Incident Stress Debriefing After A Line Of Duty Death
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 Seans 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 wasnt right, that Sean was missing?
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.
Whats it like to lose a member of your Engine? How is the firehouse
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 Seans 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.
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 Michaels 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.
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
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 Jons
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. Its 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
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 Michaels 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.
American Psychological Association
Ethical Principles of Psychologists and Code of Conduct - Excerpt
Principle C: Integrity
Psychologists seek to promote accuracy, honesty and truthfulness in the science, teaching and practice of psychology. In these activities psychologists do not steal, cheat or engage in fraud, subterfuge or intentional misrepresentation of fact. Psychologists strive to keep their promises and to avoid unwise or unclear commitments. In situations in which deception may be ethically justifiable to maximize benefits and minimize harm, psychologists have a serious obligation to consider the need for, the possible consequences of, and their responsibility to correct any resulting mistrust or other harmful effects that arise from the use of such techniques.
Principle E: Respect for People’s Rights and Dignity
Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making. Psychologists are aware of and respect cultural, individual and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language and socioeconomic status and consider these factors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices.
2.01 Boundaries of Competence.
(a) Psychologists provide services, teach and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study or professional experience.
(b) Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies.
(c) Psychologists planning to provide services, teach or conduct research involving populations, areas, techniques or technologies new to them undertake relevant education, training, supervised experience, consultation or study.
(d) When psychologists are asked to provide services to individuals for whom appropriate mental health services are not available and for which psychologists have not obtained the competence necessary, psychologists with closely related prior training or experience may provide such services in order to ensure that services are not denied if they make a reasonable effort to obtain the competence required by using relevant research, training, consultation or study.
(e) In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients and others from harm.
(f) When assuming forensic roles, psychologists are or become reasonably familiar with the judicial or administrative rules governing their roles.
3.01 Unfair Discrimination.
In their work-related activities, psychologists do not engage in unfair discrimination based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, socioeconomic status or any basis proscribed by law.
3.04 Avoiding Harm.
(a) Psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm where it is foreseeable and unavoidable.
(b) Psychologists do not participate in, facilitate, assist, or otherwise engage in torture, defined as any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person, or in any other cruel, inhuman, or degrading behavior that violates 3.04(a).
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.
3.05 Multiple Relationships.
(a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.
A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.
Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.
(b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code.
(c) When psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur. (See also Standards 3.04, Avoiding Harm, and 3.07, Third-Party Requests for Services.)
6.05 Barter with Patients/Clients.
Barter is the acceptance of goods, services, or other nonmonetary remuneration from clients/patients in return for psychological services. Psychologists may barter only if (1) it is not clinically contraindicated, and (2) the resulting arrangement is not exploitative. (See also Standards 3.05, Multiple Relationships, and 6.04, Fees and Financial Arrangements.)
3.08 Exploitative Relationships.
Psychologists do not exploit persons over whom they have supervisory, evaluative or other authority such as clients/patients, students, supervisees, research participants and employees. (See also Standards 3.05, Multiple Relationships; 6.04, Fees and Financial Arrangements; 6.05, Barter with Clients/Patients; 7.07, Sexual Relationships with Students and Supervisees; 10.05, Sexual Intimacies with Current Therapy Clients/Patients; 10.06, Sexual Intimacies with Relatives or Significant Others of Current Therapy Clients/Patients; 10.07, Therapy with Former Sexual Partners; and 10.08, Sexual Intimacies with Former Therapy Clients/Patients.)
6.07 Referrals and Fees.
When psychologists pay, receive payment from or divide fees with another professional, other than in an employer-employee relationship, the payment to each is based on the services provided (clinical, consultative, administrative or other) and is not based on the referral itself. (See also Standard 3.09, Cooperation with Other Professionals.)
10.01 Informed Consent to Therapy.
(a) When obtaining informed consent to therapy as required in Standard 3.10, Informed Consent, psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers. (See also Standards 4.02, Discussing the Limits of Confidentiality, and 6.04, Fees and Financial Arrangements.)
(b) When obtaining informed consent for treatment for which generally recognized techniques and procedures have not been established, psychologists inform their clients/patients of the developing nature of the treatment, the potential risks involved, alternative treatments that may be available and the voluntary nature of their participation. (See also Standards 2.01e, Boundaries of Competence, and 3.10, Informed Consent.)
(c) When the therapist is a trainee and the legal responsibility for the treatment provided resides with the supervisor, the client/patient, as part of the informed consent procedure, is informed that the therapist is in training and is being supervised and is given the name of the supervisor.
10.02 Therapy Involving Couples or Families
(a) When psychologists agree to provide services to several persons who have a relationship (such as spouses, significant others, or parents and children), they take reasonable steps to clarify at the outset (1) which of the individuals are clients/patients and (2) the relationship the psychologist will have with each person. This clarification includes the psychologist's role and the probable uses of the services provided or the information obtained. (See also Standard 4.02, Discussing the Limits of Confidentiality.)
(b) If it becomes apparent that psychologists may be called on to perform potentially conflicting roles (such as family therapist and then witness for one party in divorce proceedings), psychologists take reasonable steps to clarify and modify, or withdraw from, roles appropriately. (See also Standard 3.05c, Multiple Relationships.)
10.04 Providing Therapy to Those Served by Others
I10.04 Providing Therapy to Those Served by Others
In deciding whether to offer or provide services to those already receiving mental health services elsewhere, psychologists carefully consider the treatment issues and the potential client's/patient's welfare. Psychologists discuss these issues with the client/patient or another legally authorized person on behalf of the client/patient in order to minimize the risk of confusion and conflict, consult with the other service providers when appropriate, and proceed with caution and sensitivity to the therapeutic issues.
- American Psychological Association (APA). (2017, January 1). Ethical Principles of Psychologists and Code of Conduct. Retrieved from http://www.apa.org/ethics/code
Psychologist, do you know how your professional Code of Ethics
differs from your Staffs’ Professional Code of Ethics?
National Association of Social Workers Code of Ethics Excerpts
1.06 Conflicts of Interest
(a) Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers should inform clients when a real or potential conflict of interest arises, and take reasonable steps to resolve the issue in a manner that makes the client's interests primary and protects client's interests to the greatest extent possible. In some cases, protecting client's’ interests may require termination of the professional relationship with proper referral of the client.
(b) Social workers should not take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests.
(c) Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.)
(d) When social workers provide services to two or more people who have a relationship with each other (for example, couples, family members), social workers should clarify with all parties which individuals will be considered clients and the nature of social workers’ professional obligations to the various individuals who are receiving services. Social workers who anticipate a conflict of interest among the individuals receiving services or who anticipate having to perform in potentially conflicting roles (for example, when a social worker is asked to testify in a child custody dispute or divorce proceedings involving clients) should clarify their role with the parties involved and take appropriate action to minimize any conflict of interest.
(e) Social workers should avoid communication with clients using technology (such as social networking sites, online chat, e-mail, text messages, telephone, and video) for personal or non-work-related purposes.
(f) Social workers should be aware that posting personal information on professional Web sites or other media might cause boundary confusion, inappropriate dual relationships, or harm to clients.
(g) Social workers should be aware that personal affiliations may increase the likelihood that clients may discover the social worker’s presence on Web sites, social media, and other forms of technology. Social workers should be aware that involvement in electronic communication with groups based on race, ethnicity, language, sexual orientation, gender identity or expression, mental or physical ability, religion, immigration status, and other personal affiliations may affect their ability to work effectively with particular clients.
(h) Social workers should avoid accepting requests from or engaging in personal relationships with clients on social networking sites or other electronic media to prevent boundary confusion, inappropriate dual relationships, or harm to clients.
1.09 Sexual Relationships
(a) Social workers should under no circumstances engage in sexual activities or sexual contact with current clients, whether such contact is consensual or forced.
(b) Social workers should not engage in sexual activities or sexual contact with clients’ relatives or other individuals with whom clients maintain a close personal relationship when there is a risk of exploitation or potential harm to the client. Sexual activity or sexual contact with clients’ relatives or other individuals with whom clients maintain a personal relationship has the potential to be harmful to the client and may make it difficult for the social worker and client to maintain appropriate professional boundaries. Social workers—not their clients, their clients’ relatives, or other individuals with whom the client maintains a personal relationship—assume the full burden for setting clear, appropriate, and culturally sensitive boundaries.
(c) Social workers should not engage in sexual activities or sexual contact with former clients because of the potential for harm to the client. If social workers engage in conduct contrary to this prohibition or claim that an exception to this prohibition is warranted because of extraordinary circumstances, it is social workers—not their clients—who assume the full burden of demonstrating that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally.
(d) Social workers should not provide clinical services to individuals with whom they have had a prior sexual relationship. Providing clinical services to a former sexual partner has the potential to be harmful to the individual and is likely to make it difficult for the social worker and individual to maintain appropriate professional boundaries.
1.10 Physical Contact
Social workers should not engage in physical contact with clients when there is a possibility of psychological harm to the client as a result of the contact (such as cradling or caressing clients). Social workers who engage in appropriate physical contact with clients are responsible for setting clear, appropriate, and culturally sensitive boundaries that govern such physical contact.
- National Association of Social Workers. (2017). NASW Code of Ethics. Retrieved from https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English
American Association for Marriage and Family Therapy Excerpts
The Board of Directors of the American Association for Marriage and Family Therapy (AAMFT) hereby promulgates, pursuant to Article 2, Section 2.01.3 of the Association's Bylaws, the Revised AAMFT Code of Ethics, effective January 1, 2015.
1.3 Marriage and family therapists are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation. Such relationships include, but are not limited to, business or close personal relationships with a client or the client’s immediate family. When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists document the appropriate precautions taken.
1.4 Sexual intimacy with current clients or with known members of the client’s family system is prohibited.
1.5 Sexual intimacy with former clients or with known members of the client’s family system is prohibited.
1.6 Marriage and family therapists comply with applicable laws regarding the reporting of alleged unethical conduct.
1.7 Marriage and family therapists do not abuse their power in therapeutic relationships.
1.8 Marriage and family therapists respect the rights of clients to make decisions and help them to understand the consequences of these decisions. Therapists clearly advise clients that clients have the responsibility to make decisions regarding relationships such as cohabitation, marriage, divorce, separation, reconciliation, custody, and visitation.
1.9 Marriage and family therapists continue therapeutic relationships only so long as it is reasonably clear that clients are benefiting from the relationship.
1.10 Marriage and family therapists respectfully assist persons in obtaining appropriate therapeutic services if the therapist is unable or unwilling to provide professional help.
- American Association for Marriage and Family Therapy. (2015, January 1). Code of Ethics. Retrieved from http://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/Code_of_Ethics.aspx
National Board for Certified Counselors Code of Ethics Excerpts
The National Board for Certified Counselors (NBCC) provides national certifications that recognize individuals who have voluntarily met standards for general and specialty areas of counseling practice. Counselors certified by NBCC may also identify with different professional associations and are often licensed by jurisdictions that promulgate standards of behavior. Regardless of any other affiliation, this Code of Ethics is applicable to all NBCC applicants and National Certified Counselors (NCCs).
This Code establishes the minimum ethical behaviors and provides an expectation of and assurance for the ethical practice for all who use the professional services of NCCs. Furthermore, it provides an enforceable set of directives and assures a resource for those served in the case of a perceived violation.
NCCs are required to adhere to all of the directives.
Sanctions of applicants and credential holders under this Code are issued by NBCC only if the provisions of the NBCC Code of Ethics are found to have been violated.
NCCs take appropriate action to prevent harm.
1. NCCs, recognizing the potential for harm, shall not share information that is obtained through the counseling process without specific written consent by the client orlegal guardian except to prevent clear, imminent dangerto the client or others or when required to do so by a court order.
2. NCCs shall respect client’s privacy and shall solicit only information that contributes to the identified counseling goals.
3. NCCs generally shall not accept goods or services from clients in return for counseling services in recognition of the possible negative effects, including perceived exploitation. NCCs may accept goods, services or other nonmonetary compensation from clients only in cases where no referrals are possible or appropriate and if the arrangement is discussed with the client in advance, is an exchange of a reasonable equivalent value, does not place the counselor in an unfair advantage, is not harmful to the client or their treatment and is documented in the counseling services agreement.
4. NCCs shall not accept gifts from clients except in cases when it is culturally appropriate or therapeutically relevant because of the potential confusion that may arise. NCCs shall consider the value of the gift and the effect on the therapeutic relationship when contemplating acceptance. This consideration shall be documented in the client’s record.
5. NCCs shall not engage in harmful multiple relationships with clients. In the event that a harmful multiple relationship develops in an unforeseen manner, the NCC shall discuss the potential effects with the client and shall take reasonable steps to resolve the situation, including the provision of referrals. This discussion shall be documented in the client’s record.
6. NCCs shall discuss important considerations to avoid exploitation before entering into a non-counseling relationship with a former client. Important considerations to be discussed include amount of time since counseling service termination, duration of counseling, nature and circumstances of client’s counseling, the likelihood that the client will want to resume counseling at some time in the future; circumstances of service termination and possible negative effects or outcomes.
7. NCCs shall not engage in any form of sexual or romantic intimacy with clients or with former clients for two years from the date of counseling service termination.
8. NCCs shall not engage in sexual harassment, which is defined as a single act or multiple occurrences of verbal, nonverbal or physical actions that are known to be unwelcome or that are of the severity to be perceived as harassment by a reasonable person.
9. NCCs shall take proactive measures to avoid interruptions of counseling services due to illness, vacations or unforeseen circumstances. To prevent the harm that may occur if clients are unable to access professional assistance, such measures shall identify other professionals with whom the NCC has a working agreement or local emergency service agencies that can respond to clients in a mental health crisis.
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.
11. NCCs who act as counselor educators, field placement or clinical supervisors shall not engage in sexual or romantic intimacy with current students or supervisees. They shall not engage in any form of sexual or romantic intimacy with former students or supervisees for two years from the date of last supervision contact.
12. NCCs who provide clinical supervision services shall keep accurate records of supervision goals and progress and consider all information gained in supervision as confidential except to prevent clear, imminent danger to the client or others or when legally required to do so by a court or government agency order. In cases in which the supervisor receives a court or governmental agency order requiring the production of supervision records, the NCC shall make reasonable attempts to promptly notify the supervisee. In cases in which the supervisee is a student of a counselor education program, the supervisor shall release supervision records consistent with the terms of the arrangement with the counselor education program.
13. NCCs who provide clinical supervision services shall intervene in situations where supervisees are impaired or incompetent and thus place client(s) at risk.
14. NCCs who provide clinical supervision services shall not have multiple relationships with supervisees that may interfere with supervisors’ professional judgment or exploit supervisees.
Supervisors shall not supervise relatives.
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.
16. NCCs shall not release the results of tests and assessments to individuals other than the client without prior written consent except as required to prevent clear, imminent danger to the client or others; by written agreement with the client; or when legally required to do so by a court order or governmental agency.
17. NCCs shall protect the welfare of research participants by taking reasonable precautions to prevent negative psychological or physical effects.
18. NCCs shall protect the identities of research participants by appropriately disguising data except when there is a detailed written authorization.
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.
20. NCCs shall not use social media sources (e.g., updates, tweets, blogs, etc.) to provide confidential information regarding client cases that have not been consented to by the client. To facilitate the secure provision of information, NCCs shall inform clients prior to or during the initial session about appropriate ways to communicate with them. Furthermore, NCCs shall advise clients about the potential risks of sending messages through digital technology and social media sources.
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 are accountable in their actions and adhere to recognized professional standards and practices.
85. NCCs shall comply with all NBCC policies, procedures and agreements, including all disclosure requirements.
86. NCCs shall adhere to legal standards and state board regulations.
87. NCCs shall not engage in unlawful discrimination.
88. NCCs who make statements in a public manner shall state that their opinions represent their personal views and not another organization unless officially authorized to do otherwise.
89. NCCs providing public presentations by any means, shall ensure that statements are consistent with this Code of Ethics.
90. NCCs who act as university, field placement or clinical supervisors shall require that supervisees provide the supervising NCC’s name, credentials and contact information to the supervisee’s clients.
91. NCCs shall follow administration and interpretation protocols for tests and assessments, including the use of appropriate software if using electronic measures.
92. NCCs shall comply with identified security protocols when using published tests and assessments.
93. NCCs shall comply with intellectual property laws and other accepted publication guidelines.
94. NCCs shall comply with applicable guidelines when designing, conducting or reporting research, including those of an institutional review board.
95. NCCs shall credit the work of others who have contributed to research or publication either through joint authorship, acknowledgment or other appropriate means.
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, Inc. and Affiliates. (2016, October 7). NBCC Code of Ethics. Retrieved from https://www.nbcc.org/Assets/Ethics/NBCCCodeofEthics.pdf
American Counseling Association
American Counseling Association Code of Ethics Excerpt
Section A. The Counseling Relationship
A.3. Clients Served by Others
When counselors learn that their clients are in a professional relationship with other mental health professionals, they request release from clients to inform the other professionals and strive to establish positive and collaborative professional relationships
A.5.c.Sexual and/or Romantic Relationships With Former Clients. Sexual and/or romantic counselor–client interactions or relationships with former clients, their romantic partners, or their family members are prohibited for a period of 5 years following the last professional contact. This prohibition applies to both in-person and electronic interactions or relationships. Counselors, before engaging in sexual and/or romantic interactions or relationships with former clients, their romantic partners, or their family members, demonstrate forethought and document (in written form) whether the interaction or relationship can be viewed as exploitive in any way and/or whether there is still potential to harm the former client; in cases of potential exploitation and/or harm, the counselor avoids entering into such an interaction or relationship.
A.5.e. Personal Virtual Relationships With Current Clients. Counselors are prohibited from engaging in a personal virtual relationship with individuals with whom they have a current counseling relationship (e.g., through social and other media).
A.6.d. Role Changes in the Professional Relationship. When counselors change a role from the original or most recent contracted relationship, they obtain informed consent from the client and explain the client’s right to refuse services related to the change. Examples of role changes include, but are not limited to
1. changing from individual to relationship or family counseling, or vice versa;
2. changing from an evaluative role to a therapeutic role, or vice versa; and
3. changing from a counselor to a mediator role, or vice versa.
Clients must be fully informed of any anticipated consequences (e.g., financial, legal, personal, therapeutic) of counselor role changes.
A.6.e.Nonprofessional Interactions or Relationships (Other Than Sexual or Romantic Interactions or Relationships). Counselors avoid entering into non-professional relationships with former clients, their romantic partners, or their family members when the interaction is potentially harmful to the client. This applies to both in-person and electronic interactions or relationships.
A.7.a.Advocacy. When appropriate, counselors advocate at individual, group, institutional, and societal levels to address potential barriers and obstacles that inhibit access and/or the growth and development of clients.
A.7.b. Confidentiality and Advocacy. Counselors obtain client consent prior to engaging in advocacy efforts on behalf of an identifiable client to improve the provision of services and to work toward removal of systemic barriers or obstacles that inhibit client access, growth, and development.
A.8. Multiple Clients. When a counselor agrees to provide counseling services to two or more persons who have a relationship, the counselor clarifies at the outset which person or persons are clients and the nature of the relationships the counselor will have with each involved person. If it becomes apparent that the counselor may be called upon to perform potentially conflicting roles, the counselor will clarify, adjust, or withdraw from roles appropriately
A.9. Group Work
A.9.b. Protecting Clients
In a group setting, counselors take reasonable precautions to protect clients from physical, emotional, or psychological trauma.
A.10.c. Establishing Fees
In establishing fees for professional counseling services, counselors consider the financial status of clients and locality. If a counselor’s usual fees create undue hardship for the client, the counselor may adjust fees, when legally permissible, or assist the client in locating comparable, affordable services.
A.10.f. Receiving Gifts. Counselors understand the challenges of accepting gifts from clients and recognize that in some cultures, small gifts are a token of respect and gratitude. When determining whether to accept a gift from clients, counselors take into account the therapeutic relationship, the monetary value of the gift, the client’s motivation for giving the gift, and the counselor’s motivation for wanting to accept or decline the gift.
A.11. Termination and Referral
A.11.a. Competence WithinTermination and Referral.
If counselors lack the competence to be of professional assistance to clients, they avoid entering or continuing counseling relationships. Counselors are knowledgeable about culturally and clinically appropriate referral resources and suggest these alternatives. If clients decline the suggested referrals, counselors discontinue the relationship.
A.11.c. Appropriate Termination. Counselors terminate a counseling relationship when it becomes reasonably apparent that the client no longer needs assistance, is not likely to benefit, or is being harmed by continued counseling. Counselors may terminate counseling when in jeopardy of harm by the client or by another person with whom the client has a relationship, or when clients do not pay fees as agreed upon. Counselors provide pretermination counseling and recommend other service providers when necessary.
A.11.d. Appropriate Transfer of Services
When counselors transfer or refer clients to other practitioners, they ensure that appropriate clinical and administrative processes are completed and open communication is maintained with both clients and practitioners.
A.12. Abandonment and Client Neglect, Counselors do not abandon or neglect clients in counseling. Counselors assist in making appropriate arrangements for the continuation of treatment, when necessary, during interruptions such as vacations, illness, and following termination.
- American Counseling Association. (2014). ACA Code of Ethics. Retrieved from http://www.counseling.org/docs/ethics/2014-aca-code-of-ethics.pdf?sfvrsn=4
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, R. L. (1998). Milestones in the Development of Social Work and Social Welfare. Washington, DC: NASW Press.
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.
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.
NOTE: sentences and phrases are in bold type, in each Section of this Manual, for the purpose of highlighting key ideas for easy reference.
Peer-Reviewed Journal Article References:
Carsky, M. (2020). How treatment arrangements enhance transference analysis in transference-focused psychotherapy. Psychoanalytic Psychology. Advance online publication.
DeTore, N. R., Gottlieb, J. D., & Mueser, K. T. (2021). Prevalence and correlates of PTSD in first episode psychosis: Findings from the RAISE-ETP study. Psychological Services, 18(2), 147–153.
Kaufman, J. S., Allbaugh, L. J., & Wright, M. O. (2018). Relational wellbeing following traumatic interpersonal events and challenges to core beliefs. Psychological Trauma: Theory, Research, Practice, and Policy, 10(1), 103–111.
10: When a clients condition indicates that there is a clear and imminent
danger to the client or others, the certified counselor must do what? To select
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