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What is the role of the mental health clinician, and what are the skills and beliefs that allow him or her to proceed in this very difficult profession in a professional and ethical way? At its heart, this work is based upon the ability to direct others towards fulfilling the visions, goals and mission that have been defined as right and important by the parties who are connected to that mission. 

Said differently, our mission is to improve the mental health and overall well-being of the people who come to see us.

In his seminal work, Leadership without Easy Answers, Ronald Heifitz, (Director of the Leadership Program at Harvard University's Kennedy School of Government and a trained psychiatrist) describes this mission as "adaptive work", defining it as "developing the . . . capacity to meet problems successfully, according to (defined values and purposes)". (13)

When there are conflicts over values and purposes, the adaptive work will usually include engaging in the process of clarifying and integrating or merging the competing values. (13)

In the field of mental health,

"people adapt more successfully to their environments, given their purposes and values, by facing painful circumstances and developing new attitudes and behaviors. They learn to distinguish reality from fantasy, resolve internal conflicts, and put harsh events into perspective. They learn to live with things that cannot be changed and take responsibility for those that can. By improving their ability to reflect, strengthening their tolerance for frustration, and understanding their own blind spots and patterns of resistance to facing problems, they improve their general adaptive capacity for future challenge." (13)

As experts, we are charged with leading our clients from a physical, emotional, mental (and, perhaps, spiritual) place that is "worse" to a place that is "better". We help them change in ways that have better adaptive results.

This is an excellent representation of the work we do in the field of mental health. It is also deeply infused with a variety of modes of Western thought. Dr. Heifetz is very clear about this. He says that if his ideas are relevant for people from non-democratic societies, "it would be fortuitous." (13)

Other cultures do not honor "personal growth" or "individuation" with the same kind of certitude that we do. In fact, many other cultures view the American obsession with personal freedom as pathological and destructive. Other cultures view the needs of the collective or the community as being primary, and individuals are expected to relinquish their individuality rights and needs – and sometimes even give their lives - for the greater good of their culture, community or country.

As we will see when we examine the many different elements that are viewed as having value and importance to different cultures, there are many ways of approaching some of these fundamental concepts. This is a knowledge point that is integral to maintaining a high level of cultural awareness.

As leaders, we are supposed to utilize our higher degree of knowledge and skills - as well as our capacity to view a client's situation from an objective perspective - to direct our clients towards a fulfillment of the defined adaptive mission. This is leadership, and our professional authority is derived from a willingness to operate within the boundaries set by these leadership demands.

Mental health clinicians who are willing to work from a position of leadership must have a great deal of clarity on several subjects when confronting complicated ethical situations. First, they must be able to differentiate three separate - but connected - arenas that professionals must consider when they are engaged in complex decision making.

These three arenas are the legal, the moral, and the ethical. Let's look at these three areas in diagrammatic form. We will later look at how these three areas operate when in interaction with different cultures.


Pertaining to personal behavior as measured by prevailing standards of behavior as defined by a specified (usually spiritual) group.

Consequences for moral lapses are generally the domain of individual and group conscience.


Pertaining to accepted principles of right and wrong as defined by a specified (usually professional) group.

Consequences for ethical lapses are generally the domain of the profession and keepers of the profession.


Pertaining to accepted principles of right and wrong as defined by the law, rather than by equity (fairness, justice impartiality).

Consequences for legal lapses are generally the domain of the legal system.

It is possible for a clinician to act in a manner that is legal, but not ethical; or ethical, but not moral; or moral, but not legal or ethical.

Since, these three different dimensions in decision making are mentioned in codes of ethics for mental health clinicians - sometimes on the same page, within the space of a few paragraphs, it may be helpful to examine the differences.

Let's start with the Legal dimension of decision making. Laws are defined by people in legislative positions, and courts (and/or juries) that interpret and issue rulings based upon their understanding of what those laws mean. The laws are not necessarily written by those persons who are most knowledgeable about a subject, nor necessarily by people who are even interested in being either fair or equitable in writing the law.

As we know from the history of the civil rights movement, in fact, laws can be written and enforced in ways that are unfair and inequitable. Conversely, some very moral and ethical people have expressed their deep moral and ethical convictions by breaking the law.

Almost by definition, laws tend to express – more or less - the defined beliefs and values of the dominant culture. Laws attempt to create a certain measure of conformity to the standards that are deemed by the dominant culture (or at least, the people in charge of the legislative processes at any point in time) as being right and wrong. They define the standards, values and viewpoints held by the dominant culture as "right", thereby often defining any group who differs from this as "wrong" or "deviant".

The law is designed to be fluid and changing over time, but fixed and certain at any specific point in time. The law, in fact, oftentimes struggles to keep up with (and sometimes even fights back against) cultural changes in ethics and morals. Leaders who are involved in helping ethics and morals to progress forward sometimes find themselves pushing the boundaries of the law until the law can be rewritten to reflect the changes in understanding - until society does its adaptive work on a larger scale.

Many people from non-dominant cultural groups have experienced prejudice from the law as it has been written, as well as conflict with the parties who set and enforce the law. Mental health clinicians will frequently find themselves caught in the middle of this sociological conflict. It is a tension that will be present during attempts to find the best ethical outcomes. We will see in a very clear way some of these tensions as we analyze our scenarios.

The second dimension we will look at is the Moral dimension. The moral dimension is deeply involved in helping to shape both the legal and the ethical dimensions. Both laws and ethical codes, in fact, represent some attempt to codify and enforce commonly accepted moral understandings.

Ethical standards, like laws, are also at least partially derived from commonly accepted moral ideas about what is right and wrong behavior, but typically within areas relevant to specific professions.

The important distinguishing feature of the Moral dimension, however, is that it is personal in nature. Both legal and ethical lapses can set in motion the external imposition of consequences. Moral lapses that do not also break the law or violate ethical standards will not provoke any externally imposed consequences. The consequences for moral violations will play out between the person and his/her individual conscience.

This does not mean the moral dimension is less significant. In fact, the moral dimension is usually the dimension out of which leadership and change emerge. It is usually a single person or forward thinking group of persons whose moral thought and principles lead the legal and the ethical dimensions to more evolved or adaptive states of being.

The difficulty, of course, is that the moral dimension is personal in nature in negative ways, as well. When a person's own personal moral standards are less evolved than the prevailing legal and ethical standards, then this moral dimension works to sabotage the establishment of better legal and ethical standards, instead of helping to lead law and ethics towards a better place.

The proponents of segregation earlier in this century, for instance, based many of their positions upon a moral code that lagged behind changes in the prevailing social norms and standards. They did not want to adapt their values to changes in cultural norms, but instead wanted the parties being oppressed to continue to do the greater part of the adaptive work by tolerating the oppression.

This issue leads, of course, to very tricky ground. Most persons who have deeply held Moral standards feel that these standards are held for the right reasons, not the wrong ones. When they are right, the society at large benefits from their unwillingness to bend; when they are wrong, society is damaged by their inflexible attitude towards change or adaptation.

The essential question in this issue, of course, is - what is right? This is not an inconsequential question for the mental health profession. It is deeply involved in the decisions that are made about the last of our three dimensions - the Ethical dimension.

In general terms, each profession wrestles with the question of what is right on an ongoing basis. The governing bodies in each of the mental health professions attempt to work with their members in an evolving society to create workable definitions of right and wrong behaviors in important areas related to the profession.

When individuals depart from the standards set by the profession - even if the departures are based upon deeply felt moral reasons - the profession may choose to implement sanctions against that individual. The individual must evaluate this potential risk when a moral decision is made that is in conflict with the ethical standards set forth by the profession.

Each profession, of course, attempts to make their difficult judgments about which behaviors are right or wrong in well-reasoned ways. It is a complicated process which may involve dialogue and seeking consensus from members of the profession, guidance from core groups of wise and experienced leaders, and input from relevant outside parties who have a stake in the outcomes of these decisions.

In this process, the governing bodies are balancing many things. The core defining values of the profession are included in the mix. Knowledge about prevailing social standards will generally be factored in, including where those social standards differ among diverse populations of clients served. The need to protect the legal status of the profession is also considered, meaning that the core values and beliefs may need to be tempered by what the law will allow.

It is neither a perfect nor an easy process, and the conclusions that are reached are often neither clear nor fixed. Ethical practice aims at a constantly moving target, changing all the time in response to new understandings or new laws - while each profession as a profession engages in its own adaptive work to try to keep up. There is a fundamentally dialectical aspect to this process – complex systems trying to incorporate at times mutually incompatible components as the system changes and evolves over time.

This leaves individual clinicians room for both flexibility . . . and uncertainty in their choices of how to handle ethical dilemmas.
It can be frustrating for professionals to try to practice ethically without clearer and more concrete guidance from their professions. However, the lack of concrete answers is more a reflection of the difficulties of corralling an evolving and adaptive process than it is a failure of the professional bodies to do their adaptive work.

This evolutionary process defines at least two other items that need to be mentioned in this section. Both have to do with the ways in which determinations are made concerning what is "right" and what is "wrong".

The first way we will sometimes determine whether something is right or wrong is through knowledge drawn from scientific examination - latest research about what is effective, what is harmful, what is normal. This helps to define both what is possible, and what is right to aim for in clinical practice.

The information that is gathered in this process is in a state of continuous evolution. As time moves forward, an increasing amount of information is gathered and distributed. As experts, mental health clinicians are expected to do a reasonable job of keeping up with advances in this information.

But there is another evolutionary process that occurs in tandem with this increase in available information. The increased knowledge changes our understanding in areas that are not simply cognitive in nature. It is concerned with something else altogether. Let's bring in some examples of this to demonstrate.

In the not so distant past of the mental health field, pre-frontal lobotomies were considered a valid treatment approach - the reservations of the client notwithstanding! In terms of the thinking of the day, doctors determined that patients would be "better off" with a severed corpus callosum, in line with the mission of improving the well-being of the patient.

In another example, homosexuality was redefined in the 1970s - at least by the field of mental health - as a variation of human experience and sexual expression, not as a deviation or illness requiring either re-socialization or a cure. It was decided at that time that the cultural inclination to view homosexuality as a form of deviance did not align with the facts discovered in researching variations in sexuality.

The ramification of this is as follows: people who followed standard medical practice - or morally or legally acceptable positions - at one point in time would find those same positions wrong and morally reprehensible at later points in time. Conversely, the deviants – those persons who acted outside of the law or standard practice – would find their positions vindicated from a retrospective point of view.

This is a humbling understanding that must be considered very closely as we attempt to determine what is right and wrong in this period of cultural transformation.

The list of evolving ideas and understandings is very long. This re-examination of ideas takes place in a particular context, or - perhaps better said - contexts. In this evolutionary process, different people - and different groups of people - do not just evaluate new information based upon their cognitive perceptual abilities. The ideas are not just evaluated based upon what people think of them. They are also evaluated based upon what people feel about them. This is the domain of values.

In some cases, the values of the people evaluating the information will be more important in determining how evolving ideas will be received and perceived than will the facts that are presented. This is one of the domains in which culture operates.

The United States is currently in the midst of a major transitional period in the history of its shared values. This is what some in the political arena have labeled a "culture war", but it is really more properly viewed as an extension and intensification of historical forces that have always been at work in this country.

The United States, more than ever before, is struggling with its own adaptive challenges related to the integration and assimilation of ever increasing numbers of new citizens from different cultures. This has occurred in conjunction with a partial - but steadily increasing - diminishment of the hold on power traditionally held by the White (and primarily male) members of American society.

This has disrupted and challenged the predominate model of assimilation and diversity that has been held as the ideal since America came into being. Let's look at this model and also examine what are the possible future replacements for this model. This will be derived from the work of Leah Wing (32).

The model forwarded by the most conservative forces in American politics is usually described as the "white bread assimilation model". It is presented in a formula that reads like this:

A+b+c = A

This formula states that the non-dominant groups are expected to integrate into the culture that is both held and defined by the dominant group. The final culture will retain those ideals and values that the dominant culture views as important, and extinguish anything from the non-dominant groups that doesn't fit with the dominant group’s ideals. The non-dominant groups are submerged completely within the dominant group, with their cultural material lost.

This model has never been fully realized in the United States, although there are groups who have attempted to make it so. The more frequently referenced variation of this model, however, has been the "melting pot" model, which looks something like this:

A+b+c = A'

The dominant culture still retains the greatest influence over the ideals of the culture, but the inclusion of new ideas and influences changes the dominant culture in ways that allow for better integration of the non-dominant cultures' material. This melting pot theory has traditionally been viewed as the social covenant for assimilation. (32)

What does this model mean for the dominant and non-dominant groups in terms of adaptive work? It means that the dominant group has traditionally been required to do less adaptive work within this system while the non-dominant groups have been required to do more adaptive work. It's a better deal for the dominant group – which is why the dominant group tries to forward this as an ideal. It allows them to put the burden of more adaptive work on others.

This process of "passing off the adaptive work on others" is a very common phenomenon in situations of cultural clashes and challenges in the assimilation of competing values systems. Clinicians see this regularly in miniature during couples counseling, where partners blame each other for not adhering to the "right" values and beliefs about how partners "should" behave.

The values used to make these determinations are derived from each partners' own personal cultural value systems. Couples counseling, in many ways, is essentially a dialogue of cultural reformation.

The period of transition in America that is occurring at the present time is reshaping the predominate model of assimilation in a fundamental way, and it is going to affect all aspects of American culture – including mental health practice – for some time to come. However, as the traditional melting pot model loosens its grip, it creates a period of uncertainty and confusion. Consensus on a new and better model has not been reached.

The other models that have been described in the literature are possible options. Let's look at them here, although we won't go into them in any great detail.

The "quasi assimilation" model            A+b+c = A'(a'b'c')

The dominant culture provides the general framework for the workable social structure, but all cultures associate with it equally and retain elements of their own cultural ideals. (32)

The "transitive" model                            A+b+c = A+b+c

All groups remain unassimilated in the ratio in which they exist in the society, with degree of influence proportionate to this ratio. This still leaves the dominant group with the greatest degree of influence, since they have the highest proportion of people. (32)

The "reconstructionist" model                A+b+c = A'B'C'

The core culture is transformed through its interactions with other cultures – as are the other cultures through their interactions with the dominant and other cultures - and the non-dominant cultures are accorded equal influence in the definition of cultural ideals. (32)

The "pseudo assimilation" model            A+b+c = X'a'b'c'

The dominant group and the non-dominant groups work together to define a workable social structure – not based upon the historical ideals of the dominant group or any other group, but based upon the definition of a new structure created through the shared adaptive work engaged in by all parties. When the structure is formed, each group associates with it, but also retains elements of their own cultural ideals. (32)

It is still uncertain which of these models – if any - will assume a prominent position over the next part of this century. What is clear is that the old models – where the dominant culture largely dictated the terms of development – will be altered.

This will lead us to our next section, in which we study the relationship between values and culture, as well as the other elements of which culture is composed.

Applying the Stages of Ethical Decision Making

When you approach an ethical decision, there are several steps or stages involved in making a good decision. This chapter will be concerned with looking at these stages in some detail.

The following page shows, in diagram form, the different steps or stages in this process.

The Steps or Stages of the Ethical Decision Making Process

The Knowledge Stage

The Identification Stage

The Evaluation Stage

The Selection Stage

The Assessment Stage

The Adaptation Stage

Stage One: The Knowledge Stage

The first stage is the knowledge stage. It begins before you are faced with the ethical decision. As is implied by the name, this stage is concerned with knowing a number of things that are involved in the ethical decision making process.

Item 1: Code of Ethics

The first thing to know, not surprisingly, is the ethical code or codes for your profession. Most mental health clinicians are familiar with both the code developed by the national organization for their profession, and a state code associated with the licensing or certification board. These codes are usually a very good starting point for the ethical decision making process, and may define good parameters for many, but not all, of the ethical dilemmas faced by mental health clinicians.

A surprising number of clinicians, however, are not fully familiar with the codes of ethics under which they are supposed to work. The codes are evolving entities, incorporating changes in ethical thinking over time. Some clinicians do not know their codes because they have not kept up with the changes in thinking over the course of their professional career. It is important to know the present code or codes to help with making good ethical decisions.

Item 2: Laws and Statutes

The second thing that must be known is the collection of laws and statutes – at both the state and federal level – that relate to our clinical work. This includes HIPAA (Health Insurance Portability and Accountability Act), which addresses at a federal level the degree to which client information must be kept private and confidential, and the two updates to HIPAA: the HI-Tech Act and the Final Omnibus Rule of March 2013.

These two important updates, among other items, clarified how to address privacy and confidentiality when communicating with clients via smart phones, email, text and other modalities of electronic communication that were not widely prevalent when HIPAA was put into effect in 1996.

These laws and statutes address the need to protect the privacy of clients' Protected Health Information (PHI) when sending, receiving and storing electronic health information. This updated set of standards also has applications to the world of social media and the internet in general, and there are important concerns about this arena that were not present even 20 years ago.

There are amazing new capabilities for connections and social support that can be utilized to support client progress through the use of social media. However, mental health clinicians are also people with personal lives, and they may elect to use social media in ways that enrich their own person connections. This is where the role of a professional can create some disruptions to the personal life of the mental health clinicians, but with much wider distribution problems than prior to the internet era.

Mental health clinicians must be mindful at all times of how their social media activities can blur the boundaries between personal and professional lives. They need to consider the possible negative impact that social networking could have on their professional relationships. How is this possible?

First, a clinician who maintains a presence on social networking sites must clearly separate private from professional lives online. Some therapists maintain two sites: one for their private, personal relationships (friends, former schoolmates), and one for their practice (promoting the practice to attract new clients, providing information for how to access the practice, etc.) In this way, clients can access the practice information where they can learn as much about the clinician as the clinician has posted on this publicly accessible site. Meanwhile, on their personal site, it is recommended to utilize the highest, most stringent privacy settings so that the therapist’s privacy is guarded as much as possible.

However, the internet does not have infallible security features, and it is important to remember that no matter how much effort is made to maintain privacy, and even if everything is done correctly, the site might still have a security breach. In this case it is anyone’s guess how many people will have access to this “private” information. And once others outside of this security net have access, there is no control over the information that they may download.

Second, it is always good practice to discuss with clients up front 1) expectations for boundaries and 2) questions related to forming online relationships. The recommended approach is to “inform clients that any requests for “friendship,” business contacts, direct or @replies, blog responses or requests for a blog response within social media sites will be ignored and addressed subsequently in treatment, to preserve the integrity of the therapeutic relationship and protect confidentiality.” (Kolmes, Merz Nagel, and Anthony, 2011)

Because there is the potential for clients to interpret this refusal to engage in online interactions as a kind of rejection, it is a matter that must be handled with some care and preparation. Early in the formation of the therapeutic relationship, clinicians should provide to the client some education about the important purposes for retaining a professional relationship at the expense of personal interactions, and each conversation must be approached respectfully and with sensitivity.

While the maintenance of this boundary can be important for the clinician’s ability to maintain a viable private life apart from his/her clinical work, this should not be the primary element of the discussion with the client. This discussion should always be framed in terms of protecting the client’s important interests. In fact, this orientation towards the client reflects a deeper truth: the primary reason to maintain professional boundaries is to ensure that the professional relationship remains in the client’s best interest. Boundaries in helping relationships provide the structure so that there is no question about what kind of relationship it is.

With clearly outlined boundaries, a client will never confuse the therapeutic relationship with friendship or a business relationship, for example. In this way, the client improves the likelihood of gaining the maximum benefit from the therapeutic relationship, with minimal risk that the relationship will become unhelpful. Additionally, when the boundaries are crystal clear, clients are better protected from abuses of power.

This necessarily means that the professional relationship is given priority over all other relationships. Consider how damaging it could be to the therapeutic relationship for a client to see photos on a clinician’s social networking site, where the clinician is not behaving in a professional manner. If a clinician decides to maintain a presence on social media, they must remember at all times to guard their privacy by implementing the highest level of security and carefully scrutinizing all requests for access.

At a deeper level, the primacy of the clinical role also means that clinicians may have to consider imposing upon themselves a certain degree of self-censorship in terms of what they post on social media sites. Ethical conflicts might be created if a clinician chooses to post any personal information that might be deleterious for a client to see.

This is a difficult concept for most clinicians to accept. However, it cuts to the heart of some important understandings about the very nature of our profession and the ethics of being a mental health professional. The counseling profession is different from most other professions in several important - and connected - ways:

The mental health professions are defined - and thus sanctioned - as professions whose primary purpose is to promote the well-being of its clients and the public at large, not to take care of the personal or financial well-being of the clinician.

This is different than most businesses. For most businesses, the primary responsibility is to take care of the financial well-being of the business and its stakeholders. In most businesses, the well-being of the client does not really come first. Companies may lose customers for not looking out for the interests of the client, but they will not lose their right to engage in that business. Clinicians can. Every year clinicians face ethics sanctions for honoring their personal lives ahead of their professional obligations.

This speaks to a fundamental conflict that not only affects the study of ethics, but, more importantly, affects the practice of ethics. In a situation where there is ethical conflict, how much does the clinician need to put aside his or her own interests, including the right to follow one's own values and principles, or pursue a robust personal life, in order to sufficiently take care of the best interests of the client and the public? Even clinicians who feel they have a clear understanding of ethics, can find themselves in very confusing territory.

Because the government - at both the state and federal level - and the various counseling professions work together to oversee the definition of who can practice, they also involve themselves in the clarification process around this important issue for mental health clinicians. In fact, the state and federal governments continue to clarify new understandings about what constitutes legal and ethical behavior, and make demands upon counselors to know these changes and apply them in their practice.

Clinicians also need to be aware of two other important federal statutes that deal with privacy and confidentiality: 42 CFR, part II and 34 CFR, Part 99, also known as FERPA (Family Educational Rights and Privacy Act). 42 CFR part II provides special privacy protections for substance abuse clients and clients who are HIV positive. FERPA clarifies the guidelines for maintaining educational records, including records maintained by clinical professionals, social workers and psychologists who work in educational settings.

There are similarities between HIPAA guidelines and FERPA guidelines, but there are also differences between the two. There are also occasions where there is some uncertainty about whether HIPAA is the application statute or FERPA – or both. Clinicians who work in school settings need to have a solid understanding of FERPA and how to apply it.

On the other hand, all clinicians need to have a thorough grounding in HIPAA and the two updates to HIPAA in order to be prepared to operate ethically in the 21st century. As these are federal statutes, they are applicable in all 50 states, the District of Columbia and other US territories where federal statutes apply. A very useful web site for keeping up to date with HIPAA is the HIPAA Survival Guide web site found at:

There are also state laws and statutes, as well as rules enacted by the state board responsible for supervising the mental health professions, that clinicians must understand in preparation for remaining ethically compliant. These state statutes may have some areas of overlap from state to state, e. g., most states make clinicians mandatory reporters of child and elder abuse, but there are also numerous areas where state laws may be significantly different.

For instance, many states have statutes in the books that address the responsibilities of clinicians in duty to warn situations, along the lines of the California case known as Tarasoff versus Regents of the University of California. The specific statute written pursuant to this case – which is actually only in effect in the state of California – requires that clinicians issue an immediate warning to any person against whom a client has indicated clear and imminent homicidal intent. In such cases, the state provides cover for the clinician who must violate the client’s right to confidentiality in order to issue that warning.

In California, and many other states, the state law says that the clinician must issue the warning to the person at risk. However, in other states the state law says that the clinician may issue the warning to the person at risk. In one state, Georgia, there has not been codified any law that says the clinician must or may warn the person at risk. This highlights the importance of each clinician spending some time to increase his/her knowledge of state laws, rules and statutes.

There are also other important areas of law that come into clinical work and which may be different from state to state. Some states severely limit the degree to which children and adolescents can have any say in their treatment, while other states allow for some discretion on the part of the clinician about allowing their client some treatment and privacy rights before reaching the age of majority.

There are also differences from state to state in terms of what is considered to be the age of consent, the age at and circumstances under which a child may be married with and without parental consent, guidelines for emancipation of a minor child, rights of adjunct parties to treatment, how long to keep clinical records, and other areas too numerous to fully cover in this course.

Any clinician who wishes to practice in a consistently ethical manner must undertake some study in the laws and statutes related to clinical work in the state or state(s) in which practice is occurring. Furthermore, because technology now exists to practice via video-teleconferencing from one state to another, clinicians so doing must be prepared to examine the laws in any state from which they are drawing clients.

Item 3: The Moral, Ethical and Legal Dimensions of Practice

Another important piece of knowledge that must be understood in the knowledge stage is the difference between the dimensions of practice in any given situation in which ethical problems may exist. These three arenas,  the legal, the moral, and the ethical, have already been examined earlier in this section. 

Item 4: Principles and Interests that Interact in Ethical Decision Making

The next thing that the clinician must know is the collection of principles and interests that are involved in the ethical decision making process. The codes of ethics are derived from a study of these principles and interests. However, because these principles and interests interact in complicated ways, the codes of ethics are not prepared to fully resolve all ethical decisions for the clinician.

The clinician must have his or her own understanding of these principles and interests over and above the codes in order to answer some of the more complicated ethical dilemmas he or she might face in the course of a professional career. Because a detailed study of the principles and interests involved in ethical decision making is contained in the next chapter of this training, we will not discuss it further here.

Item 5: The Ethical Decision Making Process

The next item that must be known by the clinician is how to engage in an ethical decision making process, pulling together all of the pieces that must be organized and addressed in order to come to a good ethical decision in any situation where there is an ethical dilemma to be faced. This process will incorporate 1) the stages of ethical decision making, 2) all the relevant laws, statutes, code items and other items that must be known and understood to keep the clinician compliant, 3) how to define the nature of the ethical dilemma that is being faced by the clinician, 4) relevant models of ethical decision making that are considered best practices within the profession, and 5) how to pull all of this information into a well-considered resolution to the ethical dilemma the clinician is facing.

To help with the process, has developed a structured form, called the Ethical Decision Process Worksheet, to guide the clinician through a robust ethical decision making process. This form is noted below, and contains information about a number of models of ethical decision making with which the trainee should be aware. It also incorporates the stage of ethical decision making within the flow of the worksheet.


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?

Models to consider include:

Elaine Congress ETHIC Model of Decision Making; ACA Ethical Decision Making Model ; Essential Steps for Ethical Problem-Solving – Frederic Reamer and Sr. Ann Patrick Conrad; Steinman, Richardson and McEnroe Ethical Decision-Making Process; Dolgoff, Loewenberg and Harrington – A General Decision Making Model, including the Ethical Assessment Screen, the Ethical Rules Screen, and the Ethical Principles Screen (EPS); Doug Wallace and Jon Pekel - Checklist for Resolving Ethical Dilemmas; Marvin T. Brown - Diversity Ethics Process Model; Pearce and Littlejohn’s Transcendent Discourse

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 the Consequentialist test, Fairness test, Enduring Values test, Light of Day test)?

Selection Stage:
What solution has been selected to address the ethical dilemma?

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 decison?


Item 6: One’s Self

The other key item a clinician must know in the ethical decision making process is oneself: one's biases and prejudices, one's blind spots and trouble spots, and situations in which self-interest will make it hard to make the right ethical choices.

Apart from not fully understanding the code of ethics, this area is the most likely to cause the clinician to make poor ethical decisions.Clinicians, like all other people, will at times be confronted by their own tendencies to engage in decision making based upon their emotional needs and impulses, instead of a full and clear reckoning of the issues involved.

The call of self-interests clouds good judgment, whether the call is set in motion by one's attraction to a client, the promise of improving one's financial situation, or fatigue and burn out. Clinicians are intimately involved in the business of helping other people know themselves, bringing forth clarity out of the confusion.

This same process of seeking clarity must be turned on oneself if the clinical professional wishes to work at the highest level of ethical decision making.

Stage Two: The Identification Stage

The second step or stage is the identification stage. There are three important things to identify in this stage: 1) who the client is; 2) the various ethical principles and interests in operation within the actual situation that is before the clinician; 3) potential options for solving the problem.

There will be more detailed study of these items in later chapters.
It is important to identify all the principles and interests at stake in every aspect of the situation, as well as in each of the potential options for resolving the situation.

This identification process is a necessary precursor to the next stage in which the clinician must evaluate which principles and interests carry the most weight in terms of reaching a good ethical decision for that situation.

Stage Three: The Evaluation Stage

The evaluation stage is next. It is concerned with taking the principles and interests that have been identified as being at stake in the situation, and evaluating which are the most important to consider.

This will incorporate knowledge of the codes of ethics, and understanding of the principles and interests themselves.

The evaluation stage is also concerned with evaluating the options for resolving the situation. There may be a limited number of options available to the clinician, as is the case in many counseling situations.

In other cases, there may also be a great number of possible solutions to the ethical problem. The more options that are available, the more work is required of the clinician to evaluate each option fully.

However, it is also true that the more options the clinician examines, the wider is the range of possibilities for finding an option that offers the best balance of all the principles and interests at stake, including those which support and protect the interests of the clinician.

In the evaluation stage, it is important that the clinician be completely clear about how his or her personal self-interests, biases, emotional reactions and blind spots are being factored into whatever options are being considered.

Where such clarity does not exist, it is often helpful for the clinician to seek a consultation from another trusted professional, who can lend an objective perspective on the situation.

In still other instances, it must be determined whether the client can and/or should be brought into the process of evaluating the ethical situation.

While this is not an invitation to transfer responsibility for these difficult decisions to the client, the client's input can often be helpful in keeping clear the real potential outcomes from some of the decisions to be made.

At this stage of any clinical intervention, the clinical and ethical components of the clinician’s actions will often overlap.

At times, there will be an easy convergence, and the clinical work will be fully compatible with the ethical considerations. However, this will not always be the case. There may be complicated instances in which the clinician may need to choose between following professionally defined ethical guidelines and doing what is best for the client.

This can be particularly complicated in situations in which the client comes from a culture other than the dominant culture. Ethical codes, which are connected to legal and moral systems of belief in complex ways, have arisen from ideas and beliefs that hold sway in Western culture.

While professional codes of ethics make note of the need to consider cultural difference in clinical work, there are times when the clinician will be forced to choose between respecting the client’s cultural values and beliefs, and operating in a way that is consistent with their own profession’s code of ethics and the ethos from which that code arises.

This issue represents one of the most difficult areas within the arena of ethical decision making and is the subject of this course. 

Stage Four: The Selection Stage

The fourth stage or step is the selection of the best option or solution, and the putting of the option or solution into effect. This is the point at which the world of the abstract and theoretical meet the world of real life consequences and effects.

If the clinician has selected well, the choice will hopefully operate effectively in the real world. To assure that this is the case, the clinician will continue this process with the two final stages.

Stage Five: The Assessment Stage

The fifth stage is the assessment stage, in which the clinician assesses the real life effects of the selection that has been made to solve the ethical dilemma.

The real life effects must be evaluated both from the perspective of the clinician and the ethical obligations the clinician holds, and from the perspective of the client, whose life will be affected by the ethical choice that has been made.

If the results or consequences of the selection have not led to the anticipated resolution of the problem, the clinician moves to the last stage or step of this process.

Stage Six: The Adaptation Stage

The last stage of this process is the adaptation stage. In this stage, the clinician will look to adapt the selection or solution of the ethical dilemma by refining it, or by returning to the evaluation and selection stages to find and choose a better solution.

This staged process will become clearer as we look at an analysis of the scenarios. With this section completed, we will now turn to an examination of the principles and interests at stake in the decision making process.