The Gray Area: Ethics in Providing Clinical Services to Deaf and Hard of Hearing Individuals
Debra Guthmann, Ed.D.
Debra S. Guthmann, M.A., Ed.D is director of the Division of Pupil Personnel Services at the California School for the Deaf in Fremont, CA, and the former director and current project director for a long-term training grant at the Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals. Dr. Guthmann has written extensively in this field and presented and trained nationally and internationally regarding various aspects of substance abuse with Deaf and hard of hearing individuals.
Counselors and other service providers face daily ethical dilemmas that involve confidentiality, dual relationships within the Deaf community, boundary issues and questions related to self-disclosure. Most human services professions have ethical guidelines or standards that focus on various areas of professionalism. This article will provide information on issues related to professional competence, moral and legal standards, the use of professional codes of ethics and guidelines, a decision making model, the power differential and appropriate uses of supervision and peer support.
As a profession grows and changes, so do many of its practices and standards. Professionals who work with Deaf and hard of hearing individuals have grown from being a relatively small group of service providers to a full complement of specialists in a wide range of human service areas. No longer is it good enough to be able to simply communicate with consumers; it is essential that counselors, social workers, psychologists, and others understand and accept the social and cultural considerations that consumers who are Deaf bring into the counseling setting. There is more demand for specialized services than ever before as programs related to mental health services, addictions treatment, independent living, education, and recreation continue to emerge.
Through many of these changes, it is important to consider how we as professionals view ourselves and what practices we hold above all others. Most human services professions have ethical guidelines or standards that focus on various areas of professionalism including training, competence, duties, research, community outreach, and moral and legal standards. What do we perceive as our responsibility related to ethical considerations when working within the field of Deafness? Is there a different ethical code for those of us who work with Deaf people? Why is the study of ethics in the provision of services to individuals who are Deaf important?
Ethics comes from the Greek "ethos," meaning "character" or "custom." Plato and Aristotle used this concept to describe their studies of Greek values and ideals. One definition of ethics is,"Doing the right thing because it is the right thing to do" (Solomon, 1984). Aristotle believed that ethics provided guidelines for virtuous action. In his Rule of the Golden Mean, he defined the ethical choice as one that falls between two extremes. For example, trust is the virtue that lies between suspicion and foolish faith. Ethical issues revolve around setting and maintaining professional boundaries. As professionals, we deal with ethical issues and choices on a daily basis. It is important to think about the role of ethics in the human service setting and its implications for both clients and counselors. Counselors and other service providers face daily ethical dilemmas that involve confidentiality, dual roles within the Deaf community, boundary issues and questions related to self-disclosure. Professionals also need to be knowledgeable about their professional code of ethics and guidelines, agency guidelines, appropriate uses of supervision and peer support.
Ethics and Values
Everyone has an internal set of standards of behavior that reflects their own personal value system. The acquisition of this value system is a product of living and growing within a family, culture and society. Professionals need to study the correlation between ethical standards and personal values systems. Further, group and institutional ethical standards must be compared to ones own personal value system for congruency or conflict.
The terms profession and professional may bring different images to mind. Profession is defined as a group of people who share a common body of knowledge, a code of ethics, and a concern for their peers(Bissell, 1994). In athletics, for example, the major difference between the amateur and the professional is that the professional is paid. In contrast, the social and health services contain very few professionals who are more interested in money than in helping people. From another perspective, one major difference between a business and a profession is that a business emphasizes the importance of earning a profit, whereas a human service profession is primarily aimed at rendering service. The Deaf services professional does not work for a boss or for dollars, but for the purpose of serving the client. Success is not measured in profit, but in quality of service.
Legal and Ethical Conflicts
Whether or not a given behavior is legal does not determine whether or not it is ethical. It is possible for legal activities to be unethical, such as the situation of a professional dating a client. The use of marijuana for medicinal purposes in many places would be illegal, but may be viewed as ethical. The potential for conflict between the principles and practice guidelines of psychology and the law is ever present. In some instances, laws are written in ways that do not take into account the nuances or the complexities of psychological practice. In other instances, the standards that are incorporated into some laws may be more appropriate for another profession or set of concerns.
Although adherence to professional ethics has a deeper basis for right and wrong than fear of being arrested or sued, there are times that legal concerns arise. Just because we are threatened with a lawsuit does not mean we are wrong or will lose, but even good people and their colleagues can be successfully sued if they leave themselves liable. We need to reduce liability by reasonably reducing the risk of accidents or incompetent service, and by recording the remedies we adopt so that evidence can be produced in court. There will be times when we must do what we believe is honest and ethical, no matter how it may appear in a court of law. In spite of their best efforts, professionals may feel torn between the need to protect themselves or their institution from litigation and the desire to spare a client unneeded discomfort or expense.
Regardless of the circumstances surrounding a suit, the laws that permit such suits are for the protection of all who interact with the profession. Individuals must conduct themselves in ways that will conform both to the ethical and practical guidelines of the profession and the law, and they must be prepared to defend their decisions if conflicts arise. What should a psychologist do if a client who is diagnosed as having AIDS or is tested positive for HIV reveals that he is continuing to engage in sexual relations without concern for safe sex practices and without telling his partners? If the client gives the actual names of partners, does the psychologists duty to protect others extend to those partners? Does case law (decisions in actual cases) indicate that the psychologist has a legal obligation to warn them even though there are no federal or state laws requiring reporting such instances at this time? Conversely, do laws governing confidentiality prohibit the psychologist from warning the potential victims?
The professional must use his/her own sense of judgment about the issues and concerns inherent in a particular situation. The clinician may act in ways that appear to violate a clients rights, as in the situation of warning a potential victim of a clients violent intentions. They may also place themselves in direct defiance of the law, as in the situation of refusing to provide subpoenaed records in a divorce case when asked for copies of personal notes about one partner when both were treated during therapy.
Professionals are expected by the general public and by members of other professions to have high standards, to be responsible for their own colleagues, and to act with integrity. Ethical accountability applies to all decisions whether they are hard or easy to make, or personal or professional in nature. Ethical responsibility starts with the self; if one has good reasons for a specific decision, and is able to justify that decision within ones self, one is ready to justify and explain that decision to others. One is willing to accept the consequences of his or her decisions. Professionals must accept the consequences of their decisions and actions.
A frequent topic in the literature on ethics for human service providers is dual relationships. Herlihy and Corey (1992) addressed many of the issues relating to dual relationships and provided a variety of insights and perspectives on them. They defined a dual relationship as "when professionals assume two roles simultaneously or sequentially with a person seeking help" (p.3). The issue of dual relationships is especially complicated when a Deaf or hearing person who is actively involved in the Deaf community is working in the profession. That person may be a therapist, social worker, vocational counselor, teacher, substance abuse counselor, administrator, etc. Many issues surface on a daily basis for people working in this profession and living in a community where they socialize with the same Deaf people who are their clients. When dealing with a clinical situation, the dual relationship may exist at the beginning, may develop during treatment, or it may begin after the termination of the clinical relationship with the client .
Although often perceived in only negative terms, dual relationships are not necessarily problematic or unethical. One variable in determining the ethical ramifications of a potential dual relationship is its avoidability (Herlihy & Corey, 1992). In small communities, for example, some form of dual relationship may often be the rule rather than the exception. Refusing to provide counseling to individuals with whom one has another relationship would in these instances prevent people in need from receiving assistance, which would raise other ethical concerns. In the substance abuse field, the recovering counselor may occasionally attend the same Alcoholics Anonymous(A.A.) meetings as former clients who have become a part of the local recovering community, making such occurrences practically unavoidable if the counselor is to continue to attend self-help meetings. The issue of avoidability is included in the consideration of the ethical nature of a given activity and may be a mitigating factor in some situations (Hass & Malouf, 1989). This is especially applicable within the Deaf community.
The greatest potential for harm from a dual relationship, however, may result from the power held, or perceived as being held, by the counselor. Whereas the counseling relationship will eventually come to an end, the power differential may remain indefinitely, adversely affecting any future, non-therapeutic relationship between counselor and client (Haas & Malouf, 1989). Counselors may hold a great deal of power over clients that can potentially lead to exploitation. When exploitation appears in the personal interaction between counselor and client, serious dual relationship problems quickly arise.
Most ethical codes draw strong distinctions between sexual and non-sexual dual relationships. Ethical codes vary in their requirements about the length of time that must pass for another "significantly different" relationship, especially a sexual one, to be permissible(Herlihy & Corey, 1992, p.3). Although the codes considered here prohibit the counselor from having a sexual relationship with a current client, variation occurs in the prohibition of such a relationship with former clients and the length of time that must pass for such a relationship to be permissible (American Counseling Association, 1995; National Association of Alcoholism and Drug Abuse Counselors, 1995). Power issues between Deaf and hearing members of the Deaf community, or between Deaf clients and hearing therapists call for even more careful examination.
Current ethical standards do not include specific references to potentially difficult situations that face recovering counselors, especially in the area of dual relationships. The standards do, however, give general guidelines that the counselor may use to draw conclusions about his or her particular situation or ethical dilemma. Seeking supervision or consultation is, of course, another wise option for the counselor in need of an objective opinion about a dual relationship, or a potential one, involving a client.
Professional boundaries can be defined as the line that separates where the counselors influence ends and the client's autonomy begins. It is the emotional and physical space that gives clients room to focus on their own healing and not on the counselor. Boundaries dictate counselors' interactions with clients and serve as the parameters that keep the professional as objective as possible.
Most professionals have experienced boundary dilemmas and boundary violations. Our responsibility is to maintain healthy boundaries. Confucius said "where there is power, ethics must follow." Many clients are vulnerable when they seek our help; counselors hold the power, and must set and enforce boundaries to benefit and protect the client. When ensuring that appropriate boundaries are in place, we need to remember to create the emotional space that gives our clients room to focus on their own healing. Boundaries put a limit on a professionals power so clients arent hurt. They are fluid and change depending on the role we play and the clients vulnerability. Some boundary issues may be situational and interpreted differently by each person. One way to better understand the different kind of boundary issues that come up is to talk about different situations that might arise. When discussing professional boundaries, the issue of self-disclosure must be addressed. Within the counseling session, the question of self-disclosure also raises dual relationship issues. Information that the counselor discloses may introduce new elements to the counseling relationship. In the context of Deaf culture, a certain amount of self-disclosure would be culturally appropriate. Too much, however, might compromise good professional judgement.
Our personal values affect our ethical boundary decision making. We all have boundary questions and have to recognize this and talk to other professionals about this. For example, what ethical issues arise when a client gives a therapist a gift? How do you handle the situation if you get a gift? How do you acknowledge the need for clients to give back something? What are the ethical dilemmas that this raises? First you get a rose, then a dozen roses, then a rose bush, then an offer to tend to your rose garden. Where and when should professionals draw the line. The issue of gift giving is further complicated when you add factors such as cultural differences. For example, if you turn down a small gift in some cultures, this may mean total rejection of the individual or can be interpreted as lack of respect. Setting and maintaining appropriate boundaries is complicated.
Sometimes we think of boundaries in terms of what areas they affect. These areas may include physical, emotional, psychological or sexual transgressions. Examples of each are listed below(McGuire, 1996):
A. Physical Boundary Transgressions
- A client comes into your office and picks up papers on your desk.
- You are meeting with a co-worker and a colleague opens the closed door, sits down, and begins talking about a crisis.
- Your supervisor hugs you without your permission after a negative performance review.
B. Emotional Boundary Issues
- A client shares her memories of sexual abuse with members of the support staff in a crowded waiting room.
- A staff member shares the details of her divorce during a staff meeting.
- A supervisor acts as therapist for a supervisee.
C. Psychological boundary Issues
- A white client calls a black client a racist name.
- A staff member shames a co-worker by indirect criticism, ridicule, or sarcasm.
- Your supervisor answers the phone three times during a meeting that you requested.
D. Sexual Boundary Issues
- A client winks at you seductively during group therapy.
- A staff member says, "Your present position - the way youre bending over - makes me think of my wild weekend. Let me tell you about it."
- A supervisor wants to know details about your clients sex lives. Each time you try to discuss other relevant information, your supervisor steers the topic back to sex.
Boundaries are complex and our personal values affect our ethical boundary decision making. We all have boundary questions and have to recognize this and talk to other professionals about them. Often context, not content, determines the appropriate boundary. For example, if you were an outpatient therapist and you went to a movie with a client, you would violate several professional boundaries. Yet, if you were a professional in a residential setting, it may be quite appropriate to go to movies with clients as part of the program.
The American Psychological Association (APA) struggled between two ethical positions regarding contact between former clients and therapists. They recommended a waiting period of perhaps two years of no contact, or to forbid absolutely all romantic entanglements whatsoever between therapist and former client. They finally decided to recommend no sexual relationships, regardless of time(no phone calls, no greeting cards) after some initial reluctance of appearing too rigid on the issue. Experience shows that such relationships are rarely, if ever, healthy.
The Power Differential
Often boundaries become clouded or get crossed because we do not remember or understand the premise behind a particular boundary. Why do we have boundaries concerning gifts from clients when we accept gifts from friends? There is a power differential, and it is important to remember that a professional helping relationship is asymmetrical -- the interactions between the two parties are not equal. We are in a position of greater authority and clients are vulnerable. While we get paid, they dont. Although we know about their personal pain, they do not know about ours. The following scenario reminds us what it's like to be a vulnerable client(McGuire, 1996).
You are in the doctors office. You have been sitting in the waiting room a long time; it is now 9:30, and your appointment was for 9:00. You are feeling nervous because you know something is wrong with you but youre not sure what. Perhaps you are also in pain.
You finally go to up to the receptionist and ask. "How much longer will it be? My appointment was for 9:00, and I have a 10:30 meeting I have to attend." "It wont be much longer, " he answers blankly.
Do you scream at the receptionist? No, because you are dependent on the doctor for help, and showing your true feelings might jeopardize your care. Do you say: "Forget it!" And leave? No, because you need the doctors expertise. You cant get better on your own.
So, you sit down. Maybe you feel like crying (or screaming). Your life feels out of your control. Youre behind on deadlines at work because of this illness...and yet you cant take care of this with your own resources, so you have to stay...and wait...and wait. Finally, your train of thought is derailed by a voice: "Excuse me, the doctor will see you now."
With relief you get up and go into the examining room, where you wait another fifteen minutes. While waiting, you make a list of questions you want to ask about your illness.
The door opens and the doctor flies in with the comment, "What a crazy day! Lets see what we can do for you." She immediately begins to read your chart, making no eye contact with you.
The doctor proceeds to ask you questions, which you try to answer clearly...but it really is complicated, and youre confused as to when the symptoms show up or even what they are. You try to explain all this but she cuts you off. With anger rising, you find yourself thinking, Why cant I explain this? Its probably not important.
You ask three of your ten questions. You dont quite understand some of the answers, and when you ask for clarification, youre still not sure if you understand but you drop it and dont ask the other questions.
The doctor gives you a possible diagnosis, although shes not sure, and prescribes some medication. She also refers you to a specialist whose office is thirty miles away.
After the appointment, while youre standing in the clinic parking lot, you realize you dont even know what the medications side effects are. Youre fuming. "Why didnt I stand up for myself! I am the one whos paying her. Whats wrong with me? I dont have time to see another specialist!"
The scenario has been simplified in several ways. It does not reflect the following factors that may be present when the concern is psychological :
- You probably have a stronger ego than many clients in therapy.
- The scenario did not involve a chronic condition requiring you to see helping professionals routinely (daily, weekly, or monthly).
- Your job, family cohesion, or place of residence were not affected by the professionals involvement.
- You did not exhibit an illness with social and personal stigma attached.
- You were not in crisis.
There is a fine line between appropriate and inappropriate boundary and power differential issues. A professional should be close enough to the client to be sensitive to and respectful of their emotions, but not overly involved. The professional should also be distant enough to allow clients the autonomy they need to heal. Clients need to feel protected and supported in their vulnerability, as well as empowered enough to effect their own recovery. It is easy for the lines to change, moving toward inappropriate boundary and power differentials. If we, as professionals, are uncomfortable with our power, we may shrink the boundary space and reposition ourselves as buddies or peers. We come in too close, and clients may feel confused, angry, or unsafe. They know that we have more power, even though we are acting as if we dont. If we have been too close, we might react by moving too far away. We forget clients vulnerability and abandon them. We remove ourselves from the complex emotional relationship and thus act outside it. We may begin to think of clients as walking diagnoses - objects to be acted upon. Clients may feel alone, unheard, confused, or unsafe. For some Deaf clients, whose experience in their family of origin was of being "unheard" or left out, this can be particularly harmful.
Common Elements of Ethics Codes
When was the last time you reviewed your code of ethics? Is there one available to serve your professional group, or have you developed your own guidelines? Do you have a copy close at hand that you can pull out whenever you face an ethical dilemma? Ethical codes are minimal dictates. In helping relationships, they serve as guidelines for reducing harm to clients that can result from the power differential. Our ethical codes -- national, state, and agency -- protect the integrity of care: clients needs come first. "Codes are covenants that say we will give and not take."(APA, 1981). The purpose of a code of ethics is to guide professionals in helping clients and their families while behaving in a fair and decent way to colleagues. Examples of organizations that have codes of ethics include; the Registry of Interpreters for the Deaf, and the American Psychological Association(APA). The APA developed the Ethical Principles of Psychologists which is a code of conduct or ethical system, formulated by a select group of psychologists based on their experience in the field, passed by the APA and acknowledged and accepted through the act of joining the APA by psychologists who are members of the organization.
Professional ethics are standards of behavior that have evolved over time to reflect the professions desire to insure the well-being of its clients. They are expressed in a formalized code of behavior which describes the principles that are important to the profession. More importantly, they define the forms of behavior that are morally desirable by the profession in its service to consumers. They are developed because the client is the recipient of a service and therefore, as in any profession, there is the potential for abuse.
Professional codes of ethics should include the following principles:
- Avoid dual relationships that exploit clients-socially, financially, or sexually.
- Avoid discriminatory behaviors.
- Restrict treatment to your areas of competence. Know your limitations and refer the client to another professional when it is in the clients best interest.
- Respect and safeguard the autonomy of clients.
- Respect the rights, views, and clinical practices of other professionals.
- Hold colleagues accountable for ethical practices.
- Continue to grow professionally.
- Consult with other professionals when circumstances dictate. When giving direct client care, get clinical supervision.
- Adhere to all state and federal laws that govern client care, such as laws that relate to confidentiality and maltreatment of vulnerable adults.
The client needs protection during the receipt of professional service for the following reasons: The profession is in control of its own practice; the consumer may not be able and should not be required to judge what is professional and unprofessional conduct; the profession must have a basis upon which to defend its practices. Professional ethics describe "what ought to be" in a world of "what is." They define the professions belief of how its member should behave, not necessarily how they do behave. professional ethics aim to provide professionals with a standard of behavior to which they must aspire. And while they may provide the goal of professional behavior, and not the description, they serve as a guide for all professionals of good conscience.
Initial discussions of boundaries in a therapeutic setting frequently refer to the relationship between the counselor and the client. However, each professional must examine his or her own history and practice to be aware of other boundary issues that may emerge. It is important to keep boundaries from the past in the past. One's personal past affects how boundaries are set in the present. One's family of origin had its own boundary rules and problems. These factors influence the present perspective. Taking inventory, a relevant question to ask is Whats in my suitcase? That is, what personal "baggage" do you carry and how might it influence your current ethical choices? Be aware of vulnerability and things happening in your life. A social worker answers:
My boundary problem is triangles - when I was a kid I was expected to be the message carrier between my three siblings and my parents. It was my job to address my sisters hurts and grievances. I spent a lot of time trying to get my parents to change and respond. Because of this role, I have to be careful at work. Its easy for me to create triangles between angry or hurt staff and their supervisor. With me in the middle as message carrier and problem solver. I can get so caught up that Im late for client appointments.
Another example might be a Deaf therapist whose own unresolved issues with their hearing parents affect how that person perceives his/her Deaf clients' relationships with their parents, or a hearing therapist whose unresolved issues with his/her Deaf parents color their perceptions of Deaf clients who have hearing children.
In order to keep a system focused on client care, we need to also monitor and maintain our boundaries with co-workers. When youre angry with a colleague or distrust a co-worker, where is your energy going? The amount of energy we expend in self protection, anger, and indirect fighting with co-workers takes away from what we can give to our clients-immediately and in the long term.
There are many kinds of relationships going on at any worksite. Overlapping roles with co-workers made boundary-setting even harder. Co-workers may be related to each other or we have social relationships with peers. A supervisor might have once been a peer, but is still a close friend. It is difficult to approach a co-worker with boundary concerns. This action becomes even more difficult when layers of relationships exist among the staff. Since a dual relationship exists when one person interacts with another in more than one capacity at the same time, this suggests the possibility of an ethical compromise or conflict of interest. We gain by making dual relationships explicit. We can decide if such relationships energize or deplete the staff by positively or negatively affecting the team, and thus clients.
Consider the example of two co-workers who play on a softball team after work. They dont talk about work outside of the job. How might this relationship be viewed by the rest of the staff? Would their colleagues know about the boundaries that have been set? Will they trust that the boundaries are upheld? Even if the dual relationship is explicit, would their colleagues feel that the relationship is affecting work? Can they raise their concerns?
We cant keep our clients needs first unless we first meet our own needs. When we take care of ourselves, we can better take care of clients. By upholding personal boundaries between clients, colleagues, and supervisors, we get our professional needs met so that we can focus on clients. If we do not take the time and energy to fulfill our personal needs outside of work, we will fulfill them at work. By upholding boundaries, we meet personal needs so that we dont ask clients to meet them.
- Are you working regular overtime?
- Are your personal relationships "fifty-fifty?" That is, do you get as much from these relationships as you give?
- Do you take all of your vacation days? Do you have friends outside of your work?
- Do you have friends who are not in the helping fields? Do you play as hard as you work?
- Do you really leave work at work? Are you having fun in your life?
- Who are your mentors? What characteristics of theirs do you admire?
Different professions have to consider unique issues that may arise. For example, counselors who are in drug or alcohol recovery need to examine all relevant codes and regulations that apply, and be careful about how they plan to use self-disclosure of their personal recovery. Each person should establish their own personal code of ethics that they adhere to at all times.
Maintaining confidentiality is one of the core principles guiding human service professionals. Private information divulged by clients in the course of treatment may never be used or repeated in any way that can be identified with that individual. Privileged communication refers to the practice of excusing many professionals, such as physicians, nurses, clergy members, psychologists, and others from being compelled to testify in court. The principle that the relationship between patients and health care providers is confidential dates back to the Hippocratic oath. The medical privilege promotes openness on the part of the patient to make a complete disclosure of medical history and symptoms. This principle holds true for human service professionals as well. What is privileged or protected is the information given verbally by the client, any data gathered through the course of providing services to the client and any documentation which results from the client/provider relationship. The privilege to release this information whether verbally or in written or electronic form beyond the client/provider relationship belongs to the client. With some exceptions under the law, only the patient may waive the privilege to allow the release of information to a party outside of the client/provider relationship. Since Hippocrates, the parameters of this privileged have been defined, for the most part, by state statute and common law. For example, commonly the privilege is not automatically waived for health care and human service providers to provide testimony in a legal matter. Patient or client authorization may be needed.
Maintaining confidentiality means that there is no discussion or detail provided about a client in any form without the express permission of that individual. In reality, however, maintaining complete confidentiality may be impossible in some situations Furthermore, certain laws and ethical considerations infringe on a client's right to confidentiality. Child abuse reporting laws, for example, require the breach of confidentiality, as does the Tarasoff ruling, which mandates notification of intended victims of clients. When there is risk of suicide, most mental health professionals agree that taking steps to prevent suicide supersedes a client's right to confidentiality. Both the needs of the client and the appropriate needs of others must be met. If information about a client needs to be shared, the question of how much to share will arise. It may be impossible to obtain specific consent from each client every time the need to consult arises. It is also unrealistic to expect that a general consent can be given because some information may not fall into the categories that such a consent is intended to release. Thus, sound judgment must be used in determining what information will be shared with the patient and also with colleagues.
The use of the telephone may challenge even the most prudent counselor. In some communities, referring agencies may inadvertently give identifying information about a client without realizing it. Client names should never be shared on the phone. When using a TTY, the individual on the other end of the phone may not be the person they say they are. To verify a caller's identity, previously arranged passwords may be used.
Human service providers may be uncertain about maintaining records of contact with clients. One must consider the level of detail to include to support the treatment plan, but balance it with the amount of information needed to fulfill the reporting requirements of insurance companies, government agencies, elements of the legal system, and other entities to whom there are obligations.
Maintaining confidentiality may be challenged when a client engages in illegal or threatening behavior. The professional is faced with the dilemma of determining what action he/she should take to protect the well-being of others and to comply with the law. States also have varying laws of responsibility given for reporting purposes. Protecting the rights of those deemed incompetent or those who depend upon one for protection because they are vulnerable is an important responsibility. Answers should be based on such questions as What rights are involved? Whose rights take priority? Why? What values are at stake? Confidentiality is especially important within the Deaf community, where reputations follow people for life, and characteristics of clients may identify them to others.
Being a competent professional means having the knowledge, skills, and abilities necessary to perform a constellation of tasks relevant to that profession as well as understanding when it is appropriate to provide services or to refer a client. The more demanding a profession is, the greater the knowledge and number of skills and abilities that will be required and the more likely it will be that a professional will not be competent to provide service in all areas of the profession. Formal training is one way to obtain competency, and experience and continuing education are the primary means for expanding skills and becoming more effective. Having a strong belief in a particular methodology or way of life can strengthen ones competence to practice. However, ones beliefs and attitudes may begin to overshadow objectivity, and one may need to step back and reevaluate how one is providing services. Self-care and self-awareness are two of the competent psychologists most valuable tools. Personal beliefs and attitudes, physical and emotional fatigue, personal problems, and other concerns of the professional can dramatically affect how he/she provides services.
If a person is unable to view a patients concerns objectively, the effectiveness of the professionals decision-making can be reduced. He/she may even do more harm than good. A competent professional maintains his/her well-being by seeking physical and psychological care when it is needed, by being alert to the signs of stress and burnout, and by evaluating the decisions he or she has made in relation to the needs of his or her clients.
Another element of competence is knowing which services and treatments should be provided by other professionals and knowing who can provide those services. Each professional cannot provide every service needed by every client. If a person is recommending another service which will be provided by another professional, he/she needs to understand the implications for making the referral. He/she should understand enough about the services required to provide an appropriate referral or to provide guidance on how to find those services and should be able to help the client understand what to expect from the professional providing the service.
Peer consultation is one of the most important resources for maintaining and increasing competence. Within the limits of confidentiality, discussing a specific concern with more experienced colleagues about how one should provide a service can help clarify what action to take and will help resolve personal conflict. Peer consultation sharpens ones professional skills by challenging ones ability to explain the concern, providing a different viewpoint, the benefit of other experiences and, in some cases, an opportunity to correct treatment errors before a client is harmed.
Professionals also have a responsibility to monitor their colleagues competency to practice. This may seem presumptuous or even inappropriate to some, but being aware of the competence of ones colleagues allows one to identify when a professional is not providing the services he/she claims to provide in an appropriate manner. When such abuses occur, it can be possible to correct them through peer pressure. It is possible to offer a colleague critique and support, and obtain his/her cooperation. However, in order to eliminate abuse it may become necessary to file a complaint against the person with the licensing board.
Professionals recognize that not everyone is able to do everything, but where are the limits? Many skills can be learned, others perhaps never can be. In many parts of the country, there still may be no legal constraint on credentials for certain professions. Supervision of counselors by clinical professionals is imperative. It is considered irresponsible if a person isnt supervised appropriately.
Sometimes, it is obvious that counselors are being asked to undertake problems beyond their abilities. Does it make sense to ask a counselor whose only expertise at marriage counseling may be derived from the misery of his or her own three failed marriages? Sometimes counselors deal with their personal prejudices and other limitations by denying that problems exist. One counselor, when asked about his management of a clients severe anxiety over failure in sexual performance, was eager to explain that it was too early in sobriety to discuss the problem, and that time and physical healing would automatically resolve the difficulty. Some individuals may have discomfort with other races and ethnic groups. No one is comfortable with every group, or sensitive to or even informed about everyones needs. We need to be aware of what we can and cannot do, and assume responsibility for getting clients we cant help into the best situation available for their particular needs. The real failure is denying there is a problem, thus leaving the problem unresolved and preventing clients from getting help that may be available from someone else.
Going beyond ones competence is forbidden by all ethical codes. Limitations may stem from a lack of training or experience, unfamiliarity with the area in which the problem falls, the denial of the problem as described above, the difficulty or complexity of the case, or interpersonal problems between patient and counselor. Knowing ones limitations and being able to ask for assistance is part of each persons professional obligation. Part of being a responsible professional is the ability to restrict practice to ones area of training and competence. It is important to know when it is appropriate to make referrals to other agencies for services one cannot or chooses not to offer. The temptation is to want to handle everything alone. A real expert knows when to ask for help and where to get it.
Professional development and a constant upgrading of skills and knowledge is essential. Regular reading of professional journals and new books, attendance at conventions and workshops, and taking additional courses are some ways to keep up with current information and practices. Competent providers are people who:
- Receive routine clinical supervision and study their codes of ethics.
- Accept the complexity of maintaining boundaries.
- Admit when they have boundary dilemmas.
- Wrestle with these dilemmas and discuss them with colleagues.
Ethical Decision Making
One of the main frustrations in dealing with ethical dilemmas is that there is often no one right answer. A decision to act in a given way may trigger other actions that also need to be addressed. Even the most experienced professionals may encounter self-doubt when facing challenging dilemmas. If one does not have or know of a professional code of ethics to follow, these situations can become even more upsetting.
When considering the area of student services in higher education, Kitchener (1985) suggested five ethical principles to guide individuals in their work with students. These principles are to (1) respect autonomy, (2) do no harm, (3) help others, (4) be just, and (5) be trustworthy. In comparison with the complex codes of ethics established by some professions, these five principles seem rather simple at first glance. However, they can offer flexibility and permit consistency without being rigid. Because real-life situations may be unpredictable, it is possible that conflicts among the five principles may result and that the practitioner may need to consider the situation from several perspectives before taking action.
Adhering to Ethical Codes
Below is a suggested process to assist individuals when making ethical decisions(McGuire, 1996).
1. Review your code of ethics and legal mandates.
Laws are based on specific actions in specific situations. In contrast, ethics involve contextual considerations -- the various relationships involved and the ripple effects from any decision. For this reason, legal mandates can only serve as one piece in an ethical decision. Many states have a legal mandate that forbids a sexual relationship between provider and client for two years after therapy terminates. But from an ethical standpoint, other questions remain. Is it okay to have a sexual relationship with an ex-client in three years? Is it ever okay to have a sexual relationship with an ex-client? Is a client ever an ex-client and how do you decide?
2. Seek input from a second party.
These invisible boundary lines begin to take shape when you look through another persons eyes. Supervision is an essential source of objective feedback. Another suggestion is to call your professional board anonymously to ask about specific situations.
3. Determine the values (motives) involved.
Our values become hidden motives that influence all our decision. It is important to make them conscious to reassess them and reframe them if necessary. Recognize the cultural and agency values related to the situation.
4. Evaluate the long-term effects of your choices on your client.
Whose needs will be met? Whose interests will be served? Are there short term effects to consider? How will present and future clients be affected by your choice? How about the community and profession as a whole?
We have discussed several common elements of professional ethics as well as a number of specific areas of ethical concern for helping professionals in general and for those who work in the Deaf community in particular. Professionals in the human services field, especially those working with Deaf and hard of hearing clients, can only expect to face perplexing dilemmas since we have different standards and feelings about where each of us must draw the line with clients. Some behavior is so clearly unethical and unacceptable, it requires no discussion. Other actions lie in the gray areas where rationalization can make questionable practices seem all right if they are not examined closely. When considering the ethics of a given situation, we need to always think of our clients first.
It is important for professionals to uphold their code of ethics, as well, as personal boundaries between clients, colleagues and supervisors. If professionals in the human services field get their own professional needs met outside of their work setting, they will be better able to focus on clients. If professionals do not take the time and energy to fulfill their personal needs outside of work, people will try to get those needs met on the job.
A few common themes underlie our discussion of ethics. First, self-awareness and acknowledgement of our own inner conflicts, strengths, limitations, values, beliefs and needs, is essential to an ethical practice. Second, clinical consultation, through supervision and discussions with peers, is vital to maintaining a strong set of ethics. And third, there is no substitute for a good working familiarity with the laws and codes of ethics that govern one's particular profession.
Whether the question is one of role, relationships, boundaries, confidentiality or referral, a professional must first acknowledge that there is an ethical question, and be able to define the issue clearly. He or she must then be willing to explore his or her own conscious or unconscious motives, and all the possible long and short-term consequences of the issue. Next, the professional must review existing laws and codes of ethics, and consult with colleagues and supervisors to obtain objective perspectives on the issue.
It is a rigorous process, but our clients, and our profession, deserve no less.
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American Psychological Association. (1981). Ethical Principles of Psychologists. American Psychologist, 36(6), 633-638.
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Hass, L. & Malouf , J.(1989). Keeping up the good work: A practitioners guide to mental health ethics. Sarasota, FL: Professional Resource Exchange.
Gish, Sandra (1990). Ethics and Decision making for Interpreters in Health Care Settings. St. Marys Campus, The College of St. Catherine.
Herlihy, B., & Corey, G. (1992). Dual relationships in counseling. Alexandria, VA: American Association for Counseling and Development.
Kitchener, K. S. (1985). Ethical principles and ethical decisions in student affairs. In H. J. Canon & R. D. Brown (eds.), Applied Ethics in Student Services. New Directions for Student Services, 30, San Francisco: Jossey-Bass, Inc.
McGuire, S. (1996). Subtle Boundary Dilemmas: Ethical Decision Making for Helping Professionals. Hazelden Educational Materials, Center City, Minnesota.
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