As a Mental Health Counselor What Are Some Ethical Issues You Will Face?

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As a Mental Health Counselor What Are Some Ethical Issues You Will Face? image

by Dr. Mary Dowd; Updated July 01, 2018
As a mental health counselor, you will hear intimate details of clients’ lives that may spark ethical concerns. There will be times when you are ethically and legally mandated to breach confidentiality and report certain types of situations such as suspected child abuse. Dilemmas like this demonstrate the many kinds of ethical crossroads you may face when counseling clients. Working knowledge of professional codes, principals, standards, laws and regulations regarding clinical practice provides helpful guidance for resolving ethical issues in counseling.

Data Privacy Interpretations

At their initial visits, clients must receive detailed information about their ethical and legal rights to confidentiality and data privacy. Clients should be assured that they can open up and talk in confidence with certain exceptions to confidentiality such as disclosure of suicide plans. Both the mental health counselor and the client must understand that revealing certain secrets, such as intent to inflict immediate harm to self or others, requires reporting and intervention.

However, there may also be gray areas in which counselors face ethical dilemmas about breaching confidentiality when such statements are implied or thinly veiled. Consultation with other professionals is advisable when there is doubt.

Interpersonal Boundaries

Clients often feel closely connected to their counselors and may consider them friends. To show their gratitude, they may send flowers, gifts or invitations to special events such as graduations or weddings. Late night phone calls to the counselor’s home can occur when the client is inebriated, having a panic attack or just wants to talk. Romantic or sexual feelings toward the counselor may be expressed. Professional ethical codes developed by the American Psychological Association offer guidance on such matters.

Mental health counselors must establish and maintain appropriate professional boundaries and define the relationships as such. In general, small gifts of nominal value may be accepted if appropriate and not romantically suggestive. Ethical standards and sexual exploitation laws in many states strictly prohibit intimate dating relationships between a therapist and a client because of the power differential. Unethical behavior between a colleague and client must be reported even though it may strain your working relationship.

Boundaries of Professional Competency

Mental health counselors are ethically bound to counsel and conduct research only in areas within the bounds of their competency, credentials and level of education. They must be appropriately trained to understand how factors such as race, cultural beliefs, gender identity, disability and national origin influence a client's needs and desired treatment goals. A client may mention a previous diagnosis that a new mental health counselor has not yet encountered, such as multiple personality disorder.

Mental health counselors face ethical issues in honestly assessing their level of skill and competency. They must have integrity and an ethical core to recognize when they should make a referral because their knowledge in an area is insufficient and may cause harm.

Personal Problems and Conflicts

Mental health counselors are not immune from having their own personal difficulties. If a mental health counselor is experiencing emotional problems due to a pending divorce, chemical use relapse or severe depression, there is an ethical obligation to seek consultation. If personal issues affect stability, objectivity, judgment or focus, the counselor may need to take a leave while undergoing therapy.

Similarly, mental health therapists must make ethical decisions about whether their personal knowledge or connection to a particular client may require referral to another therapist due to a role conflict. For example, a mental health therapist should not counsel a next-door neighbor. Such dilemmas may be common when practicing in a small town where few therapists are available.

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A Client's Guide to Transference

Sounds like a job for In Therapy. Let’s back up to the definition of transference, because there are a few conflicting ideas. As I mentioned previously, psychology has a bit of a jargon problem, and this is one of the worst culprits. Depending on who you ask, “transference” could mean one of three things:

1. Therapists in consultation with one another may refer to transference as a general statement about the strength of the therapeutic relationship. In this view, a “good” or “positive” transference means the therapist and client get along reasonably well. “Negative” transference means some conflict or blockage prevents a good working relationship. It’s not uncommon for a supervisor to ask a trainee “how’s the transference?” and the trainee responds “good” without much elaboration.

2. The classic use of the term transference comes from psychoanalysis and includes: “the redirection of feelings and desires and especially of those unconsciously retained from childhood toward a new object.” We all do this all the time. A boss at work reminds you of your cranky grandmother, so you cower accordingly. The guy next to you on the train reminds you of your college friend Stan so you crack a joke that Stan would appreciate, to the train-stranger's bewilderment. Or the battle cry heard from loving couples around the world: “Stop treating me like I’m your mother!” Perhaps you respond to your younger-than-you female therapist as if she were your father. Transference happens everywhere, including within any therapeutic modality. Psychoanalysis just intensifies it (through all that blank screen stuff) and places it under the microscope.

3. Yet another way transference is used refers only to the loving feelings. Shorthand for what therapists call “erotic transference,” this is where the client develops romantic feelings for the therapist. It happens. More often than you think. Let’s say we’ve got a client longing to be known, with a history of misunderstandings or rejections, and we sit them down with a professional listener and understander. OF COURSE there are going to be some positive feelings. Maybe even feelings or fantasies of taking this exquisite understanding home. Living every day with this understanding in peace and harmony. Even merging with this understanding in an intimate, passionate way. The desire to connect with a caring person in a meaningful way is completely valid. But acting on it in a sexual way with a therapist is never an option.

What’s the problem with transference? Rather than connecting with the person, we’re relating to a template, which may be quite different from the flesh and blood in front of us. You’re treating Jane Doe like she’s your mother, or your grade school rival, or an idealized object of desire, when she’s actually none of the above - she’s Jane Doe. It prevents you from really connecting with Jane in a meaningful way. But it’s not always bad. Transference in therapy can be incredibly helpful, pointing us in the direction of unhealed wounds. It can transport therapy from lecture to laboratory.

Fictional Reader says the “intense attachment” is uncomfortable and difficult to discuss, and wants some coping strategies. A few come to mind:

Normalize - Some people feel ashamed for having loving, sexual, or seemingly off-the-wall feelings toward their therapist. But really, this does happen all the time. Therapists interested in relational issues and deep work expect transference of some sort to arise, and most are comfortable talking about it.

Talk about it - Fictional Reader is talking about it, and his therapist encourages it. Most of the time, this is all it takes to make these uncomfortable feelings more manageable and even help them diminish. Having difficulty getting started? How about: “I’ve been feeling a little uncomfortable here recently, and I think it has to do with our relationship.” The therapist should know where to go next.

Find the root - Transference reactions usually point to some deeper issue or unfinished business from the past. Your therapist makes you angry because he reminds you of your bully cousin? You’re in a loveless marriage but you have strong feelings for your therapist? When you can identify, discuss, and work through that deeper issue, the strong reaction to the therapist should subside as well. At least that’s what the “make the unconscious conscious” theory says!

Look for differences - If you really feel the need to end the transference pattern, you can try to actively separate the person from the template. Is your therapist really like your mother? Probably not. Is he really your ideal lover? Nope. Make a list of a dozen ways that the person differs from the template, then discuss them with your therapist. You can also ask (because you can ask anything) if the therapist is willing to disclose more information about her life to help further distinguish the two.

How do you want to relate? - Like so many situations, when we’re focusing on what not to do, we do just that. Don’t think of an elephant. Spend some time thinking about and discussing how you want to relate to your therapist, how you’d like it to feel, what you imagine it would look like. Then practice.

Leave, Part I - I’m definitely one for working relational issues through, but I can see two reasons to leave therapy due to transference. The first is if it has no impact on the rest of your life. Let’s say you have no significant problems in relationships with friends and family (and they would agree), and you come to a CBT therapist to work through your fear of bears. Your therapist happens to be a replica of your first boyfriend and you’re so smitten and tongue-tied that you can’t get any work done on the arctophobia. This is the only time you’ve felt this way, you don’t see a need to work through your feelings regarding your first boyfriend, and this bear problem needs to be addressed before your Into The Wild re-enactment vacation in a few weeks. You might as well find another therapist. And don’t forget to pack a lunch.

Leave, Part II - Fictional Reader mentions the “design flaw” inherent to this issue - the stronger the erotic or negative transference, the more difficult it can be to talk about it. If you’ve tried the points above and still this inhibition is so strong as to cause communication paralysis, no progress is being made. I’m not talking about Fictional Reader’s functional discomfort, I mean therapy is at a silent, excruciating standstill. If this is unbearable, it might be time to take a break, temporarily or permanently. I’ve known of clients who temporarily leave Therapist 1, go talk to Therapist 2 about the transference issues, then return to Therapist 1 when they feel unstuck. Or maybe you just want to leave for good. As always, it’s your time and your dime, you can terminate therapy whenever you want

As magical as it seems, transference is really just a relationship issue. You learn more about yourself when you work on your relationships, and transference gives you the opportunity to understand plenty about your thoughts, feelings, behaviors, relationships, and fantasies. Isn’t that why you came to therapy?

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