Knowledge Concerning Ethical Issues Involved

¶ … knowledge concerning ethical issues involved in counseling teenagers with alcoholism, including informed consent contents in psychotherapeutic settings, dual relationships and psychological testing considerations in personnel selection in organizational settings. In addition, the paper examines the rules governing sexual intimacy with clients and former clients as well as the value of personal psychotherapy as a requirement of a graduate training program. A discussion concerning deception in research is followed by an analysis of special concerns and particular benefits of an outpatient setting. Finally, a description of the relevant minimum HIPAA requirements is followed by a discussion concerning how psychologists become involved with fraudulent practices and an evaluation of professional responsibilities. A summary of the research and important findings are provided in the conclusion.

Ethical Issues in Counseling Teens with Alcoholism

Introduction

Counselors charged with treating young people who abuse substances in general and alcohol in particular are faced with some challenging issues as they seek to formulate timely and effective clinical interventions using evidence-based protocols. These young people are frequently abusing other substances as well, and their involvement with the law enforcement community and premarital sex further exacerbates their condition. Indeed, treating anyone suffering from alcoholism is a daunting enterprise, but these problems are especially pronounced with teenage alcoholics given their propensity for experimentation and proclivity for impulsive behaviors. To gain some fresh insights in these areas, this paper reviews the relevant literature to identify ethical issues involved in counseling teenagers with alcoholism, including informed consent contents in psychotherapeutic settings, a discussion concerning dual relationships and psychological testing in personnel selection. A discussion concerning the rules governing sexual intimacy with clients and former clients is followed by a discussion of personal psychotherapy as a requirement of a graduate training program, including an examination of deception in research. Next, an assessment of special concerns and particular benefits of an outpatient setting is followed by a description of the relevant minimum HIPAA requirements. Finally, a discussion concerning how psychologists become involved with fraudulent practices is followed by an evaluation of professional responsibilities. A summary of the research and important findings are presented in the conclusion.

Review and Discussion

Minimum contents of an informed consent for psychotherapy

Adolescents suffering from substance abuse issues have a right to understand and approve of any treatment in a process known as informed consent. Informed consent is required for all medical and research procedures based on the guiding principle that people who undergo these procedures have a fundamental right to be informed concerning the implications of the treatment and to provide their consent to that treatment with a complete understanding of those implications (Barnes & Murdin, 2001). According to Barnes and Murdin, "Informed consent means that an individual grants to someone the permission to do something they would not have the right to do without such permission. Need for consent arises from the recognition of the individual's right to autonomy and self-determination" (p. 117). The complete understanding of the treatment that is involved in a psychotherapeutic setting is regarded as an essential element for informed consent, but this level of understanding is not always attainable depending on the cognitive and emotional capabilities of the clients involved (Barnes & Murdin, 2001). In these cases, therapists should consider alternative methods of obtained informed consent (Barnes & Murdin, 2001).

Given the universal applicability of informed consent for medical treatment, it is not surprising that a growing number of authorities maintain that informed consent is also recommended for psychotherapy. In this regard, Croarkin and Berg (2003) report that many authorities have concluded that informed consent should include information relevant to the client's decision. According to Croarkin and Berg:

This includes treatment contracting, information about the effectiveness and safety of therapy, as well as alternatives and consequences of no therapy. However, applying this doctrine to psychotherapy is challenging due to the diversity of psychotherapists, the myriad of variables inherent in the process of psychotherapy, and to the potential risk of contaminating the process of psychotherapy with this information. (p. 384)

Advocates of informed consent for psychotherapeutic settings maintain that this procedure is necessary in order to "protect patients' rights to their best interests, empowers them to exercise control in their treatment, and provides a means for legal recourse should their rights be violated" (Croarkin & Berg, 2003, p. 384). In addition, informed consent for psychotherapy can provide some significant psychotherapeutic benefits. In this regard, Croarkin and Berg report that:

This interactive educational process may hone patients' self-esteem, encourage autonomy, defend against pernicious regression, and establish their active role in the therapeutic process, setting the groundwork for the therapeutic alliance and for effective psychotherapy. This process may also broaden treatment options for patients and distribute liability more judiciously. Specifically, liability is transferred from the psychotherapist to the therapeutic dyad of patient and therapist. (2003, p. 384)

Notwithstanding the foregoing considerations, the minimum contents of an informed consent for psychotherapeutic purposes consist of two elements: (a) disclosure of information the client needs to make an informed decision concerning participation in therapy and (b) free consent to therapy without experiencing undue influence from others (Charman, 2004). In this regard, Charman advises that, "Consent is grounded in the view that adult clients are fully autonomous human beings who deserve the freedom to make decisions about therapy that they exercise in other aspects of their lives" (2004, p. 350). Not only do all clients, including teenagers, have a right to informed consent, they also have a right to undergo therapy without becoming emotionally or romantically involved with their therapists and these issues are discussed further below.

Dual relationships

Dual relationships involving boundary issues have been the source of countless ethical dilemmas for psychotherapists. In this regard, Reamer (2003) reports that, "Ethical issues related to professional boundaries are among the most problematic and challenging. Boundary issues involve circumstances in which therapists encounter actual or potential conflicts between their professional duties and their social, sexual, religious, or business relationships" (p. 121). Interestingly, the boundary issues that are involved extent to others besides just clientele, and practitioners can become involved in dual relationships with colleagues as well (Reamer, 2003). In this regard, Moleski and Kiselica (2005) note that, "Some of the most challenging ethical situations result from dual relationships between counselors and others. A dual relationship is created whenever the role of counselor is combined with another relationship, which could be professional (e.g., professor, supervisor, employer) or personal (e.g., friend, close relative, sexual partner)" (p. 4).

Whatever their nature, dual relationships are considered unethical and potential threatening to the treatment process. For instance, according to Zur and Lazarus (2002), "Dual relationships between psychotherapists and clients have been frowned upon and denounced by the majority of therapists, ethicists, courts, licensing boards, ethics committees and educators" (p. 3). This disapproval of dual relationships is based on the need to protect clients as well as the validity of the treatment process itself, an issue that is especially important when adolescent patient are involved. In this regard, Zur and Lazarus add that, "The main reasons given for this proscription are that clients must be protected from exploitative and harmful therapists and that dual relationships, according to some, are not only harmful to clients but also compromise the integrity of the therapeutic process" (2002, p. 3). The research to date, though, shows that there is a divergence of opinion concerning the ethical nature of post-termination non-sexual dual relationships. In this regard, Pritchett and Fall (2001) report that:

Despite evidence that these relationships are harmful to the client, both counselor perception and ethical codes are vague about the ethics surrounding this issue. Although sexual dual relationships have clearly defined characteristics and ethical guidelines that most professionals understand, non-sexual dual relationships do not enjoy the same level of ethical clarity. (p. 73)

As a result, non-sexual relationships between clients and therapists that exist beyond the duration of treatment remain a source of ethical concern (Pritchett & Fall, 2001). In this regard, Kagle and Giebelhausen (1999) emphasize that, "Few would argue that sexual relationships between practitioners and clients are ethical. Such relationships clearly violate the norms of social work and other helping professions" (p. 213). With younger patients, sexual conduct in a dual relationship has been equated to child abuse and sexual conduct between practitioners and clients is regarded as a felony in seven states (Kagle & Giebelhausen, 1999).

A final important point is that every therapeutic relationship is unique and the boundaries that are established by the therapist will therefore be individualized to the setting. For example, Harper and Steadman (2003) emphasize that, "Many authors agree that maintaining boundaries with clients is basic to the development of an emotionally and physically safe therapeutic environment in which a trusting relationship can be developed. However, because boundaries emerge from the interaction, they are unique to each relationship" (p. 64).

Psychological testing in personnel selection

Psychological testing to identify optimal candidates for employment dates back more than 100 years. For instance, according to Scroggins, Thomas and Morris (2008), "Personnel selection in general, and the concomitant use of varied forms of psychological testing in particular, has its origins in the late 19th century" (p. 100). Much of the focus of personnel selection using psychological testing was on new troops enlisting in the military during two world wars and the explosive growth of the private sector thereafter (Scroggins et al., 2008). Psychological testing for personnel selection purposes, though, faded into disfavor during the 1960s, but it continues to be used by human resource practitioners today. In this regard, Scroggins and his colleagues advise, "Many HR practitioners, however, have continued to use personality testing with an optimistic and enduring faith in its ability to discriminate between good and poor job candidates" (p. 101).

In cases where cheating is suspected (such as in the case of an teen applicant possibly using a smartphone or consulting crib notes during testing by visiting the restroom), psychologists have a professional responsibility to conform to relevant privacy laws with respect to the results of such tests, including following the decision-making model provided by organizations such as the Canadian Psychological Association's approach which is applied to these issues in Table 1 below.

Table 1

Application of CPA's Decision-Making Model to Personnel Selection Results

Decision Step

Application

Identification of the individuals and groups potentially affected by the decision.

1. Applicant.

2. Potential employers.

3. Testing organization.

Identification of the relevant issues and practices

1. Stakeholders have a reasonable expectation of accuracy in the administration of personnel selection tests.

2. Applicants have a reasonable expectation of privacy in the release of their test results.

Consideration of how personal biases, stresses, or self-interest might influence the development of or choice between courses of action.

Testing authorities may be biased against younger applicants and translate personal cyberphobias into perceptions of cheating.

Development of alternative courses of action.

1. Reveal suspicion of cheating to stakeholders.

2. Conceal suspicion of cheating to stakeholders.

Analysis of short-term, ongoing and long-term risks and benefits of each course of action.

If the suspicion of cheating is revealed, the likelihood of the applicant receiving a job offer is seriously diminished; conversely, if the results are concealed and applicant secures employment, it may be through fraudulent methods.

Choice of course of action after conscientious application of existing principles, values and standards.

The ethical issues in this case require the testing authority to reveal the suspicion of cheating.

Action, with a commitment to assume responsibility for the consequences of the action.

Reveal the suspected cheating and recommend an alternative testing regimen to confirm or refute the initial testing results.

Evaluation of the results of the action.

This step would dictate the steps that would follow.

Assumption of responsibility for consequences of the action.

If subsequent tests confirmed cheating, the action is substantiated. If not, the suspicions of cheating may have been based on personal biases.

Appropriate action, as warranted and feasible, to prevent future occurrences of the dilemma.

Prevent all testing subjects from leaving the testing area during the administration of the test and to leave all handheld mobile devices outside the testing area.

In addition, professional psychologists must conform to the ethic guidelines and codes of conduct in their respective states, as well as in national organizations such as the American Psychology Association (APA). According to the APA, "Membership in the APA commits members and student affiliates to comply with the standards of the APA Ethics Code and to the rules and procedures used to enforce them. Lack of awareness or misunderstanding of an Ethical Standard is not itself a defense to a charge of unethical conduct" (Ethical principles of psychologists and code of conduct, 2012, para. 2).

Rules concerning sexual intimacy with a client/former client

As noted above, dual relationships threaten the integrity of the therapeutic process and sexual relations with clients are violative of most professional standards of conduct. In fact, prohibitions against dual relationships and sexual intimacy with clients have been part of professional codes of conduct for therapists for more than a half century (Coombs, 2005). In this regard, Moleski and Kiselica (2005) report that, "Ethical decision making is an ongoing process with no easy answers. In order to promote the well-being of clients, counselors must constantly balance their own values and life experiences with professional codes of ethics as they make choices about how to help their clients effectively" (p. 4). Consequently, clinicians who find themselves becoming personally involved with a client should therefore refer the individual to another practitioner to avoid any appearance of an improper dual relationship between client and therapist (Coombs, 2005).

Personal psychotherapy as a requirement of a graduate training program

Given the serious implications involved in dual relationships of this type, therapists can benefit from personal psychotherapy coursework and even treatment as a requirement of their graduate training program. For example, according to McEwan and Duncan (1999), "When being trained to work in the helping professions, many future therapists undergo some type of psychotherapeutic treatment as part of their preparation. This 'personal therapy' experience has been used in training psychoanalysts, other psychodynamic therapists, family therapists, group therapists, behaviour therapists and clinical psychologists" (p. 186). Such personal psychotherapy coursework also provides a useful foundation in conducting social research to help clinicians avoid deceptive practices that would interfere with clients' understanding of their treatment in ways that would influence their voluntary provision of informed consent (Ross & Grant, 1999).

Special concerns and particular benefits

Some adolescents who suffer from substance abuse problems require inpatient detoxification and follow-up treatment. In other cases, teenagers can avail themselves of outpatient treatments. Young clients are more likely to use outpatient services because they allow them the freedom to pursue their normal lives otherwise. For instance, on the one hand, Milhorn (1999) advises that, "The advantages of outpatient treatment include the fact that it is less expensive, allows the adolescent to live at home, and allows him to continue going to school full-time" (p. 135).

On the other hand, though, Milhorn (1999) also cites the potential downsides to the provision of outpatient care for teenage alcoholics: "The disadvantages of outpatient treatment are the lack of a structured living environment, more access to drugs, less intense treatment, less impression on the adolescent of the gravity of the situation, and less integrated health care services" (p. 135). In sum, inpatient treatment affords the best opportunity for initial intervention but outpatient care represents the optimal use of community-based resources for subsequent recovery and rehabilitation.

Other special concerns exist when there is evidence of domestic violence, particularly given that teenage substance abuser and alcoholics are at higher risk of being exposed to domestic violence as well as participating in violent acts themselves (Westman, 1999). The following vignette is illustrative of the ethical considerations and exigencies that are faced by counselors in every day situations.

Maria is a 32-year-old, Latina. Her child, Rosalinda, age 6, was referred to counseling after having been exposed to domestic violence (Maria reports having been the victim) in the home. Maria is separated from Rosalinda's father who is the alleged perpetrator in the domestic violence. When Maria brought Rosalinda to her first evaluation session (symptoms included: nightmares, regression, easily moved to tears, clingy with Maria), Maria read and signed an informed consent form while in the waiting room. The form was fairly standard issue, citing all the usual exceptions to confidentiality. The psychology intern properly introduced herself to Maria and briefly went over the informed consent. Maria expressed understanding of and agreement with the evaluation and treatment for her daughter.

Maria was the principal informant during the assessment, and the psychology intern documented in her notes that Maria reported she had started to date again. She noted that Rosalinda's symptoms had gotten worse (for example, she is upset when left with the family babysitter). Given these circumstances and the father's history of violence and abuse, Rosalinda's father should not have access to the child's record, but the reference to Maria starting to date should be documented in the record; however, as the suspected perpetrator of the domestic violence, the father should not have access to this information either. This approach is congruent with Sonkin who emphasizes that, "Therapists, because of the special relationship they have with clients, have a duty to take reasonable care to protect the intended victim" (2012, para. 2). Moreover, the potential for new violence exists even while the therapeutic interventions are ongoing and counselors must recognize when laws besides those that specifically apply to their profession are being violated and when they need to contact law enforcement authorities. For example, Sonkin adds that, "Other laws affect the profession but may not be specifically included in the licensing law. These laws often include reporting abuse. Other relevant laws address issues such as fraud, patient access to medical records, and the rights of minors to name just a few" (2012, para. 3).

The variables in the above-described vignette could be changed to reflect a virtually limitless combination of circumstances that could potentially present ethical dilemmas or questions concerning the appropriate course of conduct. Therefore, therapists must understand relevant guidance from their state licensing boards as well as other laws that may have an effect on their practice as well as their personal safety and the safety of their clientele (Sonkin, 2012). Finally, the focus of any intervention in these situations should be on reducing the harm that domestic violence causes children and abused partners (Shipway, 2004).

Minimum HIPAA requirements for a small clinic

In general, all patients have a right to know who will have access to their protected healthcare information and what will happen to such information upon release to others pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Charman, 2004). Likewise, all patients have a right to know how the use of such reimbursement mechanisms may affect the structure and duration of therapy as well as information concerning the clinician's relationship with the payor; in addition, clients are entitled to know about the financial incentives payors offer clinicians who follow standard protocols from time to time (Charman, 2004). With respect to a small clinic, the changes resulting from recent HIPPA requirements include the patients' right to access their protected health information at any time; however, in a small psychological clinic, patients are not entitled to access to the psychologists' private notes concerning a treatment session (Bersoff, 2008). Beyond the foregoing requirements, the protected healthcare information records must also be stored in a fashion that satisfies the applicable state law, federal regulations and institutional requirements (Fisher, 2008). According to Myers (2008), though, "There is confusion about the difference between privacy standards and security standards as described by HIPAA" (para. 3).

This confusion, though, is simple enough to sort out. In sum, the federal privacy protections set forth in the HIPAA Privacy Rule protect personal health information held by others and provides patients with various rights concerning their information (Understanding health information privacy, 2012). In addition, the HIPAA Privacy Rule allows for the disclosure of personal health information in those cases where it is required for patient care and other legitimate (and covered) purposes (Understanding health information privacy, 2012). Furthermore, the HIPAA Security Rule establishes various administrative, physical, and technical protections for healthcare providers holding such medical information records (Understanding health information privacy, 2012). Healthcare providers for the purposes of the HIPPA include private entities including small clinics as well as government programs such as Medicare, Medicaid, and the military and veterans health care programs (Understanding health information privacy, 2012).

Because the private notes of a psychologist are exempted from HIPPA regulatory oversight as well as from review by patients, such notes must be maintained separately from protected healthcare information records (Fisher, 2008). In addition, clients also have the right to appeal the protected healthcare information record to their treating clinicians, and in those cases where the clinicians are amenable, the medical records are so noted and written recordation should be made that the protected healthcare information was so disclosed and to whom it was disclosed (Fisher, 2008).

The privacy protections afforded by HIPAA extend to adolescent patients irrespective of the healthcare provider. According to Myers (2008), these rights include (a) the right to receive a health care provider's Notice of Privacy Practices, (b) the opportunity to object or opt-out of certain types of communications including disclosures for marketing or fundraising purposes, and (c) the right to inspect and copy their protected health information, in whole or in part, for as long as the covered entity maintains the information. (para. 3). Practitioners, though, are free to establish even stricter guidelines than those contained in the HIPAA to protect healthcare information, but they are required to abide by the minimal standards concerning the release of this information without client consent (Myers, 2008). In this regard, Myers emphasizes that, "Protected health information may be disclosed to family members or for public health activities. Generally, it is best to only release information without a written authorization if the client represents a danger to him/herself or others" (2008, para. 4).