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Spotlight on: The ACA Graduate Student Ethics Awards for Master’s Degree Students winner

This award recognizes exceptional, demonstrable understanding of the ACA Code of Ethics, the foundation of ethical professional counseling practice.

Winners: Samantha Burton, Ingrid R. Pipes, Ben Stoviak and Katie Voorman of Carlow University

Abstract

The essay addresses the ethical dilemmas that counselor Keith faces after deciding to offer distance video counseling to his client, Tina. Before Tina moved to another state, the face-to-face therapeutic relationship between Keith and Tina was trusting and effective. After a few video counseling sessions over FaceTime, Keith experiences poor video connection and some feelings of awkwardness during sessions. Tina has also followed Keith on his private social media pages and contacted Keith on his personal phone number. To review the ethical considerations of this particular issue, this dilemma will be examined through the lens of the American Counseling Association’s foundational principles. Specific ACA (2014) codes are considered and applied in relation to Keith’s dilemma. Relevant court cases, as well as the National Board for Certified Counselors Policy Regarding the Provision of Distance Counseling Services (2016) are introduced to give insight for ethical rational. Using the Forest-Miller and Davis Ethical Decision Making Model (2016), Keith will work through steps to determine a course of action.

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Essay: Application of the Forester-Miller and Davis Decision Making Model: A Case Study

This case study seeks to evaluate historical activities between a professional counselor, Keith, and individual client, Tina, who has been seeking services related to communication issues she has reported experiencing with her partner and children. In the details provided by this case, Tina has relocated to a rural area, and she and Keith have continued their counseling relationship by FaceTime, an unfamiliar professional distance counseling modality for Keith. Tina and Keith have begun to additionally interact through social media platforms and have experienced multiple technical problems, resulting in Keith developing and acknowledging a sense of discomfort.

Through the employment of a decision making model designed by Forester-Miller and Davis (2016), these counselors-in-training seek to provide recommendations to Keith that are guided by the American Counseling Association’s Code of Ethics (2014), relevant legal cases, and the National Board of Certified Counselors Policy Regarding the Provision of Distance Professional Services. Recommendations are made in alignment with the prescribed steps of this decision making model, in observation and evaluation of the ACA’s six foundational principles: autonomy, justice, beneficence, nonmaleficence, and fidelity (Forester-Miller & Davis, 2016).

Definition and Application of the Forester-Miller and Davis Decision Making Model

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These counselors-in-training have chosen to employ an ethical decision making model developed by Forester-Miller and Davis (2016). Initially published in the Practitioner’s Guide to Ethical Decision Making, by the American Counseling Association, this model was designed out of consideration of multiple pre-existing models in use by and developed for professional counselors, calling for decision-making to be grounded in observance of key foundational principles of the helping professions: autonomy, justice, beneficence, nonmaleficence, and fidelity (Forester-Miller & Davis, 2016). Furthermore, this model specifically integrates consideration and application of the American Counseling Association’s Code of Ethics among its mandatory steps, i.e., Step 2 (Forester-Miller & Davis, 2016).

Steps of Decision Making Model

This decision making model progresses through seven steps, beginning with identification of the problem and concluding with implementation and reevaluation of the proposed solution or solutions. Each step is explained and will be addressed and related to Keith’s dilemma.

Step 1: Identify the problem. In Forester-Miller and Davis’ Decision Making model, the problem is identified following a period of information gathering (Forester-Miller & Davis, 2016). Recommended strategies include asking questions and documenting acquired information in an outlined form (Forester-Miller & Davis, 2016).

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Step 2: Apply the ACA Code of Ethics. Following information gathering, outlining, and identification of the problem, the ACA Code of Ethics should be applied in a deliberate and rigorous manner (Forester-Miller & Davis, 2016). Legal and professional codes and standards, considerations of multicultural frameworks, and technical pragmatics should be applied to the case alongside the ACA Code of Ethics (Forester-Miller & Davis, 2016). It is the counselor’s responsibility to ensure that they understand all of these critically evaluative and potentially confounding factors (Forester-Miller & Davis, 2016).

Step 3: Determine the nature and dimensions of the dilemma. At this step, the identified problems should be considered in relation to any foundational principles (autonomy, justice, beneficence, nonmaleficence, and fidelity) found to be applicable, and individual applicable principles should be assigned priority values (Forester-Miller & Davis, 2016). Professional literature, peer and expert professional counselors, and relevant professional associations should be consulted for additional perspective and support (Forester-Miller & Davis, 2016).

Step 4: Generate potential courses of action. This step involves brainstorming an exhaustive list of potential courses of action, informed by the previously assigned and ranked applicable foundational values; peer consultation is recommended at this step (Forester-Miller & Davis, 2016).

Step 5: Consider the potential consequences of all options and determine a course of action. By way of careful and well-evaluated elimination of options, the counselor should choose the strongest option or options that meet the criteria of top-rated foundational values (ForesterMiller & Davis, 2016). Possible implications and consequences of and for all involved parties should be considered at this step (Forester-Miller & Davis, 2016).

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Step 6: Evaluate the selected courses of action. The selected course of action is reevaluated at this step for any issues that may have arisen or that were not previously considered (Forester-Miller & Davis, 2016). A prescribed test may be employed at this step to confirm the selected course of action; this test involves assessing for three values: justice, or evaluated fairness of choice across the potential population, publicity, or comfort with the possible outcome were it to be made public knowledge, and universality, the likelihood that you would recommend this outcome to a peer counselor (Forester-Miller & Davis, 2016).

Step 7: Implement the course of action. Given that ethical decisions may be realistically challenging to execute, this step exists to remind the counselor to carry out the diligent and thoughtful work completed in the previous six steps of this model (Forester-Miller & Davis, 2016). Follow-up and evaluation after implementation is recommended to ensure that the decision made was successful and positive, as well as if further action, reaction, or re-evaluation should be considered (Forester-Miller & Davis, 2016).

Identification of the Dilemma (Step 1)

Keith is a licensed professional counselor who had been seeing a client, Tina, for communication issues she was having with her partner and children. After building a comfortable and effective therapeutic alliance, Tina revealed that she had to move out of state. A few months later, Tina contacted Keith when she was feeling unsuccessful with her new therapist. She explained that the nearest alternative service provider is a long drive away from her rural area and requested that Keith consider tele-counseling over video chat. Keith admitted that he did not have experience with this method of counseling, but he attempted its use nonetheless. After a few sessions over FaceTime, Keith experienced several frustrating dropped calls and reported feeling awkward in offering a new medium of counseling. Keith used his personal cell phone for their FaceTime sessions and Tina began texting this personal number when she had questions. Tina sent Keith a Facebook friend request and has also followed him on Instagram and Twitter, stating that she appreciates having so many avenues to be connected to Keith since they no longer have faceto-face sessions. Keith understands that the relationship with Tina is potentially no longer therapeutic, but does not know what steps to take next.

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Ethical Codes and Relevant Considerations Identification and Applications (Step 2)

According to the prescribed steps in Forester-Miller and Davis Ethical Decision Making Model, Keith’s actions during the course of and related to the counseling relationship he established with his client, Tina, should be evaluated in relation to pertinent individual codes from the American Counseling Association’s (2014) Code of Ethics. Because this document is the de facto guide for ethical professional counseling practice responsibilities, these counselorsin-training have sought to exhaustively and collaboratively identify and apply any codes which may be valuable during the proposed course of decision-making and implementation. Keith’s dilemma, and others like it, are complex and multi-faceted, and the identified codes may not perfectly encapsulate all dimensions of the dilemma.

A.4.a Avoiding Harm. This code recognizes that counselors work to reduce or avoid situations that can cause unexpected harm to their client (ACA, 2014). Although Keith acknowledges that he has never used tele-therapy with a patient before, he fails to establish boundaries or guidelines around service delivery and instead gives his personal phone number to Tina to conduct sessions. This is a boundary crossing which impacts the therapeutic relationship and is potentially harmful for Tina.  Blumer, Hertlein and Mihaloliakos (2014) conducted a mixed methods study involving part and full time counselors as well as students enrolled in marriage and family therapy programs to assess their views on ethical issues and online counseling. One theme that emerged was the impact tele-therapy has to the therapeutic relationship, particularly boundary concerns. Participants were concerned that boundaries become blurred when clients are given access to personal contact information. For example, clients may perceive that the counselor is available at any time or the client may be able to gain access to the therapists’ social media platforms, both of which can negatively impact client care (Blumer, et.al, 2014).

A.5.e Personal Virtual Relationships with Current Clients. Code A.5.e states that counselors are not permitted to enter into personal virtual relationships with current clients; this includes social media and other media sites (ACA, 2014). Kolmes (2017) explains that multiple relationships between client and therapists are occurring more regularly and exist whether the therapist is aware or not. In this case, Keith became aware that Tina was following him on Instagram and Twitter after he received a Facebook friend request from her. Although it does not state whether Keith acknowledges these attempts by Tina to “stay connected and interact” it can be implied that her actions are the beginning stages of multiple role development in their therapeutic relationship. Multiple roles can impede on the counselors primary role as a therapist (Kolmes, 2017). A recommendation for Keith on how to navigate multiple roles when social media is involved comes from Kolmes. He suggests consultation and documentation with an expert who is proficient on the inner workings of the internet and social media (Kolmes, 2017).

A.7.a Advocacy. Code A.7.a declares that a counselor must take opportunities to advocate for clients when there is a potential barrier that may impact their development (ACA, 2014). The client now resides in a rural area, more likely with low mental health access and higher levels of suicide than other geographical areas (Cohn & Hastings, 2013). One aspect of this low access relates to high burnout among counselors in the area (Cohn & Hastings, 2013). Without proper supervision and better support from the community, mental health practitioners in rural areas will continue to struggle – and clients will continue to suffer under the lack (Werth, Hastings, & Riding, 2010). As the counselor of a client in this population, Keith should not only advocate for his client to seek out additional support in her area, but for the mental health community to show greater support for rural counselors.

A.12 Abandonment and Client Neglect. Code A.12 accredits that it is the responsibility of the counselor to ensure their client has access to treatment, even in times of the counselor’s absence (ACA, 2014). This may mean arranging a connection with another professional. Though the professional relationship between the client and counselor was ended before the client moved, the client has now faced a different environment with less resources. The counselor does not appear to have sought supervision for this new situation – wherein the client has asked for continued counseling services. It seems likely that the counselor was concerned about neglecting the mental health needs of the client due to her current struggle in a rural community. The ethics code regarding neglect and abandonment, however, applies to appropriately caring for the client and counselor relationship during the specific course of treatment – or during breaks within that treatment such as for vacation. Because the relationship between the counselor and the client ended out of necessity, if Keith appropriately closed out services, then he would have been within ethical boundaries to deny furthering services regardless of the client’s new environment.

C.2.a Boundaries of Competence. Code C.2.a states that a counselor must only offer services that are within their competency, or develop competencies to meet client needs (ACA, 2014). If offering a new service, counselors must prevent harm to their clients. As mentioned under other codes, the rural communities in America face a struggle with mental health resources. In studying ethical solutions for counselors in that area, Werth, Hastings and Riding (2010) recommend that some rural counselors refer clients to video conferences with specialists, or even tele-psychotherapy. In those recommendations, however, the counselor accepting the referral is a specialist or expert. The counselor in the proposed case, while specializing in one area of the practice, appears to have little experience with both tele-therapy and with rural culture. By not seeking greater understanding of either aspect, he is likely missing important parts of both – and will need to seek additional education or refer the client.

C.2.b New Specialty Areas of Practice. Code C.2.b contends that a counselor offers a new specialty or modality of therapy only after obtaining the specific training and supervision needed (ACA, 2014). One of the counseling concerns with rural populations relates to the cultural differences in rural and urban environments. Though the client has moved to the rural environment from a more urban space, she now faces a completely different set of resources and community supports. As Rollins (2010) points out, the cultural differences can be stark when it comes to recommendations and coping mechanisms. Urban counselors, for example, may not understand what is or is not available for clients in a rural community – where businesses, social gatherings, and accessibility may be very different than what the counselor wants to recommend. There is little indication that the counselor in the case has an understanding of these differences. As he moves forward with the client, he must seek additional education or training in virtual counseling those in rural areas. If he cannot find it, he may need to refer the client.

C.2.d Monitor Effectiveness. Code C.2.d explains that counselors should be continuously monitoring their effectiveness, as well as making appropriate relationships with other professionals for supervision (ACA, 2014). Apart from not having adequate competency about technological aspects of distance counseling, the counselor, Keith, also appears to have no knowledge of the legal consequences. His license may not be adequate for the state where his client is operating.

Alternatively, there are states where the licensed counselor doesn’t require a license for the state where the client resides, but must seek additional education and supervision under specific rules to practice there. By not mentioning this to the client, or seeking any of those additional measures, the counselor has both opened himself to legal issues, and is ignoring the basic ethics code regarding licensure and long-distance counseling.

C.7.b Development and Innovation. Code C.7.b states that counselors must explain the boundaries and risks of new areas in the field to clients before using such tools or methods (ACA, 2014). Counseling via technology poses increasingly great risks to clients, depending on the state where their licensed counselor is operating. According to Hughes (2000), “A client who obtains counseling services via the Internet from a counselor licensed in the same state has recourse to that state’s regulatory board for any violations against either the state code or standards of practice.” By not having adequate competency, the counselor has failed to give the client adequate warning about the issues related to his license and her options should malpractice or harm occur.

H.1.a Knowledge and Competency. This code demands that counselors develop adequate knowledge and competency surrounding use of technologies, distance counseling, and social media, as well as related to regulations and laws surrounding use of these kinds of technologies (ACA, 2014). Keith proceeded with using technologies for which he did not indicate he had any formal training and did not express that he was seeking the development of competencies related to using these technologies. Keith did not identify that he had knowledge of any laws surrounding distance counseling, social media, or telebehavioral health and counseling.

H.1.b Laws and Statutes. Code H.1.b. asserts that if counselors are engaging in telecounseling, they must be aware that they are held to the laws and statutes of their state and the state where their clients reside (ACA, 2014). The client’s resident state has jurisdiction over that therapeutic relationship and to protect the client. Since regulations on counseling across state lines varies from state to state, it is Keith’s duty to contact the state board in which his client, Tina, now resides to ensure the legality of temporarily counseling from a different state. A number of potential issues exist for telebehavioral health practitioners who practice across state lines, especially when state laws are notably different in the states where the client and counselor live, respectively (Maheu, 2018).

H.2.c. Acknowledgment of Limitations. Code H.2.c states that it is the counselor’s responsibility to inform the client of the limitations regarding confidentiality within technology (ACA, 2014). The counselor must ensure that the client understands the boundaries of security within the programming the counselor and client communicate on. By being clear and concise with the client about these limitations, the client is fully informed when giving consent to distance counseling. Keith acknowledged that he had never offered distance counseling, but he was not thorough in considering what steps need to be taken to protect his client’s confidentiality and security. Keith should explain the implications and boundaries of tele-counseling to Tina, including the extent of security of sessions and personal information.

H.2.d. Security. Code H.2.d requires counselors to ensure the programs they use host their website or communicate with clients have secure encryption that meet legal requirements (ACA, 2014). The client’s confidentiality must be ensured when using any digital programming by the counselor. Keith did not research or implement the use of encryption programing or HIPPA compliant tele-medical software to administer tele-counseling. The FaceTime tool that Keith used to host their video calls does not have privacy protection and although may potentially be implemented in ways that are HIPAA-compliant, for example, may not be a safe tool (O’Grady, 2011). To promote the security of his client, Keith would have to choose an encrypted program to host video sessions and communicate with the clients to whom he offers distance counseling.

H.3 Client Verification. When engaging in tele-counseling, or any form of digital communication, code H.3 states that counselors must continually verify the identity of their client (ACA, 2014). This can be done using nondescript, collaboratively chosen identifiers such as code words or phrases. No evidence was provided that Keith took appropriate and effective steps to verify Tina’s identity once the counseling modality had changed from in-person to video conference; additionally, no evidence was provided that Keith took steps to verify that social media accounts purporting to belong to or represent Tina were owned or stewarded by her.

H.4.b Professional Boundaries in Distance Counseling. Code H.4.b suggests that integrating technologies into the counseling relationship may effectively create a dual relationship, and it is important that Keith consciously maintain professionalism and professional boundaries, as well as clearly discuss these boundaries related to technology use with Tina (ACA, 2014, section H.4.b). Evidence was not provided that suggests that Keith met these professional responsibilities.  

H.4.d Effectiveness of Services. Code H.4.d confirms that if the tele-counseling sessions are ineffective, the counselor consider face-to-face sessions or referring the client to other services (ACA, 2014). Keith has experienced multiple instances of poor technical execution of the distance counseling sessions initiated with Tina. One substantial shortcoming was the ability to effectively address technology failures, e.g., dropped calls, a necessary step in the provision of distance counseling (Stolsmark, 2015). He has felt frustrated as a result of these technical issues and his own lack of competency to deliver counseling effectively via FaceTime. Keith has suspected that this new counseling modality may be ineffective, and because he can no longer provide face-toface counseling to Tina due to geographic constraints, Keith is therefore responsible for assisting

Tina with identifying appropriate, competent counseling. According to Meilman and Weatherford (2016), counselors unclear about communications using online counseling modalities might risk inaccurately assessing or overlooking potential signs or symptoms, resulting in further client harm, danger, or potentially suicide. Use of the FaceTime modality for counseling may negatively affect client disclosure or the client’s ability to speak clearly and comfortably about emotions (Mishna, Bogo, & Sawyer, 2015). Additionally, because professional counseling interactions may have taken place within the boundaries of social media platforms, anti-therapeutic communications may have occurred (Navarro, Sheffield, Edirippulige, & Bambling, 2019).

H.6.b Social Media as Part of Informed Consent. Code H.6.b states that counselors must clearly define the limitations, boundaries and advantages of social media during the informed consent process with their client (ACA, 2014). Before engaging in distance counseling with Tina, Keith did not explicitly discuss any usage of social media. As a result, Tina attempts to friend Keith on multiple social media accounts. One way Keith could have addressed social media prior with Tina is by establishing a social media policy during the informed consent process. Kolmes (2017) states that having a social media policy allows for the therapist to share their views on friending, following and other messaging which could potentially threaten counselor- client confidentiality and boundaries.

H.4.f Communication Differences in Electronic Media. Code H.f.4 ascertains that verbal and non-verbal cues occur differently while tele-counseling and that the counselor is responsible to address issues and nuances within digital communication as they arise with the client (ACA, 2014). Keith identified that he experienced the professional interactions between he and Tina as awkward. Yet, he did not proactively or reactively address these communication issues by providing information about voice inflections, a lack of visual cues, and other potential differences that may manifest in online, virtual, and video-conferencing communications.

Conflicting Factors, Dimensions, and Variables (Step 3)

Following the Forester-Miller and Davis model, the identified problems are to be considered in relation to the ACA foundational principles, which are then prioritized. Consultation of professional literature and relevant professional organizations occurs at this step, as well. Each of six foundational principles is considered, as is The National Board for Certified Counselors’ Policy Regarding the Provision of Distance Professional Services and relevant legal cases, in consultation for further best practices, perspective, and restrictions for Keith in working with Tina.

ACA Principles

In the presented case, the counselor has violated or potentially violated multiple codes under the ACA Code of Ethics. The description of the case indicates that he has begun to notice these conflicting practices and the need for an ethical assessment an action plan. If he had followed the basic principles upon which the code is written, however, he may have been more careful with both the client and the counseling relationship. The six principles (autonomy, beneficence, fidelity, nonmaleficence, justice, and veracity) are discussed here as they apply to the case. Their merits in the situation vary, but each ideal has a place in the dilemma this counselor now faces – and how his practice has reached this point.

Autonomy. The principle of Autonomy within the counseling relationship is the ideal that the therapist acknowledges and respects the client’s right to make their own decisions and actions based upon their value system, when appropriate (Davis & Forester- Miller, 2016). In the case of Keith and Tina’s counseling relationship, Tina makes new, continued, and repeated assertions of her needs, desires, and expectations, demonstrating autonomy, and Keith attempts to respect and acknowledge her autonomy therapeutically. However, as a counselor, it is Keith’s due diligence to also address when his client’s choices and actions may negatively impact the therapeutic relationship. For example, although Tina prefers to continue her services with Keith online, Keith fails to establish any guidelines or boundaries of informed consent about how the online service will be carried out. Additionally, the lack of boundaries leads to Tina finding and friending Keith on multiple social media accounts.

Nonmaleficence. This principle refers to the therapist’s duty to not inflict intentional harm nor participate in actions that could cause harm to others (Davis & Forester- Miller, 2016). Keith’s actions, though seemingly unintentional, still carry the potential risk of harming his client. At the moment in time at which Tina and Keith’s case has presented for evaluation, obvious issues exist, but client satisfaction or therapeutic effectiveness are unclear. The first action Keith should have made, in observance of the ACA Code of Ethics, would be to discuss a termination plan with Tina after she shares that she is moving. Along with the termination discussion could be information and guidance about possible in-person or distance counseling referrals for Tina to continue counseling. Not completing these steps could result in Tina being unable to receive proper care, as well as experience limitations in access to services.

Another instance where Keith did not consider the welfare of his client was in his decision to agree to provide online counseling services, without having any competence in this area and without seeking consultation prior to making this arrangement with his client.  As a consequence, frustrations develop between Keith and Tina due to dropped phone calls during sessions. Additionally, Keith is not comfortable during their sessions due to his lack of knowledge about online distance counseling. In either case, there is a risk of harm for Tina since she may no longer trust or feel safe with a counselor who appears incompetent. Also, her frustrations due to service issues are infringing on her ability to progress in therapy.

There is also a major risk of a dual relationship developing between Keith and Tina which could negatively influence Tina. As mentioned, Tina finds Keith on social media and decides to formally connect with his online account presence. She also has access to his personal phone number, which she texts whenever she has an issue. Since Keith did not establish any guidelines with Tina on how these forms of communication would be addressed, he has potentially made Tina vulnerable to harm. Whether intended or not, Keith is giving the impression that he is accessible anytime which can cause role confusion in their client- therapist relationship.

Beneficence. This value concerns itself with the acknowledgement and prioritization of work for the well-being of both the individual and society (ACA, 2014). In order to promote better mental health and wellbeing, counselors must follow ethical practices and manage their own part of the counseling relationship. By allowing boundaries to become confusing, and mishandling new professional tools, the counselor has set a poor standard for both mental health and the profession of counseling as a whole. Though he showed consideration for issues such as isolation and lack of mental health in rural areas, he also did not seek to understand what is needed in those rural areas.

Justice. This principle addresses the responsibility of the counselor to address clients fairly and equitably and to seek out means to ensure that clients experience fair and equitable care (ACA, 2014). This means that Keith, as a counselor, should be promoting accessibility for his clients. Though he has done this by treating his client when she is in need of assistance, he has ignored the complex dimensions of a relationship between client and counselor. In a counseling relationship, boundaries and expectations must be maintained and met. The boundaries of professional spaces assist clients in understanding where they have rights and independence. It is the counselor’s professional responsibility to explain these boundaries and help maintain them as the counseling relationship moves forward. Without clear communication and professional boundaries, both people in the counseling relationship are in danger, and cannot act with appropriate agency or advocate for their part of an equal relationship.

As Keith moves forward in the counseling profession, he should also spend more time understanding the cultural differences in communities. By better pursuing multicultural understanding across different cultures and environments, he can reduce the harm and inequality in his professional relationships. Currently, he has acted with an assumption that he understands an entirely different culture and does not need to work on his perceptions of environments. This may demonstrate an exercising of privilege, and denies his clients in different situations the appropriate help and resources they need – as well as setting inappropriate standards of care.

Veracity. Veracity deals with being honest or truthful with one’s clients (ACA, 2014). Keith does mention to Tina that he has never facilitated online counseling sessions before. Still, Keith should have disclosed more information about his lack of competency and sought advice from an expert in this area. In addition, Keith was not honest with Tina once issues with service connection and boundary crossings arose. In distance counseling, clients need to be made aware of the risks to their confidentiality as part of the informed consent process. There is a greater risk of clients’ personal information being accessed if technical measures are not established to secure client identity.

It is also the responsibility of the therapist to address and be honest about boundary crossings and boundary violations with their client. Keith realizes that Tina gaining access to his social media accounts is problematic. Ideally, this is another issue that should have been addressed during the informed consent process prior to engaging in online sessions. During which time Keith could have communicated his views and boundaries for social media with his client.

Fidelity. This good faith principle holds the counselor responsible to their promises, thereby increasing the profession’s holistic trustworthiness. Keith may be operating under the assumption that he must continue working with this client to fulfill a responsibility to her, or to honor a commitment to their professional relationship. However, the trust placed in Keith assumed that he would operate with appropriate competence and understanding. By disregarding supervision, education, legal concerns, and the need for informative consent between himself and the client, he has placed the client’s private information in danger and broken that trust. As a counselor, Keith is meeting basic requirements for trust – as the client continues to see him. But moving forward, he will need to work hard to improve his competencies and seek supervision. That will keep him from breaking the trust placed in him, as he is doing now.

NBCC Policy Regarding Distance Services

The National Board for Certified Counselors, a non-profit professional organization which oversees the assessment products used in part for the state licensing of counselors across the U.S., maintains a Policy Regarding the Provision of Distance Professional Services, applicable for counselors certified by the NBCC (2016). This policy document would apply to Keith’s practice as a Nationally Certified Counselor (NCC) if he is maintaining this professional status.  Because Keith has elected to proceed with the application of distance counseling modalities, the best practices outlined in this document may have useful, ethical implications and uses, regardless of whether or not he has applied for or currently maintains NCC status.

According to the NCC Distance Professional Services policy (2016), Keith should only provide services for which he is adequately qualified. He should adhere to all legal regulations which may apply to the practice of counseling and observe state regulations and laws which apply to the states in which the clients he is counseling reside or claim legal residency (NBCC, 2016). Client privacy must be prioritized and protected by way of using tools encrypted for therapeutic use, as well as warning clients about password “auto-saving” features on application and tools and potential network risks (NBCC, 2016). Records should be backed up safely and retained for a minimum of five years (NBCC, 2016). Clients and services should be assessed for appropriateness of distance counseling tools (NBCC, 2016). Clients should be screened for these services to assess for the potential risks or benefits of distance counseling use, as well as be provided with clear informed consent and engaged in ongoing identity verification practices (NBCC, 2016). Lastly, social media use policies should be provided to clients, and social media platforms should be avoided for the exchange, dissemination, or storage of confidential information (NBCC, 2016).

Many of the responsibilities outlined in this NBCC policy were not met by Keith and reflect issues aforementioned in relation to the ACA Code of Ethics. Though he was not trained in distance counseling, and did not screen his client for use in these tools, he proceeded to engage with his client using an unfamiliar distance counseling modality, and he did not indicate that he was aware of laws surrounding use of this modality. Keith did not indicate that he provided updated informed consent information to his client or warning about potential risks. He did not indicate that he was maintaining records in a consistent way. Lastly, Keith did not indicate that any kind of social media use or communications policy was provided to Tina before or during their exchanges.

Court Cases

When faced with an ethical dilemma, referencing relevant court cases can help counselors in their decision making. One ethical dilemma Keith faces is the decision to provide online counseling to his former client, Tina, who now resides in a rural area in another state. In Abraham vs. Bureau of Professional and Occupational Affairs, Board of Psychology, 2014, a psychologist from Israel was providing online counseling services to residents in Pennsylvania without being licensed in the state (Professional Licensing Report, 2014). Pennsylvania courts ruled that this was in violation of Pennsylvania laws because Abraham had a physical presence in PA via a Pennsylvania phone number and address, therefore requiring the need for him to also have a Pennsylvania license. The board felt that Abraham’s actions were potentially harmful to his clients and that he was in violation of Section 3 of the psychological practice act (Professional Licensing Report, 2014).

Other landmark cases such as Jaffee vs Redmond, 1996, highlight the importance of client confidentiality within the counseling relationship (APA, 2020). Ethical standards remain the same whether a therapist is providing face to face or online counseling sessions. This means that the online counselor may have to take additional precautions in order to ensure that their client’s vulnerable information is protected. Contech, Kaplan, Martz & Wade suggest that counselors take measures such as encryption, segregated storage, and avoidance of internet hotspots to safeguard client information (2011). Without privacy-oriented practices and competencies in place, client safety may be at risk, and harm to clients may occur.

Recommendations for and Evaluations of Professional Actions (Steps 4-7)

Following identification and explanation of Keith and Tina’s dilemma, and the characterization and formal identification of relevant ACA codes applicable to this case, these counselors-in-training have designed a proposal which continues to adhere to Forester-Miller and Davis’ decision making model. Foundational principles were considered, rated, and applied to the selection and design of the proposed recommendations; next, actions were proposed and both unconsidered and selected actions were re-evaluated; lastly, these actions were recommended for implementation with model-aligned meta-implementation steps, considerations, and activities.

Selection of Priority Foundational Principle: Nonmaleficence

These counselors-in-training individually ranked the six foundational principles by two domain variables, perceived case relevance and perceived case impact. Following individual ranking, assessed values were applied collaboratively to determine the rank-order in which these variables would be applied to this case’s evaluation. These counselors-in-training determined that non-maleficence would be prioritized in this case’s evaluation as the most critical value, sharing in agreement that reducing or eliminating potential harm to Tina, through counseling, was necessary groundwork in order to pursue therapeutic beneficent work, increase and acknowledge autonomy, act or continue to act in just ways, pursue honest interactions, and thereby develop good faith promises that could be and should be kept.

In observance of the value of nonmaleficence, these counselors-in-training concurred that Keith’s lack of competencies related to online and distance counseling, the tools selected for distance counseling, social media use within the counseling relationship, legal issues surrounding distance counseling, and rural populations needs and interests were a significant risk of harm to the counseling relationship and Tina’s wellness. Adequate resources were not provided to Tina, including a well-informed opportunity for referral to a competent community or distance counselor. Lastly, Keith’s engagement with Tina through use of social media may be potentially harmful to both their counseling relationship and her wellbeing. If these several issues are not addressed and resolved, Keith risks engaging with his client in a way that is not only unethical, but potentially detrimental to her.

Recommended Courses of Action

These counselors-in-training recommend that Keith immediately seek professional consultation and acquire professional development on the matters of online and distance counseling tools and best practices, counseling populations recently relocated to rural communities, and use of social media in the counseling relationship. Keith should contact the licensing boards in both the state where he resides and the state in which Tina resides to determine if he is legally and ethically eligible to provide counseling through this modality to his client. Should it be determined that he is able to continue treating Tina through distance counseling means, he should develop new informed consent documentation which outlines the potential benefits and risks of providing counseling this way and clearly outlines professional boundaries that must be observed related to their counseling relationship, social media, and personal phone use. Keith should not continue to provide any online or distance counseling until he has determined, through formal supervision, that he is competent to provide this type of counseling in a way that does not risk harm to Tina or the counseling relationship he has established with Tina. Furthermore, he should be advised to create a new online website presence with documentation related to his licensing information and create a separate social media presence, should he wish to engage with any clients on these platforms, for professional use only. During his next exchange with Tina, he should be prepared to provide her with well-researched professional referral opportunities who can provide counseling to her until he has developed competencies that will enable him to provide nonmaleficent and beneficent professional counseling support, explaining that he will not be able to provide further counseling to her in a time-sensitive manner, pending development of competency.

Further Evaluation of Unselected Courses of Action

These counselors-in-training determined that continuing to provide online, distance counseling to Tina may risk harming or continuing to harm her and their therapeutic relationship. Additional risks include a lack of perceived competency or helpfulness leading to early termination, doubt in the counseling profession on behalf of the client, and unnecessary generalized frustrations with personal wellness positive behaviors and technology use. Continued use of social media use, without clearly outlined boundaries provided through informed consent, could create an uncomfortable or problematic dual relationship or continue to encourage one should it be determined that one has already been created accidentally. Research should be applied towards the pursuit of suggesting referral, as these counselors-in-training determined that there may be counselors who can specifically benefit Tina by way of competency related to moves to a rural community, and not selecting a competent counselor may result in harm to Tina.

Lastly, without selection of the appropriate tools and the inclusion of intentional supervision, Keith risks harming not only Tina, but also other current or future clients through the modalities and tools he has begun using without seeking appropriate consultation and supervision.

Evaluation of Recommended Courses of Action

These counselors-in-training determined that, in subscribing to the ACA Code of Ethics, this strategy provides for fair treatment across Keith’s possible client population, i.e., that it meets the test of justice. Were Tina not to contact Tina on social media, Keith may not have agreed to continue interacting with her that way, and Keith did not indicate that he had established online relationships with any other clients. Furthermore, Keith can explain to Tina that he cannot make exceptions for her related to online counseling, social media use, or the provision of services for which he has not developed competencies as it is not fair to each of the clients with whom he has a counseling relationship. These counselors-in-training determined, furthermore, that this recommendation meets the test of publicity, as public knowledge that a counselor sought professional development and consultation, declined to proceed in a potentially problematic dual relationship, and referred a client for whom he felt he was not competent to provide nonmaleficent care would not be harmful to a counselor’s reputation or professional identity. Lastly, because this rationale was designed by way of the ACA Code of Ethics, relevant laws and legal cases, and policy published NBCC, these counselors-in-training are confident that this rationale could be recommended to a professional peer interested in pursuing distance counseling as a new counseling practice modality, thereby passing the test of universality.

Implementation of Recommended Courses of Action

Should there have been any further progress related to this case made, these consequential recommendations would require reassessment by Keith. Furthermore, following the implementation of these recommendations, Keith should reassess this plan at each step of the proposed implementation to determine that he is continuing to provide professional service that is nonmaleficent, as well as in alignment with the other ACA principles. These steps should be completed in concert with a competent supervisor or supervisory team who has expertise in the domains of action in which Keith is pursuing changes. Any subsequent changes to these recommendations should be made under supervision. Following complete implementation of these recommendations, Keith and his supervisor or supervisory team should re-assess the success of these recommendations, document success and failures, and pursue any necessary further actions potentially prescribed by the ACA principles and Code of Ethics.

Conclusion

In the provided case study, technological tools and counseling modalities were introduced into Keith and Tina’s counseling relationship. Keith proceeded in providing counseling through this new manner without seeking supervision, developing competencies, determining applicable laws, providing updated informed consent, or assessing objective risks and benefits of doing so. Furthermore, Keith and Tina’s counseling relationship began to move into other technical realms, including social media platforms, risking the creation of a potentially harmful dual relationship.

This team of counselors-in-training evaluated this case with guidance from the American Counseling Association’s Code of Ethics, relevant legal cases, and the National Board of Certified Counselors Policy Regarding the Provision of Distance Professional Services, through the framework of the Forester-Miller and Davis’ decision making model. This team collaboratively prioritized nonmaleficence as the chief foundational principle though which to determine recommendations, based on possible professional outcomes. Recommendations and steps for careful re-evaluation and implementation that included the pursuit of supervision, development of professional competencies, provision of updated informed consent, careful selection of tools, and temporary referral or termination were provided so that Keith may be empowered to provide services which, among the profession’s other values, contribute to “enhancing human development throughout the life span,” and “honoring diversity…,” which uphold the counseling profession’s commitment to “practicing in a competent and ethical manner” and ultimately “safeguarding the integrity of the counselor-client-relationship” (ACA, 2014).

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

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