) meetings as former clients who
have become a part of the local recovering community, making
such occurrences practically unavoidable if the counselor
is to continue to attend self-help meetings. The issue of
avoidability is included in the consideration of the ethical
nature of a given activity and may be a mitigating factor
in some situations (Hass & Malouf, 1989). This is especially
applicable within the Deaf community.
The greatest potential for harm from a dual
relationship, however, may result from the power held, or
perceived as being held, by the counselor. Whereas the counseling
relationship will eventually come to an end, the power differential
may remain indefinitely, adversely affecting any future, non-therapeutic
relationship between counselor and client (Haas & Malouf,
1989). Counselors may hold a great deal of power over clients
that can potentially lead to exploitation. When exploitation
appears in the personal interaction between counselor and
client, serious dual relationship problems quickly arise.
Most ethical codes draw strong distinctions
between sexual and non-sexual dual relationships. Ethical
codes vary in their requirements about the length of time
that must pass for another "significantly different"
relationship, especially a sexual one, to be permissible(Herlihy
& Corey, 1992, p.3). Although the codes considered here
prohibit the counselor from having a sexual relationship with
a current client, variation occurs in the prohibition of such
a relationship with former clients and the length of time
that must pass for such a relationship to be permissible (American
Counseling Association, 1995; National Association of Alcoholism
and Drug Abuse Counselors, 1995). Power issues between Deaf
and hearing members of the Deaf community, or between Deaf
clients and hearing therapists call for even more careful
examination.
Current ethical standards do not include specific
references to potentially difficult situations that face recovering
counselors, especially in the area of dual relationships.
The standards do, however, give general guidelines that the
counselor may use to draw conclusions about his or her particular
situation or ethical dilemma. Seeking supervision or consultation
is, of course, another wise option for the counselor in need
of an objective opinion about a dual relationship, or a potential
one, involving a client.
Professional Boundaries
Professional boundaries can be defined as the
line that separates where the counselors influence ends and
the client's autonomy begins. It is the emotional and physical
space that gives clients room to focus on their own healing
and not on the counselor. Boundaries dictate counselors' interactions
with clients and serve as the parameters that keep the professional
as objective as possible.
Most professionals have experienced boundary
dilemmas and boundary violations. Our responsibility is to
maintain healthy boundaries. Confucius said "where there
is power, ethics must follow." Many clients are vulnerable
when they seek our help; counselors hold the power, and must
set and enforce boundaries to benefit and protect the client.
When ensuring that appropriate boundaries are in place, we
need to remember to create the emotional space that gives
our clients room to focus on their own healing. Boundaries
put a limit on a professionals power so clients arent
hurt. They are fluid and change depending on the role we play
and the clients vulnerability. Some boundary issues
may be situational and interpreted differently by each person.
One way to better understand the different kind of boundary
issues that come up is to talk about different situations
that might arise. When discussing professional boundaries,
the issue of self-disclosure must be addressed. Within the
counseling session, the question of self-disclosure also raises
dual relationship issues. Information that the counselor discloses
may introduce new elements to the counseling relationship.
In the context of Deaf culture, a certain amount of self-disclosure
would be culturally appropriate. Too much, however, might
compromise good professional judgement.
Our personal values affect our ethical boundary
decision making. We all have boundary questions and have to
recognize this and talk to other professionals about this.
For example, what ethical issues arise when a client gives
a therapist a gift? How do you handle the situation if you
get a gift? How do you acknowledge the need for clients to
give back something? What are the ethical dilemmas that this
raises? First you get a rose, then a dozen roses, then a rose
bush, then an offer to tend to your rose garden. Where and
when should professionals draw the line. The issue of gift
giving is further complicated when you add factors such as
cultural differences. For example, if you turn down a small
gift in some cultures, this may mean total rejection of the
individual or can be interpreted as lack of respect. Setting
and maintaining appropriate boundaries is complicated.
Sometimes we think of boundaries in terms of
what areas they affect. These areas may include physical,
emotional, psychological or sexual transgressions. Examples
of each are listed below(McGuire, 1996):
a.) Physical Boundary Transgressions
-
A client comes into your office and
picks up papers on your desk.
-
You are meeting with a co-worker
and a colleague opens the closed door, sits down,
and begins talking about a crisis.
-
Your supervisor hugs you without
your permission after a negative performance review.
b.) Emotional Boundary Issues
-
A client shares her memories of sexual
abuse with members of the support staff in a crowded
waiting room.
-
A staff member shares the details
of her divorce during a staff meeting.
-
A supervisor acts as therapist for
a supervisee.
c.) Psychological boundary Issues
-
A white client calls a black client
a racist name.
-
A staff member shames a co-worker
by indirect criticism, ridicule, or sarcasm.
-
Your supervisor answers the phone
three times during a meeting that you requested.
d.) Sexual Boundary Issues
-
A client winks at you seductively
during group therapy.
-
A staff member says, "Your present
position - the way youre bending over - makes
me think of my wild weekend. Let me tell you about
it."
-
A supervisor wants to know details
about your clients sex lives. Each time you
try to discuss other relevant information, your supervisor
steers the topic back to sex.
Boundaries are complex and our personal values
affect our ethical boundary decision making. We all have boundary
questions and have to recognize this and talk to other professionals
about them. Often context, not content, determines the appropriate
boundary. For example, if you were an outpatient therapist
and you went to a movie with a client, you would violate several
professional boundaries. Yet, if you were a professional in
a residential setting, it may be quite appropriate to go to
movies with clients as part of the program.
The American Psychological Association (APA)
struggled between two ethical positions regarding contact
between former clients and therapists. They recommended a
waiting period of perhaps two years of no contact, or to forbid
absolutely all romantic entanglements whatsoever between therapist
and former client. They finally decided to recommend no sexual
relationships, regardless of time(no phone calls, no greeting
cards) after some initial reluctance of appearing too rigid
on the issue. Experience shows that such relationships are
rarely, if ever, healthy.
The Power Differential
Often boundaries become clouded or get crossed
because we do not remember or understand the premise behind
a particular boundary. Why do we have boundaries concerning
gifts from clients when we accept gifts from friends? There
is a power differential, and it is important to remember that
a professional helping relationship is asymmetrical -- the
interactions between the two parties are not equal. We are
in a position of greater authority and clients are vulnerable.
While we get paid, they dont. Although we know about
their personal pain, they do not know about ours. The
following scenario reminds us what it's like to be a vulnerable
client(McGuire, 1996).
The appointment
You are in the doctors office. You
have been sitting in the waiting room a long time; it is now
9:30, and your appointment was for 9:00. You are feeling nervous
because you know something is wrong with you but youre
not sure what. Perhaps you are also in pain.
You finally go to up to the receptionist
and ask. "How much longer will it be? My appointment
was for 9:00, and I have a 10:30 meeting I have to attend."
"It wont be much longer, " he answers blankly.
Do you scream at the receptionist? No, because
you are dependent on the doctor for help, and showing your
true feelings might jeopardize your care. Do you say: "Forget
it!" And leave? No, because you need the doctors
expertise. You cant get better on your own.
So, you sit down. Maybe you feel like crying
(or screaming). Your life feels out of your control. Youre
behind on deadlines at work because of this illness...and
yet you cant take care of this with your own resources,
so you have to stay...and wait...and wait. Finally, your train
of thought is derailed by a voice: "Excuse me, the doctor
will see you now."
With relief you get up and go into the examining
room, where you wait another fifteen minutes. While waiting,
you make a list of questions you want to ask about your illness.
The door opens and the doctor flies in with
the comment, "What a crazy day! Lets see what we
can do for you." She immediately begins to read your
chart, making no eye contact with you.
The doctor proceeds to ask you questions,
which you try to answer clearly...but it really is complicated,
and youre confused as to when the symptoms show up or
even what they are. You try to explain all this but she cuts
you off. With anger rising, you find yourself thinking, Why
cant I explain this? Its probably not important.
You ask three of your ten questions. You
dont quite understand some of the answers, and when
you ask for clarification, youre still not sure if you
understand but you drop it and dont ask the other questions.
The doctor gives you a possible diagnosis,
although shes not sure, and prescribes some medication.
She also refers you to a specialist whose office is thirty
miles away.
After the appointment, while youre
standing in the clinic parking lot, you realize you dont
even know what the medications side effects are. Youre
fuming. "Why didnt I stand up for myself! I am
the one whos paying her. Whats wrong with me?
I dont have time to see another specialist!"
The scenario has been simplified in several
ways. It does not reflect the following factors that may be
present when the concern is psychological :
-
You probably have a stronger ego than
many clients in therapy.
-
The scenario did not involve a chronic
condition requiring you to see helping professionals
routinely (daily, weekly, or monthly).
-
Your job, family cohesion, or place
of residence were not affected by the professionals
involvement.
-
You did not exhibit an illness with
social and personal stigma attached.
-
You were not in crisis.
There is a fine line between appropriate and
inappropriate boundary and power differential issues.
A professional should be close enough to the client
to be sensitive to and respectful of their emotions, but not
overly involved. The professional should also be distant enough
to allow clients the autonomy they need to heal. Clients need
to feel protected and supported in their vulnerability, as
well as empowered enough to effect their own recovery. It
is easy for the lines to change, moving toward inappropriate
boundary and power differentials. If we, as professionals,
are uncomfortable with our power, we may shrink the boundary
space and reposition ourselves as buddies or peers. We come
in too close, and clients may feel confused, angry, or unsafe.
They know that we have more power, even though we are acting
as if we dont. If we have been too close, we might react
by moving too far away. We forget clients vulnerability
and abandon them. We remove ourselves from the complex emotional
relationship and thus act outside it. We may begin to think
of clients as walking diagnoses - objects to be acted upon.
Clients may feel alone, unheard, confused, or unsafe. For
some Deaf clients, whose experience in their family of origin
was of being "unheard" or left out, this can be
particularly harmful.
Common Elements of Ethics Codes
When was the last time you reviewed your code
of ethics? Is there one available to serve your professional
group, or have you developed your own guidelines? Do you have
a copy close at hand that you can pull out whenever you face
an ethical dilemma? Ethical codes are minimal dictates. In
helping relationships, they serve as guidelines for reducing
harm to clients that can result from the power differential.
Our ethical codes -- national, state, and agency -- protect
the integrity of care: clients needs come first. "Codes
are covenants that say we will give and not take."(APA,
1981). The purpose of a code of ethics is to guide professionals
in helping clients and their families while behaving in a
fair and decent way to colleagues. Examples of organizations
that have codes of ethics include; the Registry of Interpreters
for the Deaf, and the American Psychological Association(APA).
The APA developed the Ethical Principles of Psychologists
which is a code of conduct or ethical system, formulated by
a select group of psychologists based on their experience
in the field, passed by the APA and acknowledged and accepted
through the act of joining the APA by psychologists who are
members of the organization.
Professional ethics are standards of behavior
that have evolved over time to reflect the professions
desire to insure the well-being of its clients. They are expressed
in a formalized code of behavior which describes the principles
that are important to the profession. More importantly, they
define the forms of behavior that are morally desirable by
the profession in its service to consumers. They are developed
because the client is the recipient of a service and therefore,
as in any profession, there is the potential for abuse.
Professional codes of ethics should include
the following principles:
-
Avoid dual relationships that exploit
clients-socially, financially, or sexually.
-
Avoid discriminatory behaviors.
-
Restrict treatment to your areas of
competence. Know your limitations and refer the client
to another professional when it is in the clients
best interest.
-
Respect and safeguard the autonomy of
clients.
-
Respect the rights, views, and clinical
practices of other professionals.
-
Hold colleagues accountable for ethical
practices.
-
Continue to grow professionally.
-
Consult with other professionals when
circumstances dictate. When giving direct client care,
get clinical supervision.
-
Adhere to all state and federal laws
that govern client care, such as laws that relate
to confidentiality and maltreatment of vulnerable
adults.
The client needs protection during the receipt
of professional service for the following reasons: The profession
is in control of its own practice; the consumer may not be
able and should not be required to judge what is professional
and unprofessional conduct; the profession must have a basis
upon which to defend its practices. Professional ethics describe
"what ought to be" in a world of "what is."
They define the professions belief of how its member
should behave, not necessarily how they do behave. professional
ethics aim to provide professionals with a standard of behavior
to which they must aspire. And while they may provide the
goal of professional behavior, and not the description, they
serve as a guide for all professionals of good conscience.
Personal Conduct
Initial discussions of boundaries in a therapeutic
setting frequently refer to the relationship between the counselor
and the client. However, each professional must examine his
or her own history and practice to be aware of other boundary
issues that may emerge. It is important to keep boundaries
from the past in the past. One's personal past affects how
boundaries are set in the present. One's family of origin
had its own boundary rules and problems. These factors influence
the present perspective. Taking inventory, a relevant question
to ask is Whats in my suitcase? That is, what
personal "baggage" do you carry and how might it
influence your current ethical choices? Be aware of vulnerability
and things happening in your life. A social worker answers:
My boundary problem is triangles - when
I was a kid I was expected to be the message carrier between
my three siblings and my parents. It was my job to address
my sisters hurts and grievances. I spent a lot of
time trying to get my parents to change and respond. Because
of this role, I have to be careful at work. Its
easy for me to create triangles between angry or hurt
staff and their supervisor. With me in the middle as message
carrier and problem solver. I can get so caught up that
Im late for client appointments.
Another example might be a Deaf therapist whose
own unresolved issues with their hearing parents affect how
that person perceives his/her Deaf clients' relationships
with their parents, or a hearing therapist whose unresolved
issues with his/her Deaf parents color their perceptions of
Deaf clients who have hearing children.
In order to keep a system focused on client
care, we need to also monitor and maintain our boundaries
with co-workers. When youre angry with a colleague or
distrust a co-worker, where is your energy going? The amount
of energy we expend in self protection, anger, and indirect
fighting with co-workers takes away from what we can give
to our clients-immediately and in the long term.
There are many kinds of relationships going
on at any worksite. Overlapping roles with co-workers made
boundary-setting even harder. Co-workers may be related to
each other or we have social relationships with peers. A supervisor
might have once been a peer, but is still a close friend.
It is difficult to approach a co-worker with boundary concerns.
This action becomes even more difficult when layers of relationships
exist among the staff. Since a dual relationship exists when
one person interacts with another in more than one capacity
at the same time, this suggests the possibility of an ethical
compromise or conflict of interest. We gain by making dual
relationships explicit. We can decide if such relationships
energize or deplete the staff by positively or negatively
affecting the team, and thus clients.
Consider the example of two co-workers who play
on a softball team after work. They dont talk about
work outside of the job. How might this relationship be viewed
by the rest of the staff? Would their colleagues know about
the boundaries that have been set? Will they trust that the
boundaries are upheld? Even if the dual relationship is explicit,
would their colleagues feel that the relationship is affecting
work? Can they raise their concerns?
We cant keep our clients needs first
unless we first meet our own needs. When we take care of ourselves,
we can better take care of clients. By upholding personal
boundaries between clients, colleagues, and supervisors, we
get our professional needs met so that we can focus on clients.
If we do not take the time and energy to fulfill our personal
needs outside of work, we will fulfill them at work.
By upholding boundaries, we meet personal needs so that we
dont ask clients to meet them.
Are you working regular overtime?
Are your personal relationships "fifty-fifty?"
That is, do you get as much from these relationships as
you give?
Do you take all of your vacation days?
Do you have friends outside of your work?
Do you have friends who are not in the
helping fields? Do you play as hard as you work?
Do you really leave work at work? Are
you having fun in your life?
Who are your mentors? What characteristics
of theirs do you admire?
Different professions have to consider unique
issues that may arise. For example, counselors who are in
drug or alcohol recovery need to examine all relevant codes
and regulations that apply, and be careful about how they
plan to use self-disclosure of their personal recovery. Each
person should establish their own personal code of ethics
that they adhere to at all times.
Confidentiality
Maintaining confidentiality is one of the core
principles guiding human service professionals. Private information
divulged by clients in the course of treatment may never be
used or repeated in any way that can be identified with that
individual. Privileged communication refers to the practice
of excusing many professionals, such as physicians, nurses,
clergy members, psychologists, and others from being compelled
to testify in court. The principle that the relationship between
patients and health care providers is confidential dates back
to the Hippocratic oath. The medical privilege promotes openness
on the part of the patient to make a complete disclosure of
medical history and symptoms. This principle holds true for
human service professionals as well. What is privileged or
protected is the information given verbally by the client,
any data gathered through the course of providing services
to the client and any documentation which results from the
client/provider relationship. The privilege to release this
information whether verbally or in written or electronic form
beyond the client/provider relationship belongs to the client.
With some exceptions under the law, only the patient may waive
the privilege to allow the release of information to a party
outside of the client/provider relationship. Since Hippocrates,
the parameters of this privileged have been defined, for the
most part, by state statute and common law. For example, commonly
the privilege is not automatically waived for health care
and human service providers to provide testimony in a legal
matter. Patient or client authorization may be needed.
Maintaining confidentiality means that there
is no discussion or detail provided about a client in any
form without the express permission of that individual. In
reality, however, maintaining complete confidentiality may
be impossible in some situations Furthermore, certain laws
and ethical considerations infringe on a client's right to
confidentiality. Child abuse reporting laws, for example,
require the breach of confidentiality, as does the Tarasoff
ruling, which mandates notification of intended victims of
clients. When there is risk of suicide, most mental health
professionals agree that taking steps to prevent suicide supersedes
a client's right to confidentiality. Both the needs of the
client and the appropriate needs of others must be met. If
information about a client needs to be shared, the question
of how much to share will arise. It may be impossible to obtain
specific consent from each client every time the need to consult
arises. It is also unrealistic to expect that a general consent
can be given because some information may not fall into the
categories that such a consent is intended to release. Thus,
sound judgment must be used in determining what information
will be shared with the patient and also with colleagues.
The use of the telephone may challenge even
the most prudent counselor. In some communities, referring
agencies may inadvertently give identifying information about
a client without realizing it. Client names should never be
shared on the phone. When using a TTY, the individual on the
other end of the phone may not be the person they say they
are. To verify a caller's identity, previously arranged passwords
may be used.
Human service providers may be uncertain about
maintaining records of contact with clients. One must consider
the level of detail to include to support the treatment plan,
but balance it with the amount of information needed to fulfill
the reporting requirements of insurance companies, government
agencies, elements of the legal system, and other entities
to whom there are obligations.
Maintaining confidentiality may be challenged
when a client engages in illegal or threatening behavior.
The professional is faced with the dilemma of determining
what action he/she should take to protect the well-being of
others and to comply with the law. States also have varying
laws of responsibility given for reporting purposes. Protecting
the rights of those deemed incompetent or those who depend
upon one for protection because they are vulnerable is an
important responsibility. Answers should be based on such
questions as What rights are involved? Whose rights take
priority? Why? What values are at stake? Confidentiality
is especially important within the Deaf community, where reputations
follow people for life, and characteristics of clients may
identify them to others.
Competent Professionals
Being a competent professional means having
the knowledge, skills, and abilities necessary to perform
a constellation of tasks relevant to that profession as well
as understanding when it is appropriate to provide services
or to refer a client. The more demanding a profession is,
the greater the knowledge and number of skills and abilities
that will be required and the more likely it will be that
a professional will not be competent to provide service in
all areas of the profession. Formal training is one way to
obtain competency, and experience and continuing education
are the primary means for expanding skills and becoming more
effective. Having a strong belief in a particular methodology
or way of life can strengthen ones competence to practice.
However, ones beliefs and attitudes may begin to overshadow
objectivity, and one may need to step back and reevaluate
how one is providing services. Self-care and self-awareness
are two of the competent psychologists most valuable
tools. Personal beliefs and attitudes, physical and emotional
fatigue, personal problems, and other concerns of the professional
can dramatically affect how he/she provides services.
If a person is unable to view a patients
concerns objectively, the effectiveness of the professionals
decision-making can be reduced. He/she may even do more harm
than good. A competent professional maintains his/her well-being
by seeking physical and psychological care when it is needed,
by being alert to the signs of stress and burnout, and by
evaluating the decisions he or she has made in relation to
the needs of his or her clients.
Another element of competence is knowing which
services and treatments should be provided by other professionals
and knowing who can provide those services. Each professional
cannot provide every service needed by every client. If a
person is recommending another service which will be provided
by another professional, he/she needs to understand the implications
for making the referral. He/she should understand enough about
the services required to provide an appropriate referral or
to provide guidance on how to find those services and should
be able to help the client understand what to expect from
the professional providing the service.
Peer consultation is one of the most important
resources for maintaining and increasing competence. Within
the limits of confidentiality, discussing a specific concern
with more experienced colleagues about how one should provide
a service can help clarify what action to take and will help
resolve personal conflict. Peer consultation sharpens ones
professional skills by challenging ones ability to explain
the concern, providing a different viewpoint, the benefit
of other experiences and, in some cases, an opportunity to
correct treatment errors before a client is harmed.
Professionals also have a responsibility to
monitor their colleagues competency to practice. This
may seem presumptuous or even inappropriate to some, but being
aware of the competence of ones colleagues allows one
to identify when a professional is not providing the services
he/she claims to provide in an appropriate manner. When such
abuses occur, it can be possible to correct them through peer
pressure. It is possible to offer a colleague critique and
support, and obtain his/her cooperation. However, in order
to eliminate abuse it may become necessary to file a complaint
against the person with the licensing board.
Professionals recognize that not everyone is
able to do everything, but where are the limits? Many skills
can be learned, others perhaps never can be. In many parts
of the country, there still may be no legal constraint on
credentials for certain professions. Supervision of counselors
by clinical professionals is imperative. It is considered
irresponsible if a person isnt supervised appropriately.
Sometimes, it is obvious that counselors are
being asked to undertake problems beyond their abilities.
Does it make sense to ask a counselor whose only expertise
at marriage counseling may be derived from the misery of his
or her own three failed marriages? Sometimes counselors deal
with their personal prejudices and other limitations by denying
that problems exist. One counselor, when asked about his management
of a clients severe anxiety over failure in sexual performance,
was eager to explain that it was too early in sobriety to
discuss the problem, and that time and physical healing would
automatically resolve the difficulty. Some individuals may
have discomfort with other races and ethnic groups. No one
is comfortable with every group, or sensitive to or even informed
about everyones needs. We need to be aware of what we
can and cannot do, and assume responsibility for getting clients
we cant help into the best situation available for their
particular needs. The real failure is denying there is a problem,
thus leaving the problem unresolved and preventing clients
from getting help that may be available from someone else.
Going beyond ones competence is forbidden
by all ethical codes. Limitations may stem from a lack of
training or experience, unfamiliarity with the area in which
the problem falls, the denial of the problem as described
above, the difficulty or complexity of the case, or interpersonal
problems between patient and counselor. Knowing ones
limitations and being able to ask for assistance is part of
each persons professional obligation. Part of being
a responsible professional is the ability to restrict practice
to ones area of training and competence. It is important
to know when it is appropriate to make referrals to other
agencies for services one cannot or chooses not to offer.
The temptation is to want to handle everything alone. A real
expert knows when to ask for help and where to get it.
Professional development and a constant upgrading
of skills and knowledge is essential. Regular reading of professional
journals and new books, attendance at conventions and workshops,
and taking additional courses are some ways to keep up with
current information and practices. Competent providers are
people who:
Ethical Decision Making
One of the main frustrations in dealing with
ethical dilemmas is that there is often no one right answer.
A decision to act in a given way may trigger other actions
that also need to be addressed. Even the most experienced
professionals may encounter self-doubt when facing challenging
dilemmas. If one does not have or know of a professional code
of ethics to follow, these situations can become even more
upsetting.
When considering the area of student services
in higher education, Kitchener (1985) suggested five ethical
principles to guide individuals in their work with students.
These principles are to (1) respect autonomy, (2) do no harm,
(3) help others, (4) be just, and (5) be trustworthy. In comparison
with the complex codes of ethics established by some professions,
these five principles seem rather simple at first glance.
However, they can offer flexibility and permit consistency
without being rigid. Because real-life situations may be unpredictable,
it is possible that conflicts among the five principles may
result and that the practitioner may need to consider the
situation from several perspectives before taking action.
Adhering to Ethical Codes
Below is a suggested process to assist individuals
when making ethical decisions(McGuire, 1996).
1. Review your code of ethics and legal
mandates.
Laws are based on specific actions in specific
situations. In contrast, ethics involve contextual considerations
-- the various relationships involved and the ripple effects
from any decision. For this reason, legal mandates can only
serve as one piece in an ethical decision. Many states have
a legal mandate that forbids a sexual relationship between
provider and client for two years after therapy terminates.
But from an ethical standpoint, other questions remain. Is
it okay to have a sexual relationship with an ex-client in
three years? Is it ever okay to have a sexual relationship
with an ex-client? Is a client ever an ex-client and how do
you decide?
2. Seek input from a second party.
These invisible boundary lines begin to take
shape when you look through another persons eyes. Supervision
is an essential source of objective feedback. Another suggestion
is to call your professional board anonymously to ask about
specific situations.
3. Determine the values (motives) involved.
Our values become hidden motives that influence
all our decision. It is important to make them conscious to
reassess them and reframe them if necessary. Recognize the
cultural and agency values related to the situation.
4. Evaluate the long-term effects of
your choices on your client.
Whose needs will be met? Whose interests will
be served? Are there short term effects to consider? How will
present and future clients be affected by your choice? How
about the community and profession as a whole?
Conclusion
We have discussed several common elements of
professional ethics as well as a number of specific areas
of ethical concern for helping professionals in general and
for those who work in the Deaf community in particular. Professionals
in the human services field, especially those working with
Deaf and hard of hearing clients, can only expect to face
perplexing dilemmas since we have different standards and
feelings about where each of us must draw the line with clients.
Some behavior is so clearly unethical and unacceptable, it
requires no discussion. Other actions lie in the gray areas
where rationalization can make questionable practices seem
all right if they are not examined closely. When considering
the ethics of a given situation, we need to always think of
our clients first.
It is important for professionals to uphold
their code of ethics, as well, as personal boundaries between
clients, colleagues and supervisors. If professionals in the
human services field get their own professional needs met
outside of their work setting, they will be better able to
focus on clients. If professionals do not take the time and
energy to fulfill their personal needs outside of work, people
will try to get those needs met on the job.
A few common themes underlie our discussion
of ethics. First, self-awareness and acknowledgement of our
own inner conflicts, strengths, limitations, values, beliefs
and needs, is essential to an ethical practice. Second, clinical
consultation, through supervision and discussions with peers,
is vital to maintaining a strong set of ethics. And third,
there is no substitute for a good working familiarity with
the laws and codes of ethics that govern one's particular
profession.
Whether the question is one of role, relationships,
boundaries, confidentiality or referral, a professional must
first acknowledge that there is an ethical question, and be
able to define the issue clearly. He or she must then be willing
to explore his or her own conscious or unconscious motives,
and all the possible long and short-term consequences of the
issue. Next, the professional must review existing laws and
codes of ethics, and consult with colleagues and supervisors
to obtain objective perspectives on the issue.
It is a rigorous process, but our clients, and
our profession, deserve no less.
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