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by Sally Sutton, MA, MSSW

Sally Sutton, MA, MSSW, is a Senior Policy Analyst at the Institute for Health Policy, Muskie School of Public Service, University of Southern Maine. Ms. Sutton completed her graduate work in social work and public policy and administration at the University of Wisconsin-Madison. In addition to over 25 years work as a social justice advocate, managing nonprofits and being involved in the debate on many public policy issues impacting social workers and their clients, Ms. Sutton has taught graduate level courses in legal and ethical issues in social work, provided continuing education workshops on the same topics, and currently serves as an officer on the board of the state chapter of the NASW as well as on that group’s ethics committee.

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The objective of this course is to instruct mental health clinicians in the use of the best practice ethical decision making models for addressing complex ethical dilemmas. When the trainee completes this course, he or she will:

1) Grasp the most important models for addressing and resolving ethical dilemmas
2) Understand factors that may impact the use of the best practices approaches
3) Learn the special complications created by ethical practice with clients from non-majority cultures
4) Comprehend the factors involved in cultural competency
5) Know the model for addressing ethical decision making in cross-cultural counseling

This course is designed for mental health clinicians in the early to intermediate stage of their career, or for clinicians seeking review in this area.

Course length:
3 contact hours: Ethics

Section I: Introduction
Section II: Best Practice Models of Ethical Decision Making
Section III: A Six-Stage Model for Ethical Decision Making
Section IV: Business Approaches to Ethical Decision Making
Section V: Models for Cultural Diversity
Section VI: Applications of an Ethical Decision Making Model
References and Test


Section I: Introduction

Please note the following three paragraphs from the preamble to the codes of ethics for, respectively, social workers, counselors and marriage and family therapists:

NASW code: This code offers a set of values, principles, and standards to guide decision making and conduct when ethical issues arise. It does not provide a set of rules that prescribe how social workers should act in all situations. Specific applications of the code must take into account the context in which it is being considered and the possibility of conflicts among the code’s values, principles, and standards. Ethical responsibilities flow from all human relationships, from the personal and familial to the social and professional.

ACA Code: When counselors are faced with ethical dilemmas that are difficult to resolve, they are expected to engage in a carefully considered ethical decision-making process. Reasonable differences of opinion can and do exist among counselors with respect to the ways in which values, ethical principles and ethical standards would be applied when they conflict. While there is no ethical decision-making model that is most effective, counselors are expected to be familiar with a credible model of decision making that can bear public scrutiny and its application.

AAMFT code: The absence of an explicit reference to a specific behavior or situation in the Code does not mean that the behavior is ethical or unethical. The standards are not exhaustive. Marriage and family therapists who are uncertain about the ethics of a particular course of action are encouraged to seek counsel from consultants, attorneys, supervisors, colleagues, or other appropriate authorities.

Each of these statements speaks to the complex relationship between the codes of ethics and responsible ethical decision making. Mental health clinicians in each of the three major counseling disciplines are expected to thoroughly understand their code of ethics and use their code as a starting point for guiding their decision making in situations of ethical conflict.

However, each code states, in essence, that the code - by itself - is insufficient to resolve all ethical dilemmas. In order to practice ethically, each mental health clinician ultimately must develop their ethical understanding to the point where good ethical decision making is almost second nature, incorporating a thorough knowledge of ethical decision making approaches into a systematic and thorough model for identifying ethical violations and resolving ethical dilemmas.

To help the trainee to expand their knowledge of ethical decision making, this course will present a number of best practice models or approaches that can be used for resolving ethical dilemmas. While there is a great deal of overlap between many of these models, each one presents somewhat different aspects of the ethical decision making process. Taken together, they form a solid foundation for understanding how to approach complex ethical dilemmas.

To take this knowledge one step further, the course will also present a discussion of some factors that will influence the successful application of any decision making model, such as the need to be culturally competent or aware of your own values, or how to be an ethics advocate.

Integrating the Codes of Ethics with Best Practices Models

While the code of ethics for each profession is not sufficient by itself to resolve all ethical dilemmas, knowledge of the code is a key component of good ethical decision making. For trainees who are interested in expanding their knowledge of the code of ethics, offers an alternative five-hour introductory course on ethical decision making that includes both the ethical decision making models covered in this course and a detailed overview of the codes of ethics. This course is entitled: Using Best Practice Ethical Decision Making Models and the Code of Ethics: A Guide for Mental Health Clinicians.

It is our hope and expectation that each mental health clinician has read the code of ethics for their profession and keeps on hand at all times a copy of the code for easy reference. It may be useful for trainees to have available their code of ethics as they take this course. In this way, it will be easier to integrate the guidelines presented in the code with the ethical decision making models. For convenience sake, we have provided below an easy link to the three main codes of ethics for mental health clinicians.

You do not need to disconnect from this course in order to print out these codes. You should be able to return easily to the course by clicking the return, or back, arrow at the top left of your web browser once you have finished printing the code. You will not need to log back in.

(If you prefer not to print the code, but wish to have the code available as you read through this course, you can minimize this screen by clicking on the minimization box at the top right of this page. This will keep the course open while you navigate elsewhere on your computer. Leaving the course minimized, re-open your web browser application, and enter the URL address as shown below to take you to the code of ethics. When both windows are open, you can go back and forth between this course and the code.)

Connect to the Appropriate Code of Ethics

NASW Code of Ethics

American Association for Marriage and Family Therapists

American Counseling Association

Important Code Updates

It is important to note that the most recent updates to the Codes of Ethics have addressed a new and disruptive area of social change that has far reaching implications for practice in the field of mental health. This set of changes also has implications for ideas of when the client is a client and when treatment is occurring.

Over the past couple of decades, the emergence of new technologies - the internet, social media, new technological devices - has offered both new opportunities and new challenges for people who engage in mental health practice. The ease of communication with these new technologies means that interactions between clients and clinicians can be more easily achieved, which can enhance the capacity of clinicians to remain in closer contact with clients, refer them to useful resources, and even provide counseling without the necessity of being in the same place at the same time.

However, it also means that clients can do an internet search on the people providing mental health services to them, can easily remain in touch long after the treatment goals have been reached and the treatment has been concluded, and have higher expectations for their clinicians to be available to them day and night.

These changes - and the ethical considerations related to them - have been addressed in's course, Ethical Considerations of Practice in the Age of Social Media and Electronic Communications. The changes include legal considerations of technology, including two updates to the Health Insurance Portability and Accountability Act (HIPAA) in 2010 and 2013 that redefine guidelines for protecting the privacy of Protected Health Information (PHI) in the era of electronic modes of storing, sending and receiving health information.

However, the changes also include ethical considerations of privacy, safety, and the maintenance of professional authority and the professional relationship when personal information about clients and clinicians is so much more easily available on online search engines and social media, and when counseling can be performed over distant modes of communication: Telemental Health.

There can be separate sets of challenges for mental health clinicians in addressing some of these changes from the technology revolution. Clinicians who came of age prior to the emergence of these technologies may not fully understand how to maximize the opportunities presented by increased communication connection.

Younger clinicians, whose formative experiences were in a more technologically connected world - with an enhanced degree of self-disclosure - may have internalized a different sense of what represents an appropriate level of privacy. This may affect their sense of where to draw boundaries for themselves and their clients in ways that clash with values in the Code of Ethics for their profession. They may underestimate the risks of operating in a technologically robust environment while working as a professional in this field.

For this reason, it is important for each professional to keep their ethical knowledge base up to date, and spend some time exploring the implications of these changes for the work that they do.


The Ethical Decision Process Worksheet

Throughout this program, reference will also be made to the overall process of ethical decision making which is fundamentally integrative in nature. Towards this end, has developed form to provide structure and focus to the essential elements of ethical decision making. This form is called the Ethical Decision Process Worksheet, and it may serve as both a tool for organizing a robust ethical decision making process and a tool for recording the process in a manner that may be used within the client record to demonstrate the steps taken to ensure that the right ethical approach has been undertaken. Built into this form are the steps and stages of the ethical decision making process, with each of the stages noted in sequence. These steps and stages will be addressed more thorough in a later section. 

Below is copy of this form, with each of the elements noted:


                  Ethical Decision Process Worksheet

Client Name:                                                    Date/Time:

Nature of ethical dilemma:

Knowledge Stage:

What knowledge must be known to address this ethical dilemma? (laws and statutes, regulations, code of ethics sections, moral considerations, etc.)

Identification Stage:

What ethical principles and considerations are in conflict?

What model(s) of ethical decision making will be used to address this ethical dilemma?

What other parties will be involved in examining and resolving this ethical dilemma?

What are the best potential solutions to resolve this ethical dilemma?

Evaluation Stage:

What are the strengths and weakness of each potential solution (Apply appropriate tests: the Consequentialist test (what are the consequences from the choice), Fairness test (is the choice fair to all parties), Enduring Values test (does the choice align with core values), Light of Day test (if the choice were publicly known, would you expect others to approve or disapprove of the decision))?

Selection Stage:

What solution has been selected to address the ethical dilemma?

Comments on the selection:

Assessment Stage:

What occurred as the result of the implementation of this selection?

Adaptation Stage:

What changes to the ethical decision were implemented based upon assessment of the outcomes of the initial ethical decision?

Comments on the need to adapt the decision:


 Using the Models and the Ethical Decision Process Worksheet

The Ethical Decision Process Worksheet, as a tool to show the work of the clinician in engaging a thorough and robust ethical decision making approach, incorporates the models of ethical decision making in the identification stage of the ethical decision making process. The use of a model or models of ethical decision making demonstrates that the clinician possesses expert knowledge in the area of ethical decision making and clarifies that this expert knowledge will be utilized as a guide for reaching the best conclusion about how to proceed with a complex ethical situation. 

When the ethical decisions of clinicians are reviewed by outside parties, either as the result of legal action or as the result of complaints to the licensing board within the clinician's state, the key question will involve scrutiny of whether the clinician has engaged a best practices approach to the decisions that were made in the course of treatment. If reference is made to the best practice models of ethical decision making that are available in the literature, it helps establish a clear orientation towards best practices approaches. This may offer an enhanced degree of protection for the clinician where his/her choices are being questioned.