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Ethically Treating PTSD Resulting from Terroism and other Traumas

Manual of Articles Sections 10 - 16
Section 10
PTSD: Code of Ethics: NASW, AAMFT, APA, NBCC, and ACA
History and Evolution of Values and Ethics in Social Work
3 Key Legal Requirements and Considerations

Question 10 | Answer Booklet | Table of Contents | Printable Page

Critical Incident Stress Debriefing After A Line Of Duty Death
By Carol Fizer

Carol Fizer worked with rescue workers at the World Trade Center following the September 11th attacks. She is an Independent Clinical Social Worker in the greater Boston area. Carol trained with the International Critical Incident Stress Foundation and Smith College School for Social Work.

A debriefing is essentially a highly structured conversation, which moves from the cognitive to the affective and back to the cognitive level, from person to person around the group. This is done in a series of seven steps:

1. Introduction
– this is when the leader tells the group its focus and set the group boundaries. “We are here to talk about Sean’s death in the fire on Monday.”

2. Fact Stage – the leader asks each participant his or her recollection of the trauma. “How did you know something wasn’t right, that Sean was missing?”

3. Thought Stage – the leader focuses on the cognitive reaction. “What was the first thought that came into your mind when you realized that he had not come out of the building?”

4. Reaction Stage - there is more sharing of feeling about the trauma and is usually the most extended in time. “What’s it like to lose a member of your Engine? How is the firehouse doing?”

5. Symptom Stage - the leader asks directly whether group members have had any unusual thoughts or feelings since the event. “What has been going on internally since Monday? Has anything been unusual for you?”

6. Teaching Stage - in this stage the leader tries to normalize symptoms and offer self-help steps. “What you all are feeling, the anger, the sadness, is what happens when someone close to you dies. I want to make suggestions about how you can help yourself feel better.” Specific steps to reduce stress are offered at this point. They include using less alcohol and caffeine, emphasizing the need for exercise and a balanced diet, encouraging communication with friends, and doing activities which feel good or whatever is stress reducing.

7. Reentry Stage - the leader wraps up the group, but leaves open the door for future contact. “Thank you all for being here when you would rather be at home. I know this has been a tough thing to talk about, but it helps. Please feel free to contact us if there is anyway we can be of help in the next days or weeks.” At this point, the group leader may ask to talk privately to targeted group members, for example, someone who is drinking more than usual, or has stopped taking his or her medication and is showing signs of decomposition, or has been reluctant to participate in the group. The remainder of this article contains a narrative as to how I applied the Seven Steps to a group of firefighters.

It had been five days since the trauma took the lives of two firefighters, Sean and Michael, experienced veterans of the department whom all the rest looked up to. There had been two funerals and life had gone on as “normal” in the firehouse, but the chief, James, had heard more than the usual complaints of not sleeping, arguing with family members, meetings at the local bar, and a general sense of tension among the men. James’ attempts to talk about Michael and Sean’s death had been met with a wall of silence. At that point James decided to call the local County Critical Incident Stress Team. As its Mental Health Coordinator, I discussed various options with him and set a time for the next morning to debrief the group of ten firefighters from the house who were all at the fire. We did not include firefighters from other houses since this group had a unique relationship with the two dead men. It was best not to meet in the firehouse, so we met at the Community Center. James arranged for transportation. I contacted Randy, a County Critical Incident team member and a firefighter, who has been trained in Critical Incident Stress Debriefing. Randy works in another town, and we ran through the plan for the debriefing.

Beginning the Meeting: I walked into the meeting room to see nine tired-looking men and one woman. They ranged in experience from young newcomers of the department to seasoned veterans of thirty years. The mix was about half and half. There was minimal conversation, but a lot of cigarette smoking and coffee drinking. Randy, the peer leader, and I worked out who should take the lead. I leapt in with a brief introduction that we were here because of Sean and Michael’s death. I briefly explained that everything that was said was confidential, that we were here for them, and what was happening to them. There was some grumbling from an older man about “psychological crap,” which I just chose to ignore.

Something was Wrong: We initiated a round-robin style group discussion by giving each person the opportunity to speak about when they first realized something was wrong. Each person gave his or her perspective. The general consensus in the group was that during the fire quite a bit of time elapsed before fellow firemen realized Michael and Sean were missing. In fact, it had been at least fifteen minutes after the building evacuation was called since there was so much confusion between the four different companies.

First Thoughts: A second round focused on the first thoughts which popped into their minds after realizing that the two were missing. The responses ranged from who was going to tell their wives to what they would do without them. Several men said nothing.

Sadness, Guilt and Anger: Feelings started to emerge and the conversation focused on how hard it was to go to the funeral and go to work without Sean and Michael. There were feelings of guilt when no one realized that Sean and Michael had been caught in a quick burn. Sadness for their families surfaced, and Julia cried as she talked about seeing the kids at the funeral. The guilt emerged and the focus switched to what could have been done differently. I gently reminded the group that this was not an operational critique, and again talked about how sad it was to lose someone in this way. Ralph turned away, hiding his tears. There was an immediate group response in terms of several people talking about their sadness. The group stopped. I asked what was going on that had stopped everyone in their tracks. A younger firefighter said he really thought their deaths were stupid, they had been doing something risky and left them with this mess. The group tentatively talked about their anger for the guys “who left us.” The group went back and forth between sadness, guilt, and anger, until they all seemed somewhat relieved.

Behavioral Changes: I summarized the feelings they had talked about and moved on to ask them about changes in their behavior and feelings during the past week. I heard complaints of sleeplessness, preoccupation with how “we could have done it differently,” and fears about the “next time the bell rings.” Another person kept wondering whether it could be himself the next time. A joke about nightly trips to the bar made me concerned about Jon’s increased drinking as a response to the situation. Randy addressed the feelings and behavior as a normal reaction to a major loss in their lives that not only affected their work lives, but also their personal lives. “It’s like losing a family member, so you are going to feel this way.” I interjected specific, concrete ways of handling these types of uncomfortable feelings…for example, talking to buddies and family members, as well as doing the activities that help them feel good. These were stressed as ways to get through the next week. The group then spontaneously planned a memorial for Sean and Michael. The group decided to hang Sean and Michael’s pictures in the kitchen, a place where they both liked being. As we ended, I thanked them all for being there and left the door wide open by giving them each our cards for further assistance if they or their families needed it. We said goodbye. As the group lingered to talk, I approached Jon, the person who joked about drinking. He quickly told me that he had not been to an AA meeting, but promised to go at the end of his shift. I told him I would check in with him the next day.

The Seven Stage Critical Incident Stress Debriefing, described by Mitchell in his 1983 article, has been shown to help individuals, like this group of firefighters, move from a traumatic situation back to work life. The debriefing is a group crisis intervention, a healing conversation, not psychotherapy and, when used correctly, shows the potential for reduced symptomatic behavior.

This is a brief overview of debriefing (CISD) which used with other interventions (CISM) can be potentially powerful in helping a wide variety of populations through traumatic situations with a reduced potential for long range symptoms.

National Association of Social Workers
Code of Ethics
(excerpt summary)

1.07 Privacy and confidentiality
(a) Social workers should respect clients’ right to privacy. Social workers should not solicit private information from clients unless it is essential to providing services or conducting social work evaluation or research. Once private information is shared, standards of confidentiality apply.

(b) Social workers may disclose confidential information when appropriate with valid consent from a client or a person legally authorized to consent on behalf of a client.

(c) Social workers should protect the confidentiality of all information obtained in the course of professional service, except for compelling professional reasons. The general expectation that social workers will keep information confidential does not apply when disclosure is necessary to prevent serious, foreseeable, and imminent harm to a client or other identifiable person. In all instances, social workers should disclose the least amount of confidential information necessary to achieve the desired purpose; only information that is directly relevant to the purpose for which the disclosure is made should be revealed.

(d) Social workers should inform clients, to the extent possible, about the disclosure of confidential information and the potential consequences, when feasible before the disclosure is made. This applies whether social workers disclose confidential information on the basis of a legal requirement or client consent.

(e) Social workers should discuss with clients and other interested parties the nature of confidentiality and limitations of clients’ right to confidentiality. Social workers should review with clients circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. This discussion should occur as soon as possible in the social worker-client relationship and as needed throughout the course of the relationship.

(f) When social workers provide counseling services to families, couples, or groups, social workers should seek agreement among the parties involved concerning each individual’s right to confidentiality and obligation to preserve the confidentiality of information shared by others. Social workers should inform participants in family, couples, or group counseling that social workers cannot guarantee that all participants will honor such agreements.

(g) Social workers should inform clients involved in family, couples, marital, or group counseling of the social worker’s, employer’s, and agency’s policy concerning the social worker’s disclosure of confidential information among the parties involved in the counseling.

(h) Social workers should not disclose confidential information to third-party payers unless clients have authorized such disclosure.

(i) Social workers should not discuss confidential information in any setting unless privacy can be ensured. Social workers should not discuss confidential information in public or semipublic areas such as hallways, waiting rooms, elevators, and restaurants.

(j) Social workers should protect the confidentiality of clients during legal proceedings to the extent permitted by law. When a court of law or other legally authorized body orders social workers to disclose confidential or privileged information without a client’s consent and such disclosure could cause harm to the client, social workers should request that the court withdraw the order or limit the order as narrowly as possible or maintain the records under seal, unavailable for public inspection.

(k) Social workers should protect the confidentiality of clients when responding to requests from members of the media.

(l) Social workers should protect the confidentiality of clients’ written and electronic records and other sensitive information. Social workers should take reasonable steps to ensure that clients’ records are stored in a secure location and that clients’ records are not available to others who are not authorized to have access.

(m) Social workers should take precautions to ensure and maintain the confidentiality of information transmitted to other parties through the use of computers, electronic mail, facsimile machines, telephones and telephone answering machines, and other electronic or computer technology. Disclosure of identifying information should be avoided whenever possible.

(n) Social workers should transfer or dispose of clients’ records in a manner that protects clients’ confidentiality and is consistent with state statutes governing records and social work licensure.

(o) Social workers should take reasonable precautions to protect client confidentiality in the event of the social worker’s termination of practice, incapacitation, or death.

(p) Social workers should not disclose identifying information when discussing clients for teaching or training purposes unless the client has consented to disclosure of confidential information.

(q) Social workers should not disclose identifying information when discussing clients with consultants unless the client has consented to disclosure of confidential information or there is a compelling need for such disclosure.

(r) Social workers should protect the confidentiality of deceased clients consistent with the preceding standards.
Code of Ethics of the National Association of Social Workers


American Association of Marriage and Family Therapists
Code of Ethics

2. Confidentiality
Marriage and family therapists have unique confidentiality concerns because the client in a therapeutic relationship may be more than one person. Therapists respect and guard the confidences of each individual client.

2.1 Disclosing Limits of Confidentiality.
Marriage and family therapists disclose to clients and other interested parties at the outset of services the nature of confidentiality and possible limitations of the clients’ right to confidentiality. Therapists review with clients the circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. Circumstances may necessitate repeated disclosures.

2.2 Written Authorization to Release Client Information.
Marriage and family therapists do not disclose client confidences except by written authorization or waiver, or where mandated or permitted by law. Verbal authorization will not be sufficient except in emergency situations, unless prohibited by law. When providing couple, family or group treatment, the therapist does not disclose information outside the treatment context without a written authorization from each individual competent to execute a waiver. In the context of couple, family or group treatment, the therapist may not reveal any individual’s confidences to others in the client unit without the prior written permission of that individual.

2.3 Client Access to Records.
Marriage and family therapists provide clients with reasonable access to records concerning the clients. When providing couple, family, or group treatment, the therapist does not provide access to records without a written authorization from each individual competent to execute a waiver. Marriage and family therapists limit client’s access to their records only in exceptional circumstances when they are concerned, based on compelling evidence, that such access could cause serious harm to the client. The client’s request and the rationale for withholding some or all of the record should be documented in the client’s file. Marriage and family therapists take steps to protect the confidentiality of other individuals identified in client records.

2.4 Confidentiality in Non-Clinical Activities.
Marriage and family therapists use client and/or clinical materials in teaching, writing, consulting, research, and public presentations only if a written waiver has been obtained in accordance with Standard 2.2, or when appropriate steps have been taken to protect client identity and confidentiality.

2.5 Protection of Records.
Marriage and family therapists store, safeguard, and dispose of client records in ways that maintain confidentiality and in accord with applicable laws and professional standards.

2.6 Preparation for Practice Changes.
In preparation for moving a practice, closing a practice, or death, marriage and family therapists arrange for the storage, transfer, or disposal of client records in conformance with applicable laws and in ways that maintain confidentiality and safeguard the welfare of clients.

2.7 Confidentiality in Consultations.
Marriage and family therapists, when consulting with colleagues or referral sources, do not share confidential information that could reasonably lead to the identification of a client, research participant, supervisee, or other person with whom they have a confidential relationship unless they have obtained the prior written consent of the client, research participant, supervisee, or other person with whom they have a confidential relationship. Information may be shared only to the extent necessary to achieve the purposes of the consultation.
Code of Ethics of the American Association for Marriage and Family Therapy


American Psychological Association
Ethical Principles of Psychologists and Code of Conduct

1. Resolving Ethical Issues
1.01 Misuse of Psychologists' Work
If psychologists learn of misuse or misrepresentation of their work, they take reasonable steps to correct or minimize the misuse or misrepresentation.

1.02 Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority
If psychologists’ ethical responsibilities conflict with law, regulations or other governing legal authority, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights.

1.03 Conflicts Between Ethics and Organizational Demands
If the demands of an organization with which psychologists are affiliated or for whom they are working are in conflict with this Ethics Code, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights.

1.04 Informal Resolution of Ethical Violations
When psychologists believe that there may have been an ethical violation by another psychologist, they attempt to resolve the issue by bringing it to the attention of that individual, if an informal resolution appears appropriate and the intervention does not violate any confidentiality rights that may be involved. (See also Standards 1.02, Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority, and 1.03, Conflicts Between Ethics and Organizational Demands.)

1.05 Reporting Ethical Violations
If an apparent ethical violation has substantially harmed or is likely to substantially harm a person or organization and is not appropriate for informal resolution under Standard 1.04, Informal Resolution of Ethical Violations, or is not resolved properly in that fashion, psychologists take further action appropriate to the situation. Such action might include referral to state or national committees on professional ethics, to state licensing boards or to the appropriate institutional authorities. This standard does not apply when an intervention would violate confidentiality rights or when psychologists have been retained to review the work of another psychologist whose professional conduct is in question. (See also Standard 1.02, Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority.)

1.06 Cooperating with Ethics Committees
Psychologists cooperate in ethics investigations, proceedings and resulting requirements of the APA or any affiliated state psychological association to which they belong. In doing so, they address any confidentiality issues. Failure to cooperate is itself an ethics violation. However, making a request for deferment of adjudication of an ethics complaint pending the outcome of litigation does not alone constitute noncooperation.

1.07 Improper Complaints
Psychologists do not file or encourage the filing of ethics complaints that are made with reckless disregard for or willful ignorance of facts that would disprove the allegation.

1.08 Unfair Discrimination Against Complainants and Respondents
Psychologists do not deny persons employment, advancement, admissions to academic or other programs, tenure, or promotion, based solely upon their having made or their being the subject of an ethics complaint. This does not preclude taking action based upon the outcome of such proceedings or considering other appropriate information.

4. Privacy and Confidentiality
4.01 Maintaining Confidentiality
Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship. (See also Standard 2.05, Delegation of Work to Others.)

4.02 Discussing the Limits of Confidentiality
(a) Psychologists discuss with persons (including, to the extent feasible, persons who are legally incapable of giving informed consent and their legal representatives) and organizations with whom they establish a scientific or professional relationship (1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities. (See also Standard 3.10, Informed Consent.)

(b) Unless it is not feasible or is contraindicated, the discussion of confidentiality occurs at the outset of the relationship and thereafter as new circumstances may warrant.

(c) Psychologists who offer services, products, or information via electronic transmission inform clients/patients of the risks to privacy and limits of confidentiality.

4.03 Recording
Before recording the voices or images of individuals to whom they provide services, psychologists obtain permission from all such persons or their legal representatives. (See also Standards 8.03, Informed Consent for Recording Voices and Images in Research; 8.05, Dispensing with Informed Consent for Research; and 8.07, Deception in Research.)

4.04 Minimizing Intrusions on Privacy
(a) Psychologists include in written and oral reports and consultations, only information germane to the purpose for which the communication is made.

(b) Psychologists discuss confidential information obtained in their work only for appropriate scientific or professional purposes and only with persons clearly concerned with such matters.

4.05 Disclosures
(a) Psychologists may disclose confidential information with the appropriate consent of the organizational client, the individual client/patient or another legally authorized person on behalf of the client/patient unless prohibited by law.

(b) Psychologists disclose confidential information without the consent of the individual only as mandated by law, or where permitted by law for a valid purpose such as to (1) provide needed professional services; (2) obtain appropriate professional consultations; (3) protect the client/patient, psychologist, or others from harm; or (4) obtain payment for services from a client/patient, in which instance disclosure is limited to the minimum that is necessary to achieve the purpose. (See also Standard 6.04e, Fees and Financial Arrangements.)

4.06 Consultations
When consulting with colleagues, (1) psychologists do not disclose confidential information that reasonably could lead to the identification of a client/patient, research participant or other person or organization with whom they have a confidential relationship unless they have obtained the prior consent of the person or organization or the disclosure cannot be avoided, and (2) they disclose information only to the extent necessary to achieve the purposes of the consultation. (See also Standard 4.01, Maintaining Confidentiality.)

4.07 Use of Confidential Information for Didactic or Other Purposes
Psychologists do not disclose in their writings, lectures or other public media, confidential, personally identifiable information concerning their clients/patients, students, research participants, organizational clients or other recipients of their services that they obtained during the course of their work, unless (1) they take reasonable steps to disguise the person or organization, (2) the person or organization has consented in writing, or (3) there is legal authorization for doing so.
- The American Psychological Association's (APA) Ethical Principles of Psychologists and Code of Conduct (hereinafter referred to as the Ethics Code)


American Counseling Association Code of Ethics Excerpt - Section B: Confidentiality and Privacy

Counselors recognize that trust is a cornerstone of the counseling relationship. Counselors aspire to earn the trust of clients by creating an ongoing partnership, establishing and upholding appropriate boundaries, and maintaining confidentiality. Counselors communicate the parameters of confidentiality in a culturally competent manner.

B.1. Respecting Client Rights
B.1.a. Multicultural/Diversity Considerations
Counselors maintain awareness and sensitivity regarding cultural meanings of confidentiality and privacy. Counselors respect differing views toward disclosure of information. Counselors hold ongoing discussions with clients as to how, when, and with whom information is to be shared.

B.1.b. Respect for Privacy
Counselors respect the privacy of prospective and current clients. Counselors request private information from clients only when it is beneficial to the counseling process.

B.1.c. Respect for Confidentiality
Counselors protect the confidential information of prospective and current clients. Counselors disclose information only with appropriate consent or with sound legal or ethical justification.

B.1.d. Explanation of Limitations
At initiation and throughout the counseling process, counselors inform clients of the limitations of confidentiality and seek to identify situations in which confidentiality must be breached.

B.2. Exceptions
B.2.a. Serious and Foreseeable Harm and Legal Requirements
The general requirement that counselors keep information confidential does not apply when disclosure is required to protect clients or identified others from serious and foreseeable harm or when legal requirements demand that confidential information must be revealed. Counselors consult with other professionals when in doubt as to the validity of an exception. Additional considerations apply when addressing end-of-life issues.

B.2.b. Confidentiality Regarding End-of-Life Decisions
Counselors who provide services to terminally ill individuals who are considering hastening their own deaths have the option to maintain confidentiality, depending on applicable laws and the specific circumstances of the situation and after seeking consultation or supervision from appropriate professional and legal parties.

B.2.c. Contagious, Life-Threatening Diseases
When clients disclose that they have a disease commonly known to be both communicable and life threatening, counselors may be justified in disclosing information to identifiable third parties, if the parties are known to be at serious and foreseeable risk of contracting the disease. Prior to making a disclosure, counselors assess the intent of clients to inform the third parties about their disease or to engage in any behaviors that may be harmful to an identifiable third party. Counselors adhere to relevant state laws concerning disclosure about disease status.

B.2.d. Court-Ordered Disclosure
When ordered by a court to release confidential or privileged information without a client’s permission, counselors seek to obtain written, informed consent from the client or take steps to prohibit the disclosure or have it limited as narrowly as possible because of potential harm to the client or counseling relationship.

B.2.e. Minimal Disclosure
To the extent possible, clients are informed before confidential information is disclosed and are involved in the disclosure decision-making process. When circumstances require the disclosure of confidential information, only essential information is revealed.

B.3. Information Shared With Others
B.3.a. Subordinates
Counselors make every effort to ensure that privacy and confidentiality of clients are maintained by subordinates, including employees, supervisees, students, clerical assistants, and volunteers.

B.3.b. Interdisciplinary Teams
When services provided to the client involve participation by an interdisciplinary or treatment team, the client will be informed of the team’s existence and composition, information being shared, and the purposes of sharing such information.

B.3.c. Confidential Settings
Counselors discuss confidential information only in settings in which they can reasonably ensure client privacy.

B.3.d. Third-Party Payers
Counselors disclose information to third-party payers only when clients have authorized such disclosure.

B.3.e. Transmitting Confidential Information
Counselors take precautions to ensure the confidentiality of all information transmitted through the use of any medium.

B.3.f. Deceased Clients
Counselors protect the confidentiality of deceased clients, consistent with legal requirements and the documented preferences of the client.
B.4. Groups and Families
B.4.a. Group Work
In group work, counselors clearly explain the importance and parameters of confidentiality for the specific group.

Couples and Family Counseling
In couples and family counseling, counselors clearly define who is considered “the client” and discuss expectations and limitations of confidentiality. Counselors seek agreement and document in writing such agreement among all involved parties regarding the confidentiality of information. In the absence of an agreement to the contrary, the couple or family is considered to be the client.

B.5. Clients Lacking Capacity to Give Informed Consent
B.5.a. Responsibility to Clients
When counseling minor clients or adult clients who lack the capacity to give voluntary, informed consent, counselors protect the confidentiality of information received—in any medium—in the counseling relationship as specified by federal and state laws, written policies, and applicable ethical standards.

B.5.b. Responsibility to Parents and Legal Guardians
Counselors inform parents and legal guardians about the role of counselors and the confidential nature of the counseling relationship, consistent with current legal and custodial arrangements. Counselors are sensitive to the cultural diversity of families and respect the inherent rights and responsibilities of parents/guardians regarding the wel-fare of their children/charges according to law. Counselors work to establish, as appropriate, collaborative relationships with parents/guardians to best serve clients.

B.5.c. Release of Confidential Information
When counseling minor clients or adult clients who lack the capacity to give voluntary consent to release confidential information, counselors seek permission from an appropriate third party to disclose information. In such instances, counselors inform
clients consistent with their level of understanding and take appropriate measures to safeguard client confidentiality.

B.6. Records and Documentation
B.6.a. Creating and Maintaining Records and Documentation
Counselors create and maintain records and documentation necessary for rendering professional services.

B.6.b. Confidentiality of Records and Documentation
Counselors ensure that records and documentation kept in any medium are secure and that only authorized persons have access to them.

B.6.c. Permission to Record
Counselors obtain permission from clients prior to recording sessions through electronic or other means.

B.6.d. Permission to Observe
Counselors obtain permission from clients prior to allowing any person to observe counseling sessions, review session transcripts, or view recordings of sessions with supervisors, faculty, peers, or others within the training environment.

B.6.e. Client Access
Counselors provide reasonable access to records and copies of records when requested by competent clients. Counselors limit the access of clients to their
records, or portions of their records, only when there is compelling evidence that such access would cause harm to the client. Counselors document the request of clients and the rationale for withholding some or all of the records in the files of clients. In situations involving multiple clients, counselors provide individual clients with only those parts of records that relate directly to them and do not include confidential information related to any other client.

B.6.f. Assistance With Records
When clients request access to their records, counselors provide assistance and consultation in interpreting counseling records.

B.6.g. Disclosure or Transfer
Unless exceptions to confidentiality exist, counselors obtain written permission from clients to disclose or transfer records to legitimate third parties. Steps are taken to ensure that receivers of counseling records are sensitive to their confidential nature.

B.6.h. Storage and Disposal After Termination
Counselors store records following termination of services to ensure reasonable future access, maintain records in accordance with federal and state laws and statutes suchas licensure laws and policies governing records, and dispose of client records and other sensitive materials in a manner that protects client confidentiality. Counselors apply careful discretion and deliberation before destroying records that may be needed by a court of law, such as notes on child abuse, suicide, sexual harassment, or violence.

B.6.i. Reasonable Precautions
Counselors take reasonable precautions to protect client confidentiality in the event of the counselor’s termination of practice, incapacity, or death and appoint a records custodian when identified as appropriate.

B.7. Case Consultation
B.7.a. Respect for Privacy
Information shared in a consulting relationship is discussed for professional purposes only. Written and oral reports present only data germane to the purposes of the consultation, and every effort is made to protect client identity and to avoid undue invasion of privacy.

B.7.b. Disclosure of Confidential Information
When consulting with colleagues, counselors do not disclose confidential information that reasonably could lead to the identification of a client or other person or organization with whom they have a confidential relationship unless they have obtained the prior consent of the person or organization or the disclosure cannot be avoided. They disclose information only to the extent necessary to achieve the purposes of the consultation.
2014 American Counseling Association’s Code of Ethics


National Board for Certified Counselors Code of Ethics

NCCs take appropriate action to prevent harm.
10. NCCs shall create written procedures regarding the handling of client records in the event of their unexpected death or incapacitation. In recognition of the harm that may occur if clients are unable to access professional assistance in these cases, these procedures shall ensure that the confidentiality of client records is maintained and shall include the identification of individual(s) who are familiar with ethical and legal requirements regarding the counseling profession and who shall assist clients in locating other professional mental health providers as well as ensure the appropriate transfer of client records. These written procedures shall be provided to the client, and the NCC shall provide an opportunity for the client to discuss concerns regarding the process as it pertains to the transfer of his or her record.

15. NCCs who seek consultation (i.e., consultees) shall protect client’s confidentiality and unnecessary invasion of privacy by providing only the information relevant to the consultation and in a manner that protects the client’s identity.

19. NCCs shall recognize the potential harm of informal uses of social media and other related technology with clients, former clients and their families and personal friends. After carefully considering all of the ethical implications, including confidentiality, privacy and multiple relationships, NCCs shall develop written practice procedures in regard to social media and digital technology, and these shall be incorporated with the information provided to clients before or during the initial session. At a minimum, these social media procedures shall specify that personal accounts will be separate and isolated from any used for professional counseling purposes including those used with prospective or current clients. These procedures shall also address “friending” and responding to material posted.

21. NCCs who use digital technology (e.g., social media) for professional purposes shall limit information posted to that which does not create multiple relationships or which may threaten client confidentiality.

NCCs promote the welfare of clients, students, supervisees or the recipients of professional services provided.
34. NCCs shall protect the confidentiality and security of tests or assessments, reports, data and any transmission of information in any form.

NCCs communicate truthfully.
45. NCCs who provide supervision services shall present accurate written information to supervisees regarding the NCC’s credentials as well as information regarding the process of supervision. This information shall include any conditions of supervision, supervision goals, case management procedures, confidentiality and its limitations, appraisal methods and timing of evaluations.

NCCs recognize that their behavior reflects on the integrity of the profession as a whole, and thus, they avoid actions which can reasonably be expected to damage trust
55. NCCs shall retain client records for a minimum of five years unless state or federal laws require additional time. After the required retention period, NCCs shall dispose of records in a manner that protects client confidentiality.

56. NCCs shall act in a professional manner by protecting against unauthorized access to confidential information. This includes data contained in electronic formats. NCCs shall inform any subordinates who have physical or electronic access to information of the importance of maintaining privacy and confidentiality.

NCCs recognize the importance of and encourage active participation of clients, students or supervisees.
67.NCCs conducting counseling with more than one client at a time (e.g., group or family counseling) shall discuss with clients the nature, the rights and responsibilities as well as the possible additional limitations of confidentiality. NCCs shall also describe the steps that they will take in the event that having multiple clients in session creates issues between or concerning clients.

NCCs recognize the importance of and encourage active participation of clients, students or supervisees.
69. NCCs shall inform clients of the purposes, goals, procedures, limitations, potential risks and benefits of services and techniques either prior to or during the initial session. NCCs also shall provide information about client’s rights and responsibilities including billing arrangements, collection procedures in the event of nonpayment, confidentiality and its limitations, records and service termination policies as appropriate to the counseling setting. This professional information shall be provided to the client in verbal and written forms (i.e., the counseling services agreement). NCCs shall have a reasonable basis for believing that the information provided is understood. NCCs shall document any client concerns related to the information provided in the client’s record.

84. NCCs shall carefully consider ethical implications, including confidentiality and multiple relationships, prior to conducting research with students, supervisees or clients. NCCs shall not convey that participation is required or will otherwise negatively affect academic standing, supervision or counseling services.
Approved by the NBCC Board of Directors: June 8, 2012
2012 National Board for Certified Counselors, Inc. and Affiliates (NBCC)
National Board for Certified Counselors (NBCC) Code of Ethics


Evolution of Social Work Ethics by Mary Rankin, J.D.

The c­hange in a social worker’s approach to ethical concerns is one of the most significant advances in our profession.  Early in the 20th century, a social worker’s concern for ethics centered on the morality of the client, not the ethics of the profession or its practitioners.  Over the next couple of decades, the emphasis on the client’s ethics began to weaken as social workers began developing new perspectives and methods that eventually would be fundamental to the profession, all in an effort to distinguish social work’s approach from other allied health professions. 

The first attempt at creating a code of ethics was made in 1919, and by the 1940s and 1950s, social workers began to focus on the morality, values, and ethics of the profession, rather than the ethics and morality of the patient.  As a result of the turbulent social times of the 1960s and 1970s, social workers began directing significant efforts towards the issues of social justice, social reform, and civil rights.
In the 1980s and 1990s, the focus shifted from abstract debates about ethical terms and conceptually complex moral arguments to more practical and immediate ethical problems.   For example, a significant portion of the literature from the time period focuses on decision-making strategies for complex or difficult ethical dilemmas.   More recently, the profession has worked to develop a new and comprehensive Code of Ethics to outline the profession’s core values, provide guidance on dealing with ethical issues and dilemmas, and also to describe and define ethical misconduct.  Today, ethics in social work is focused primarily on helping social workers identify and analyze ethical dilemmas, apply appropriate decision-making strategies, manage ethics related risks, and confront ethical misconduct within the profession.

The following contains thee key Legal issues for mental health professionals: Tarasoff - Duty to Warn, Duty to Protect; and Mandatory Reporting of Child Abuse

Tarasoff - Duty to Warn, Duty to Protect
Most states have laws that either require or permit mental health professionals to disclose information about patients who may become violent – often referred to as the duty to warn and/or duty to protect. These laws stem from two decisions in Tarasoff v. The Regents of the University of California. Together, the Tarasoff decisions impose liability on all mental health professionals to protect victims from violent acts. Specifically, the first Tarasoff case imposed a duty to verbally warn an intended victim victim of foreseeable danger, and the second Tarasoff case implies a duty to protect the intended victim against possible danger (e.g., alert police, warn the victim, etc.).

Domestic Violence – Confidentiality and the Duty to Warn
Stemming from the decisions in Tarasoff v. The Regents of the University of California, many states have imposed liability on mental health professionals to protect victims from violent acts, often referred to as the duty to warn and duty to protect. This liability extends to potential victims of domestic violence. When working with a client who has a history of domestic violence, a social worker should conduct a risk assessment to determine if whether there is a potential for harm, and take all necessary steps to diffuse a potentially violent situation.

Mandatory Reporting of Child Abuse
All states have laws that identify individuals who are obligated to report suspected child abuse, including social workers – these individuals are often referred to as “mandatory reporters.” The requirements vary from state to state, but typically, a report must be made when the reporter (in his or her official capacity) suspects or has reason to believe that a child has been abused or neglected. Most states operate a toll-free hotline to receive reports of abuse and typically the reporter may choose to remain anonymous (there are limitations and exceptions that vary by state so please review your state’s laws).
- Barker, Robert L. Milestones in the Development of Social Work and Social Welfare, Washington, DC NASW Press, 1998

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 125 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #1
The preceding section contained Codes of Ethics for mental health professionals. Write two case study examples regarding applications of Ethical Principles you feel might be in conflict with national terrorist activities such as the September 11, 2001, attack on the New York World Trade Center. Much fear was generated by these attacks; thus, patient symptoms in many cases were amplified. An anxiety disordered client may have experienced heightened feelings of anxiety and a mood disordered client may have experienced increased depression. These may include Major Depressive Episode, Manic Episode, Mixed Episode, Hypomanic Episode, Major Depressive Disorder, etc. Conflicts with your profession’s code of ethics may arise regarding the therapist’s personal feelings concerning a certain religion or cultural ethnicity related to clients’ viewpoints. Ethical principles of self-determination, cultural competence, conflict of interest, and perhaps personal problems may present some ethical questions in your mind.

Record the letter of the correct answer on the Answer Booklet.

NOTE: sentences and phrases are in bold type, in each Section of this Manual, for the purpose of highlighting key ideas for easy reference.

QUESTION 10: When a client’s condition indicates that there is a clear and imminent danger to the client or others, the certified counselor must do what? To select and enter your answer go to Answer Booklet.

Answer Booklet for this course
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The article above contains foundational information. Articles below contain optional updates.
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