ETHICS for TEXAS LICENSED PROFESSIONAL COUNSELORS: General Requirements
(3 hours)
Introduction
Overview
Laws, regulations, and
ethical guidelines figure very importantly in the conduct of counselors and
other professionals. Laws and regulations serve a variety of purposes. They may
provide for needs as concrete as the equity transfer of taxes and licensing
fees that support communities and help to maintain the regulatory
infrastructure. They may fulfill vision as esoteric as the mandates of
constitutional law. Of course, they are mostly for the more obvious purposes,
those of protecting the public and improving mental health.
LPC’s have the duty to ensure that
their conduct meets ethical and legal standards, regardless of their
theoretical orientation. Further, though a specific situation may not be
described in the standard, the counselor is responsible for applying the
principles set forth as they apply to that situation.
This course serves to familiarize
students and counselors with the legal and ethical issues in psychotherapy. It
specifically covers law and regulations applying to
licensed professional counselors in Texas.
Thus, this course will include many specific citations such as state and
federal laws, and ethical codes such as those of the American Counseling
Association and in Texas
law.
Known ethical standards for
healers date back to the Hippocratic Oath, developed roughly 2,500 years ago
(Hippocratic) and even farther back to the Nigerian healer’s code. (O’Donohue, W. T. & Ferguson, K. E., 2003) Attempts to regulate professions have a long history, and
many have been triggered by problems with the conduct of the professionals
themselves, as is discussed in the section on boundaries. Enforcement ranges
from warnings such as “formal advisory letters,” (Texas Administrative Code, §681.204)
to punishments that can include loss of license,
fines, and imprisonment.
LPC’s were first licensed
in Texas in
1981. The licensing laws have evolved to include higher education and
experience requirements, rules of professional conduct, and licensing exams. As
of this writing, there are roughly 14,000 LPC’s in Texas. (DSHS, 2007)
Laws pertaining to
counseling can be found in various statutes and codes that serve a variety of
purposes such as maintaining confidentiality and requiring adequate levels of
training. There are also laws collected together under the rubric of
professional conduct. Violations constitute unprofessional conduct, for which
there are various enforcement measures. (Tex
Occ. Code §105, 2007)
In the United States,
state boards have the primary responsibility to regulate professional behavior.
In Texas, the
Texas State Board of Examiners of Professional Counselors, under the Department
of State Health Services, regulates LPC’s.
There are numerous laws and
regulations that give this board the authority, responsibility, and the
procedures to regulate the professionals under its authority. The board itself
must obey numerous laws and regulations pertaining to its conduct. The board’s
regulatory responsibilities include reviewing complaints from the public,
issuing sanctions and even working with law enforcement when necessary.
The next two paragraphs
tell you about the state laws that are primarily concerned with LPC’s. This is
here so you can look things up if you need to. It isn’t intended for you to
memorize.
The state law primarily
enacted to regulate LPC’s is chapter 503 of the Texas Occupations Code, known
as The Licensed Professional Counselor Act. (Tex. Occ. Code §503,
2007)
The regulations relevant to
this training are largely codified in chapter 681, entitled Licensed
Professional Counselors, and contained in part 30, entitled Texas State Board
of Examiners, which is within Title 22, entitled Examining Boards, of the Texas
Administrative Code. This chapter is intended to implement The Licensed
Professional Counselor Act. In particular, the General Ethical Requirements
(chapter 681.41) contains most of the state regulations relevant to this
training. (Tex.
Admin. Code, Title 22, §681, 2007)
The student is encouraged
to participate in this course with an eye to the principles that underlie the
specific laws, regulations and guidelines covered. Understanding these
principles will help the student learn and apply the material in this course.
This introductory section has already taken a stab at describing such
principles by touching on the sources and motivations for the regulation of
professional conduct.
LPC’s should include in
their perspective on legal and ethical issues the fact that their profession
must be aware not only of individual psychology, but also on the dynamics of
social systems, including the family. Awareness of these systems can extend the
focus of intervention beyond the individual client and create challenges in
identifying desired outcomes. As Maddock put it, “The
willingness to bring social systems into the domain of mental health care has
created added layers of legal and ethical complexity never envisioned by the original
architects of the psychotherapeutic process…” (Maddock,
J. W., 1993)
The American Heritage
Dictionary defines ethics as, “The study of the general nature of morals and of
the specific moral choices to be made by a person; moral philosophy.” (American
Heritage Dictionary, 2007) It defines morality as, “The quality of being in
accord with standards of right or good conduct. (Ibid)
In addition to legal
requirements, ethical guidelines regulate professional conduct. The Texas
Counseling Association points to multiple sources of ethical guidelines,
stating that, “This is due in part to the manifold areas in which we specialize
and the populations with which we work.” (Texas Counseling Association, 2007) The
association’s Ethics page provides a link to the ethical guidelines of the
American Counseling Association (ACA). (Ibid.) In the
preamble to those guidelines, the ACA states,
When counselors are faced with ethical dilemmas that are difficult
to resolve, they are expected to engage in a carefully considered ethical
decision-making process. Reasonable differences of opinion can and do exist
among counselors with respect to the ways in which values, ethical principles,
and ethical standards would be applied when they conflict. While there is no
specific ethical decision-making model that is most effective, counselors are
expected to be familiar with a credible model of decision making that can bear
public scrutiny and its application. (American Counseling Association, 2007)
The ACA Code of Ethics
covers responsibility to patients, students, supervisees, colleagues, research
participants, the profession and the legal system, as well as covering
confidentiality, financial arrangements, and advertising. The code is comprised
of the following sections: (ACA, 2005)
Section A: The Counseling Relationship
Section B: Confidentiality, Privileged Communication, and Privacy
Section C: Professional Responsibility
Section D: Relationships With Other
Professionals
Section E: Evaluation, Assessment, and Interpretation
Section F: Supervision, Training, and Teaching
Section G: Research and Publication
Section H: Resolving Ethical Issues
The following guidelines are adapted from Pope and Vasquez’
textbook on ethics in psychotherapy. (Pope, K. S. & Vasquez, J. T.,
2007).
Many factors can
challenge and even interfere with ethical decision making. Laws and ethical
codes cannot foresee every circumstance. Thus, a commitment to conscious
analysis of ethical issues and gaining support for ethical conduct are
essential.
Literature,
training and research can result in conflicting and erroneous claims and ideas,
or be misapplied through overgeneralization or misinterpretation. It is
important to think critically and compare multiple sources and biases in
developing and applying therapeutic procedures and ethical behavior.
Most counselors
are dedicated, caring individuals who are committed to competent, ethical
practice. However, we can make mistakes or inadvertently succumb to pressures
that result in breaches of ethics or effectiveness. By being open-minded about
one’s own fallibility, and by thinking critically, the counselor is in a better
position to prevent or recover from errors while minimizing harm. Continuous
questioning as to better ways to perform or think critically is needed. Preoccupation
with the faults of others is a red flag that we are distracted from our own
faults. Even where large numbers of counselors have been highly confident,
history has shown that we can be wrong.
The counselor
must accept that struggling with ethical dilemmas is an inevitable part of work
as subtle and complex, and as fraught with societal and legal issues as
counseling (or any other healing art). This provides further justification for
related continuing education and peer support. Where legal implications exist,
consulting with the state board, agencies that are involved in the case, and an appropriate attorney are advisable to consider.
Rather than being preoccupied with eliminating all risk of complaint or
liability, the counselor should be actively involved in reducing risk in an
ethical and lawful manner. Counselors who pursue perfect absence of risk tend
to harm their performance through anxiety and perseveration. These symptoms
deserve attention and help.
Counselors sometimes
complain about situations in which there is no guarantee that a successful
lawsuit can be prevented. Even an unsuccessful lawsuit can pose great demands
and stress. Much of the ambiguity of the legal environment comes from changes
in society. It takes time for laws and court cases to catch up with changes in
society. Even then, there may be conflicts between laws and between court
judgments and laws. Further, technology has completely changed the face of
confidentiality, leading to extensive federal law.
Sometimes laws seem to go
against common sense, or at least the instincts of counselors and the people
they serve. When we trace a law or judgment back to its roots, we can usually
understand and comply in good conscience. However, it is not always possible to
convince an angry parent or spouse of its wisdom.
Nonetheless, counselors
must determine how much defensive practice is too much. Wishing to avoid
liability and even the risk of an unfounded complaint or lawsuit, counselors
may be tempted to go too far. Excessively defensive practice can deprive
clients of appropriate and needed services. In other words, the counselor must
ask whether a defensive strategy is an ethical one. The counselor must accept a
certain level of risk along with the privilege of licensure in a healing
profession.
An example of an
excessively risk-aversive approach would be refusing to work with children
going through divorce simply because there is a higher likelihood of complaints
or suits. Another is that of the psychiatrist who complacently prescribes
medication to relatively easy cases, but will not accept cases that are
complex, and neglects or actively alienates clients who become complex, simply
because they are not as profitable. Refusing to accept cases that may be
demanding is known as cherry picking.
On the other hand, one can
proceed with too much abandon. Counselors driven to play the hero may mishandle
delicate ethical or legal issues. For example, one counselor took his client’s
problems so personally, that he would make bold moves without initially gaining
adequate rapport. When a client expressed hopeless self-pity, he tried to prove
that people would be helpful. He offered to loan her money to get out of a jam.
The client was so confused, surprised and alienated that she left his care.
This same counselor later ended up with two separate disciplinary actions by
the board for other infractions, and got the highest rate of complaints to a managed
care company.
Counsleors should not react with excessive risk aversion, nor
with rash heroism. Instead, ocunselors should take
care to draw the line between these extremes with an ethical perspective that
considers client welfare. By considering their existing competencies,
counselors can ethically reduce risk of complaints and lawsuits. Appropriate
strategies include the following:
Provide informed consent
(as covered later in this course).
Set expectations of clients
at the beginning of treatment.
Educate clients about what
you can and cannot do, and about the legal and ethical requirements that are
relevant to the situation at hand. Do this in a preventative manner, rather
than reactively.
Stay up-to-date with the
changing legal landscape and evolving ethical guidelines.
Get adequate support when
an ethical or legal concern arises. Use contact with experienced peers, the
state board, the attorney available through your professional organizational
membership, educational materials, and reviewing the actual laws and
guidelines.
Emotion, the drive to
exceed one’s boundaries
Philosophy and Values
in Ethics
Whether you know it or not,
your actions are based upon a philosophy that embodies values to produce your
ethics. These ethics have a profound effect on your work as a counselor. Your
ethics have either a harmonious or stressful relationship with the more general
ethical frameworks of the law and your profession. The American Heritage
Dictionary defines philosophy as:
A study that attempts to discover the
fundamental principles of the sciences, the arts, and the world that the
sciences and arts deal with; the word philosophy is from the Greek for “love of
wisdom.” Philosophy has many branches that explore
principles of specific areas, such as knowledge (epistemology), reasoning (logic), being in general (metaphysics), beauty
(aesthetics), and human conduct (ethics).
Different approaches to philosophy are also called philosophies.
(See also epicureanism,
existentialism, idealism, materialism, nihilism, pragmatism, stoicism, and
utilitarianism.) (The American heritage, new dictionary of cultural literacy,
2005)
Whatever answers one finds
in philosophy, it is not a fixed base of knowledge or opinion. It is highly
influenced by the biases of its culture, and it is ultimately personal. For
example, the very influential philosopher, Schopenhauer was quite misogynistic
and anti-Semitic, and felt that sex was disgusting. (Janaway,
C., 1999) Philosophers and their philosophies need to
be seen not only as being influential, but also as having been profoundly
influenced.
From the counselor’s
perspective, “philosophy is a set of generalizations and guidance regarding the
identification and expression of human values…” Psychotherapy is “value laden”
not value free. (Tjeltveit, A. C., 1999)
Everything you do can be
seen as an expression of values. Consider the act of opening a can of tuna. You
can view it in terms of contributing to your health and family, taking a
political position on the hunting of dolphins, or the ecological aspects of
waste management. These views depend on what kind of tuna you purchased, who
you gave the tuna to, and what you did with the can. Esthetics looms large in
some schools of philosophy. It would affect how you prepare tuna.
Values are so deeply
embedded in our culture from thousands or millions of years of patterned
behavior, that identifying values can be like trying to get a fish to identify
water. Values can be seen in the highest aspirations and the most
raw physiology, as in the drives that support procreation and survival.
It is an essential responsibility of counselors to “unpack,”
inspect, and refine their values in ways that are of practical value to
their clients and to their own careers. A great additional benefit to this
process is that it makes the counselor more effective at helping clients
identify and act on their own highest and practical values.
One of the challenges to
identifying values and adhering to functional values is that of rationalization.
A counselor who states that he or she is having sex with a client because it is
giving him or her a positive relational experience and practice at being
uninhibited is actually performing a very commonplace mental trick. Here are
the steps: 1) Disguise physiologically primitive drives (the drives to
procreate and to pursue pleasure, or hedonism). Do this by unconsciously
generating a higher-level value statement (value to the client). 2) Adopt this
higher-level value as the surrogate reason for the behavior (soliciting sex).
This mental prestidigitation serves the parallel purposes of shielding the
counselor’s awareness from information that would damage his or her
self-esteem, while permitting the counselor to act on primitive impulses.
Mental tricks such as this
have survival value. From the perspective of evolutionary psychology, the
conscious mind and rational thought are of less value than procreation and
survival. Rationality and ethical principles are younger and more delicate than
our more primitive impulses. It’s no wonder that ethics in psychotherapy has
such a checkered past, and poses great challenges to counselors and to the
legal system.
A substantial percentage of
counselors who sexually transgress are repeat offenders and are difficult or
impossible to rehabilitate. Therefore, it is important to distinguish between
counselors who need to refine their values as opposed to counselors who
perceive people as objects whose needs exist only to manipulate so as to
fulfill the counselor’s needs. This kind of narcissistic, antisocial character
pathology is not a matter of limited insight, psychological defenses, and
surrendering to impulses. It is not a matter of limited professional
experience. It is a highly ingrained way of being and perceiving that is very
difficult to treat, and generally leads the offender to evade treatment except
in so far as it can be used to manipulate the system. This is a very good
argument for taking assertive action that will create oversight and
accountability when violations of ethics are discovered, particularly where
personal boundaries are concerned.
Self Management
Our culture values will
power and conscious decision-making, but managing our impulses can be more
about preventing the need to use much will power. This is about preventing
overly risky situations and cultivating ethical habits. Comparing will-power to
managing influences is a little like comparing steering a car to navigating a
boat while playing the piano. However, for a counselor with antisocial
personality disorder, it’s more like sailing a piano.
In thinking about
self-management where impulses may attempt to overwhelm ethics, the
neuropsychological concept of kindling is of value. It means what it sounds
like it means, that impulses, given enough promotion, become increasingly
powerful. A common expression for this, where sexuality is concerned, is
“playing with fire.” A strategy to avoid kindling where sexual attraction is
concerned would be in refraining from sexual fantasies about clients. It is
important to respect the power of our own physiology, and to manage it
effectively.
Another approach is to
self-monitor for signs of losing objectivity. Such signs include
rationalization, changes in physiology such as heart rate, beginning to think of
ways to cross boundaries, and finding oneself
unconsciously crossing boundaries. Isolation is bad for ethics. It is very
valuable to discuss ethical challenges with supervisors and mature, experienced
peers.
The counselor must have
effective ways of responding to clients whose religious beliefs differ from
those of the counselor. This situation can create special challenges for
rapport-building and the pursuit of therapeutic outcomes.
Religious beliefs and
attitudes span the range from values that are aligned with client welfare to
values that are unhinged from client welfare. The disconnection from client
welfare occurs when the intervention is based exclusively on principles that
must be applied regardless of their outcome, as we shall show below.
Insularity is an adjective
that can refer to applying principles without regard to outcomes, or with blind
faith that the outcomes will be good. Related words are fanaticism, zealotry,
doctrine, and dogma. Counseling modalities applied in an insular manner can
produce disastrous results. Rigid adherence to prescribed techniques or acting
on a theory independently of its outcome are two ways a doctrinaire approach to
treatment can fail clients. Three red flags for insular or overzealous
treatment include the counselor being unable to adequately explain the theory
behind the treatment, limiting client assessment to areas that the counselor’s
biases allow, or not changing the approach to treatment despite bad results.
An Example of Insularity
in Rebirthing
The smothering of a young girl undergoing rebirthing therapy (a
part of her attachment therapy) as a treatment for attachment disorder, as
diagnosed by an unlicensed and unregistered Colorado counselor, resulted from applying
the technique despite abundant evidence that it was harming the child. (Nicholson, K., 2001) The counselor, her three assistants, and
the adoptive mother had every intention of helping the girl, but her pleas for
help and insistence that she was dying were misperceived through the
therapeutic orientation or “filter” of the rebirthers.
Among other evidence, videotape of the session convinced jurors to convict the
counselors in the child’s death. (Lowe, P. & Ames, M., 2001)
Two of the counselors were
sentenced to sixteen years in prison for reckless child abuse resulting in
death. They received the minimum punishment because the judge believed that
they did not intend to harm the victim. (Janofsky,
M., 2001) The deaths of several other children have
been linked to rebirthing, also known as holding therapy. (Chaffin M, et. al.,
2006)
This case had additional
elements of zealotry, in that promotional materials and statements about
rebirthing stated that it was the only therapy that was evidence based, when
there was no research supporting it, and in that the primary counselor
indicated in her materials that she was a licensed clinical social worker,
which was false. The strength of the rebirthers’
beliefs eclipsed fundamental principles of clinical thought and ethics, despite
the fact that the primary counselor was a nurse.
Additionally, they were
using somatic interventions in the sense that there was physical restraint,
application of physical pressure, and deprivation of oxygen. When using methods
that can have a direct physiological impact (or an acute or dramatic
psychological impact, for that matter) it is especially important to become
well-informed about any potential risks and any advisable safety measures. This
assumes that the methods are appropriate in the first place.
The Example of
Recovered Memory
The recovery of repressed
memories of child abuse was popularized in the early 1980’s. A wave of
prosecutions and law suits against alleged perpetrators followed. At the same
time, many children provided accounts of current or recent abuse as well. In
the 1990’s a wave of malpractice claims against counselors and organizations
accused of eliciting false memories followed. The recovered memories were often
elicited through methods such as hypnosis and manipulative interrogation
techniques directed at children. The incidents were often unsupportable by
evidence or even extremely improbable.
The debate over recovered
memories has often occurred as a polarity between whether or not abuse occurs
and whether or not a person is a true feminist. Many feel that this period
constituted a modern witch-hunt. In Manhattan Beach, California, as the McMartin Preschool case was unfolding, many cars displayed
bumper stickers saying, “We Believe the Children.”
A sober discussion of the issue
centers on science and the establishment of facts. Despite the emotion and
smear campaigns directed at people who questioned the recovered memory
movement, guidelines for interviewing children and for assessing symptoms that
may occur as the result of a history of child abuse have been established.
There is a great deal of research that has helped clarify the nature of memory,
therapy, and testimony relevant to this issue. (Loftus, E. F. & Davis, D.,
2006)
Successful cases against
counselors using inappropriate means of producing memories of childhood abuse
have resulted in large penalties. (Star Tribune, 1995)
The wave of repressed
memory and questionable abuse cases peaked in the mid 1990’s, and have greatly
diminished as a result of research and increased sophistication in the courts,
social services, the public, and counseling.
“The ability of a therapist
to help a client is strongly influenced by the nature of that therapist’s
psychological functioning.” (Epstein, R. S., 1994, p. 35)
For this section, the word
integrity is not used in a moralistic sense, but in a structural sense.
Intactness of the counselor’s ego boundaries will vary with stress on the counselor.
Depending on the counselor’s existing vulnerabilities, which will in some cases
include a mental disorder, stressors such as illness, relationship problems,
lack of sexual satisfaction, loss of self esteem, legal problems, loss, and
trauma may result in an increase in impulsiveness or neediness on the part of
the counselor that may intrude upon the therapeutic relationship. The
counselor’s self assessment, preparedness for such eventualities, and external
support from family, friends, peers, supervision, and counseling are all
factors that may help to prevent a bad outcome and even improve the quality of
good therapy. (Ibid)
The following subsections
provide examples of opportunities for counselors to improve their
self-knowledge, as well as their assessment of clients and supervisees,
coworkers and employees.
Cognitive strengths and
vulnerabilities have implications for ethics. If the counselor has significant
cognitive difficulties, he or she may have trouble with a large caseload, case
management, or case conceptualization and treatment planning. Problems such as
attention deficit disorder may leave treatment planning intact, but interfere
with managing details when case management demands exceed a certain threshold.
Counselors must know their cognitive abilities to avoid taking on
responsibilities outside their scope of competence. This may require outside
assistance, because persons with some neurological problems may experience what
is known as a positive illusory bias, in which they overestimate their
abilities.
The counselor’s personal
reaction (countertransference) to clients can
significantly alter the course of treatment for better or worse. One area where
this issue has received attention is the treatment of individuals with
personality disorders. For example, counselors have been shown to be more
likely to have negative reactions to clients with cluster A and B personality
disorders. This tended to be associated with high drop out rates, and affected
clients’ feelings about therapy. (Rossberg,
J. I., Karterud, S., Pedersen, G, Friis,
S., 2007)
Much research has shown a
correlation between the quality of the counselor-client relationship and good
therapeutic outcomes. In a good counselor-client relationship, the counselor’s
personal issues do not interfere.
A divergent theory is that the
counselor’s ability to form a good relationship is actually symptomatic of the
counselor not having a personality disorder or other problems that interfere
with mature relationships. Accordingly, the counselor’s ability to mature and
to adapt are the key to this effectiveness, rather
than the relationship itself. This would explain why treatment that does not
involve developing much of a relationship with the client can still be
effective. For example, hypnosis with amnesia, “content-free” work, and very
brief therapy involve a superficial relationship, but can be effective.
Red flags that tell a
counselor that he or she may have critical needs for personal development
include their reaction to people with personality disorder symptoms, to highly
victimized people, and to highly assertive people.
Counselors with impulse
control difficulties may have a history of “blurting” that is, saying something
that is not altogether socially acceptable (or of therapeutic value) before
they think about the consequences, or they may experience little concern for
the consequences. There may be a history of poorly thought out efforts to be
the hero or to react to perceived slights. These incidents may be more likely
when there is a sense of heightened emotion or urgency, or when there is more
sensory stimulation or recent blows to the ego.
Counselors with this kind
of history must work conscientiously with supervision to develop accommodative
measures and stress reduction or self-soothing methods.
Clinicians are facing
increasing challenges to justify their approaches in terms of evidence such as
outcome studies and other research published in peer-reviewed journals. Experts
have raised concerns regarding inadequate training in evidence-based practice
on the part of academic institutions. (The Institute of Medicine of the
National Academies, 2006, pp. 264-299) (The President’s New Freedom Commission
on Mental Health, 2003) (Hoge, M. A., Morris, J. A.,
Daniels, A. S., Stuart, G. W., Huey, L.Y., & Adams, N. 2007) The
prosecution for the case of Candace Newmaker, the
girl who died in rebirthing therapy, repeatedly returned to this issue in
cross-examination the counselors.
However, there are
significant challenges in fulfilling this aspiration. There can be difficulty,
“converting clinical guidelines into active performance measures,” or in,
“integration of findings into daily operations.” (Stout,
C. E., Hayes, R. A., 2005) Research may appear to
have implications for therapy in real-life situations that are misleading.
Research studies may not be as relevant to practice conditions as they appear.
Counselors in research studies may not actually carry out therapy with as much
fidelity to the prescribed method as is believed, because they may put clients’
needs ahead of the research objectives, or because the client cohort is not as
homogenous as intended.
Often, there is not enough
consistent data available to form a secure evidence-based opinion, despite the
existence of practice guidelines and texts that synthesize what information is
available. Counselors often use methods that are not yet well-researched, but
that they have faith in because of an abundance of clinical experience. In this
circumstance, avoiding blind faith by staying outcome-focused and carefully
assessing risks and one’s own scope of practice and competence are essential.
Staying up-to-date is the first
priority in evidence-based practice. However, it is important to understand the
limitations of research such as biases. This topic is covered in research
courses. Much medical research has been called into question because of the
influence of “big pharma” (the pharmaceutical
industry) on research and its publication. This has included the suppression of
negative information about medications.
At the outset of therapy,
clinicians provide their clients with verbal and written information, much of
which is legally required. Some information is not legally required to be
offered, but affords some legal protection to the counselor. Other information
provided is helpful in setting client expectations in order to improve client
understanding and adherence to terms and conditions of the services provided by
the counselor. HIPAA and state regulations require counselors to provide
specific information in the service of informed consent at the outset of
treatment.
Informed consent refers to
a client having adequate information to make a decision regarding medical care.
This prevents a medical procedure from being considered battery. (Alban, A.,
2007) Information that assists the client in understanding the risks
and rewards of their mental health services affords the client the ability to
give “informed consent.”
In Texas, § 681.41(e) requires LPC’s to inform
new clients, in writing, of a variety of specific aspects of the counseling
process. This information must be provided before or during the initial
consultation. Under the statute, such information includes:
(1) fees and arrangements for payment;
(2) counseling purposes, goals, and
techniques;
(3) any restrictions placed on the
license by the board;
(4) the limits on confidentiality;
(5) any intent of the licensee to use
another individual to provide counseling treatment intervention to the client;
and
(6) supervision of the licensee by
another licensed health care professional including the name and qualifications
of the supervisor.
Subsection (f) of § 681.41 requires
that an LPC advise the client, in writing and in advance, of any changes to any
of the information required under subsection (e). This requirement applies
regardless of when any such change is made. For example, if the state legislature
passes a new law that will alter confidentiality and reporting requirements, an
LPC must notify each of his clients of the changes in writing before the new
law actually takes effect. Moreover, he must notify every client, from the
person who has been his client since day he began his practice to the new
client who received her initial consultation only one day previously.
Subsection (e) of § 681.41 also
requires that an LPC inform clients in writing, either before or during the
initial consultation, of "counseling purposes, goals, and techniques"
that may exist or be used. Again, this is an area where the LPC must use her
professional judgment to determine the extent of the information encompassed by
the phrase "counseling purposes, goals, and techniques."
The degree of detail that should be
shared with clients will vary greatly according to individual circumstances. A
client's psychological state, including mental and intellectual capacities and
levels of emotional vulnerability, will often dictate the amount and type of
information that an LPC feels should legitimately be shared. During the course
of treatment, if a client's condition improves or deteriorates, it may become
necessary to reevaluate the amount and type of information that has been
disclosed thus far, and adjust such disclosures accordingly.
How to reconcile client welfare with
obligations of informed consent may present challenges for LPC’s. Pope, et al.,
summarize the problem succinctly:
Should the clients have full access to
assessment and treatment data that concern them? On the one hand, access to
data about the client's condition may be important to the client's reaching a
truly informed decision about initiating or continuing treatment. For example,
if clients are not honestly told the diagnosis, it may be hard for them to know
whether they want to be treated without knowing what they are to be treated
for. On the other hand, psychologists may feel that certain technical terms or
raw data may actually exacerbate the client's condition. (Pope, K. S. & Vasques, J. T., 1998)
They cite the results of one study
showing that, with regard to determining appropriate levels of disclosure about
the therapeutic process, LPC’s' opinions vary. "About one in five believe
that it is unethical to refuse to disclose the diagnosis (21.5%) or to refuse
access to a test report (21.7%)." (Ibid) However, far fewer LPC’s see
ethical problems with denying patients access to "chart notes
(14.5%)" or "raw test data (12.1%)." (Ibid) Refusing to share
particular types of information with clients is not uncommon: "Around half
of the respondents have denied their clients access to the diagnosis (48.0%),
to the testing report (49.6%), to their chart notes (55.5%), or to raw test
data (57.4%)." (Ibid)
Other duties associated directly with
the counseling process arise under separate subsections. Under § 681.41(u), an
LPC is prohibited from "persistently or flagrantly over[treating] a
client." In addition, subsection (s) provides that an LPC has a duty to
"terminate a professional counseling relationship when it is reasonably
clear that the client is not benefiting from the relationship," and where
"counseling is still indicated," to take "reasonable steps to
facilitate the [client's] transfer" to another appropriate provider. An
LPC should advise clients of their rights under each of these subsections.
Under § 681.41(e)(3), an LPC is
required to inform clients, in writing and before or during the initial
consultation, of "any restrictions placed on the [practitioner's] license
by the board." Again, this is an issue of informed consent, which requires
that the client be made fully aware of the LPC's professional qualifications, and
of any limits on them.
Subsection (e)(6) also requires that an
LPC advise the client in writing and before or during the initial consultation,
if the LPC is subject to supervision by another "licensed health care
professional." Such notice must include the supervisor's name and
professional qualifications.
These subsections generally become
applicable in two types of situations: 1) with student practitioners who are
not yet fully licensed and are thus subject to professional supervision; and 2)
with practitioners whose practices have been restricted because of professional
disciplinary sanctions. In either situation, clients cannot reasonably be said
to have given informed consent to treatment if they are unaware that the
therapist who will be treating them is lacking in experience, is not yet
qualified to handle certain forms of treatment, or has been disciplined for
engaging in misconduct.
Subsection (e)(5) contains a related
requirement: If an LPC intends "to use another individual to provide
counseling treatment intervention to the client," she must advise the
client of that fact in writing, before or during the initial consultation. This
requirement also applies to LPC’s whose licenses are not restricted in any way.
With fully licensed practitioners in good professional standing, this
requirement is likely to become applicable where it is clear that the client
will also need a specialized form of therapy that the primary LPC is unable to
provide. In addition, as with all other elements of subsection (e), should any
of these situations arise at any point during the course of treatment, the LPC
must notify the client of the impending change in writing, before the change
takes effect.
Those LPC’s who do advertise their
services presumably do so to recruit clients. Client recruitment also occurs
through non-standard methods, such as referrals. Professionals in some fields
are permitted to use the referral process with few limits. However, LPC’s must
be aware of the significant restrictions that § 681.41(h) imposes on referral
processes for counselors.
This subsection provides:
A licensee shall not intentionally or
knowingly offer to pay or agree to accept any remuneration directly or
indirectly, overtly or covertly, in cash or in kind, to or from any person,
firm, association of persons, partnership, corporation, or entity for securing
or soliciting clients or patronage for or from any health care professional.
LPC’s are forbidden to provide or
accept any form of compensation for referrals to or from another individual or
entity, or on behalf of another individual or entity. Under § 681.41(h)(1),
"a licensee is subject to disciplinary action if the licensee directly or
indirectly offers to pay or agrees to accept remuneration to or from any person
for securing or soliciting a client or patronage."
First, even if an LPC does not intend
to exchange some form of compensation ("remuneration") for a
referral, but knows that giving or receiving compensation will occur, she will
likely be found to have violated this subsection. Second, this subsection
applies regardless of whether the LPC is making or receiving the referral: Se
may not accept compensation for referring a client to another provider, nor may
she compensate another provider for referring a client to her.
Third, this subsection prohibits any
form of compensation made via any method; it need not be an explicit financial
reward for making a referral. These restrictions apply regardless of whether
the compensation takes the form of direct cash payment or is compensation
"in kind" (i.e., providing a non-cash payment or reward).
"In-kind" compensation may include virtually anything: free products
or services; payment of tuition or professional fees; meals or tickets to entertainment
or recreational events; or any number of other benefits, both tangible and
intangible. The restrictions also apply regardless of how the payment is made:
Examples may include (but are not limited to) sending a check,
"bundling" payment into a payment for other services, providing cash
"off the books," or providing special services for equivalent value
(e.g., providing free advertising in an amount equal to the cost of the
referral).
Fourth, the subsection prohibits
compensation for referrals "to or from any person, firm, association of
persons, partnership, corporation, or entity." This language makes these
restrictions applicable to virtually any individual or entity, including other
LPC’s, hospitals, clinics, educational, religious, or charitable institutions,
and most other sources. One exception applies under 681.41(h)(2)
A
licensee employed or under contract with a chemical dependency facility or a
mental health facility shall comply with the requirements in the Texas Health
and Safety Code, § 164.006, relating to soliciting and contracting with certain
referral sources. Compliance with the Treatment Facilities Marketing Practices
Act, Texas Health and Safety Code, Chapter 164, shall not be considered as a
violation of state law relating to illegal remuneration.
A thorough understanding of the LPC's
fees and payment structure is necessary to the client's informed consent.
Clients seeking counseling are likely to be under significant pressures; in
some instances, financial pressures may play a role. As noted above, some
clients may be uninsured or underinsured and unable to afford private therapy
fees. Some LPC’s, or their affiliating organizations, may not accept particular
insurance plans. Clients thus need to be fully apprised of the costs of the therapeutic
process in order to make an informed decision as to whether such counseling is
affordable (or, for some, even possible). Under § 681.41(k)(3), LPC’s are
prohibited from "enter[ing] into barter for
services" or "accept[ing] payment in the
form of services rendered by a client."
As noted in the previous subsection, §
681.41(f) requires that an LPC notify clients in writing of any changes,
including changes in fees or payment arrangements. However, the LPC must notify
clients of such a change in writing, and must do so before the change takes
effect. This requirement is emphasized in subsection (r), as discussed below.
Under § 681.41(r), an LPC is permitted to bill clients only those services
actually rendered or agreed to by mutual understanding at the beginning of
services or as later modified by mutual written agreement." Read in
conjunction with the language of subsections (e) and (f), this language makes
clear that LPC’s must notify clients in writing of any changes in fees,
billing, or payment before those changes take effect.
Moreover, advising the client in
writing at the outset of the therapeutic relationship helps an LPC to avoid
misunderstandings and conflicts later. Written explanations of fees, costs, and
payment expectations helps clients understand their own responsibilities in the
patient/therapist relationship. In the event of a client's subsequent failure
or refusal to pay, it also provides evidence that the client received notice of
fees and costs.
360-degree quality
management is a business term that refers to having a well-rounded approach to
quality. It involves taking stock and intervening anywhere in the spectrum of
services and products that may adversely affect the customer experience of
quality. Importing this concept to the provision of counseling means reviewing
infrastructure and policies necessary to ensure safety, consistent care,
confidentiality, outcomes and all other aspects of quality care.
Examples of specific
elements include having coverage while away in case of a client emergency,
secure and confidential records management, orientation and contracts with
staff and contractors and services, and consistent provision of informed
consent at the outset of therapy. A professional will, that is, having a will
that specifies how your clinical and administrative records will be handled in
the event of your death or infirmity, is an important example. It is
specifically considered to be an important ethical requirement.
Thinking of therapy as a
complete cycle, with a beginning, middle and end, can help the counselor
enhance quality. Initiation and termination of therapy are each very important
subjects that command considerable attention from ethical, legal, and clinical
perspectives. Termination, for example, brings up issues such as avoiding
client abandonment (such as through transfer of care), terminating when therapy
is no longer cost effective for the client (as opposed to the counselor),
appropriate follow up, making sure the client feels comfortable about resuming
therapy if needed, and collaboration with the client to ensure a clinically
appropriate termination process.
One of the most important
criticisms leveled at the mental health field is the inadequacy of assessment,
and the resulting errors in diagnosis. Research has shown a tendency for
counselors to have pet diagnoses and to do overly brief assessments that rely
too much on initial comments by the client. In many cases, problems such as
drug and alcohol abuse, domestic violence, cognitive impairment, and
personality disorders go unacknowledged and untreated, ultimately sabotaging
the treatment.
Highly naïve, defensive,
and cognitively impaired clients, especially those with problems that impair
thinking and judgement, such as substance abuse,
antisocial personality disorder, and psychosis, may be very difficult to
collaborate with. There are many reasons such clients may be unable to see the
wisdom of the treatment plan the counselor is inclined to propose. One of the
highest arts of counseling is that of rapport building with these defensive,
resistant clients. Some trainers say that there is no such thing as a resistant
client, only a failure to gain rapport. This is an extreme position taken in
order to make a point. Clients should not be written off as resistant, at least
not after creative work to gain collaboration. After all, clients come to
counseling because they are experiencing mental or emotional distress. The
greatest source of such distress is that of mental disorders. A knee-jerk
response to a resistant client is akin to saying that such persons should seek
mental health treatment from a skilled counselor. The obvious conclusion is
that the counselor seeing the resistant client needs more training,
specifically on managing defenses and difficult-to-treat problems.
There are two primary
blocks to gaining agreement on the treatment plan. One is that the client has
an agenda that is antithetical to their well-being. Substance abuse is an
obvious example. This “agenda” may be conscious or unconscious, but can be very
powerful. Many substance abusers do not hit bottom, but die instead. The other
block is high sensitivity to any specific demands that tend to occur in
counseling. These demands can include work to increase inner awareness, work to
take on new demands such as being more assertive, and even tasks as seemingly
innocuous as relaxing or imagining a positive outcome in a job interview.
Generally, these high sensitivities occur in people with high levels of
dissociation and significant trauma histories. Often this is coupled with
difficulty maintaining emotional stability or engaging in normal self-soothing
behaviors. Borderline Personality Disorder involves a challenging mix of these
problems.
One of the most important
areas in which a counselor can grow, is in developing skill in working with
challenging clients in a way that does not alienate or destabilize them. Taking
this on as a professional challenge is very commendable. Some counselors
unwittingly write off such clients or take their behavior personally,
responding in a moralistic, but futile manner.
As scientific study of
mental health yields new information, it challenges moral positions that are so
much a part of our culture that people defend and act them out unconsciously,
but often with very firmly held rationales that do not fully address the
sources of their biases. Polls have shown that much of the American public believe
that persons who exhibit mental illnesses could behave normally if they wanted
to. The high number of persons with mental illnesses in jails is testimony to
the bias toward personal responsibility that overrides current medical
knowledge about the nature of those mental illnesses, and worse, the ability of
the medical and psychotherapy fields to treat and manage those illnesses in
less restrictive and non-punitive environments. If jail is hellish for a person
without a mental illness, that hell must be multiplied many times over for a
person with a mental illness. Such people are not merely sensitive to their
environment and more inclined to regress or decompensate, but are also much
more vulnerable to abuse by other inmates.
Attributions of blame come
from pervasive beliefs of the culture in which they occur. Belief in demonic
possession led to thousands of deaths of persons believed to be possessed or
practicing witchcraft. Bizarre tests for these conditions had no basis in
reality.
As demonic metaphysics
yielded to a more scientific perspective, the bulk of society has managed to
hold onto a more subtle metaphysics of personal responsibility. Often this
perspective is revealed by a simple act of complacence; the statement that a
person is, “just that way.” This implies that there is no explanation other
than free will. This, in turn, implies that there can be no alternative but
making life miserable enough that the person will stop the behavior. In other
words, when suffering, the person is getting what he or she deserves.
This simplistic view fails
to account for the dramatic improvements in behavior and stability that occur
when appropriate treatment is provided. It cannot square itself with the
increased attention, responsibility and academic performance of a child with
attention deficit disorder who receives appropriate medication, nor the veteran
with post traumatic stress disorder who becomes interested in seeking
employment after successful counseling. There was no punishment involved in
such dramatic turnarounds.
Where there is an impulse
on the part of the counselor to punish, write off, or blame the client, the
counselor should carefully inspect the source of such impulses, and make sure
that he or she truly is up-to-date on the evidence-based approaches to the
problem at hand. Morality in a clinical setting should be an expression of
values that contribute to the welfare of clients, not the poorly inspected
acting out of cultural patterns that are based on harmful beliefs such as
demonic possession, the absence of a medical basis for mental disorders, and
the counselor as an authority empowered with the responsibility to dispense
punishment for what he or she had judged to be bad behavior.
The most essential red flag
for the counselor is a sense of impulse that is not well inspected for groundedness in clinical knowledge that can be defended in
terms of the treatment plan and evidence-based practice. Perhaps the key to
today’s morality is in being highly accountable for getting outcomes that express
our highest values.
There is a strong trend in
our culture to be content with beliefs that support our biases and satisfy our
desire to have socially desirable opinions, or at least opinions that are
desirable within our professional community. The satirist Stephen Colbert
refers to this as “truthiness.” This is identical to the concept from George
Orwell’s dystopian and socially critical novel, 1984, of “bellyfeel.”
What matters, though, is
what matters. That is to say, that outcomes are our business. The more research
is available, and the more sophisticated the research becomes, the more we are
challenged to adapt our opinions and practices to new, useful knowledge. It is
very important that counselors not only engage in continuing education, but
that they select educational material and journal articles that are recent and
help the counselor understand current research.
An excellent example of an
important trend in research is the influence of genetics on our understanding
of psychology. Genetics is upending some of our beliefs about the causes of
developmental, behavioral and family problems. Research is showing us that
there is a widespread influence of genetic factors on risk to psychopathology.140
For example, consider the
widely held belief that corporal punishment causes children to become violent.
Genetic research suggests that children are not made more violent by corporal
punishment. Instead, it appears that the more violent or conduct disordered children
are more likely to receive corporal punishment, and are more likely to have
parents who are prone to administering corporal punishment.141 142
One study was this
straightforward, “There is a cross-situational conduct problems' phenotype,
underlying the behavior measured by all informants, that is wholly genetic in
origin. No significant influence of shared environmental effects was found.”143
For many cases, this
knowledge will shift the focus to interventions that assist multiple family
members in reducing incidences of violence, crime, and harmful involvement with
authorities, from the prior focus on preventing corporal punishment as an
isolated problem and cause of violence in minors and adults. Genetic research
is likely to expand the emphasis on systems interventions, which are emphasized
in the training of social workers and family counselors. This kind of systems
thinking is likely to expand attention beyond the victim perpetrator dyad to
include a broader assessment of needs and potential interventions.
The cornerstone of
continuing education is asking what makes a difference in people’s lives.
Adapting to managed care
has posed ethical challenges to counselors. Counselors have been tempted to use
an inaccurate diagnosis in order to get the client’s insurance to cover
treatment, counselors have been troubled by managed care companies refusing to
cover legitimate and necessary treatment, and counselors have been pushed to
provide treatment that is too short where shorter treatment is rewarded with
more referrals regardless of the client diagnosis. Managed care companies
conduct utilization review in which statistics pertaining to each counselor
result in designation of certain counselors as preferred providers for their
referrals. A counselor was told by a managed care executive that she should
consider reducing the ratio of highly traumatized clients she saw, even though
this was her specialty, in order to change her utilization numbers and receive
more referrals.144 Obviously, this recommendation would result in
more referrals of these challenging cases to less specialized and qualified
counselors, and presumable result in poorer outcomes and higher drop out rates.
The economic concept of “perverse incentives” refers to people and systems
reacting to incentives in a manner that is not good for their customers or for
society, especially where there is a duty to society, such as to prevent
pollution or improve clinical services. It is a ponderous issue in managed
care. Peer support can be especially valuable in navigating managed care
issues.
Counselors and other clinicians have
found a number of ways to use electronic communication in conducting and
augmenting therapy. This may include email, instant messaging, and
videoconferencing. This is referred to as telemedicine.
Telemedicine is becoming increasingly
commonplace, and is used to increase the services available to rural areas, and
to provide specialists to areas where such specialists are not readily available.
It is also used to reduce costs by reducing travel, and to increase appropriate
utilization by individuals who have difficulty travelling to the physician’s
office. All of these benefits can apply to counseling so long as certain
standards are applied. There is a growing body of research supporting the use
of telemedicine and telephone contact in counseling.
(Lovell K, Cox D, Haddock G, Jones C, Raines D, Garvey R, Roberts C, Hadley S.,
2006) (Sulzbacher, S., Vallin,
T., & Waetzig, E. Z., 2006) (Carlbring
P, Gunnarsdóttir M, Hedensjö
L, Andersson G, Ekselius L,
Furmark T., Linköping.,
2007) (Shepherd, L., Goldstein, D., Whitford, H., Thewes, B., Brummell, V., & Hicks, M., 2006)
Counselors are cautioned to carefully
consider the risks inherent in telemedicine. It is important to have policies
and procedures in place for responding to interruptions in service, for
evaluating whether a client is appropriate for telemedicine, and for coping
with the limitations inherent in the medium being used. The mood and intent of
a communication can be misperceived more easily when it is not in face-to-face
communication. The provider must be competent in the use of the technology
required for the services he or she intends to provide.
The confidentiality of client information
is at increased risk through telemedicine. The counselor should be fully
competent in protecting privacy when using the desired technology.
Telemedicine makes it feasible to work
with clients who do not reside in the same state as the counselor. The state in
which the client resides may have laws regulating such practice, and it may be
considered an unlicensed practice of psychotherapy and, as such, illegal.
Remember that all the legal and ethical responsibilities apply to your work,
whether or not is occurs through an electronic medium.
Appendix: Texas Administrative Code,
Title 22, Part 30, Chapter 681:
RULE §681.41 General Ethical Requirements
(a) A licensee shall not
make any false, misleading, deceptive, fraudulent or exaggerated claim or statement
about the licensee's services, including, but not limited to:
(1) the
effectiveness of services;
(2) the
licensee's qualifications, capabilities, background, training, experience,
education, professional affiliations, fees, products, or publications; or
(3) the
practice or field of counseling.
(b) A licensee shall not
make any false, misleading, deceptive, fraudulent or exaggerated claim or
statement about the services of a mental health services organization or
agency, including, but not limited to, the effectiveness of services,
qualifications, or products.
(c) A licensee shall
discourage a client from holding exaggerated or false ideas about the
licensee's professional services, including, but not limited to, the
effectiveness of the services, practice, qualifications, associations, or
activities. If a licensee learns of exaggerated or false ideas held by a client
or other person, the licensee shall take immediate and reasonable action to
correct the ideas held.
(d) A licensee shall make
reasonable efforts to prevent others whom the licensee does not control, from
making misrepresentations; exaggerated or false claims; or false, deceptive, or
fraudulent statements about the licensee's practice, services, qualifications,
associations, or activities. If a licensee learns of a misrepresentation;
exaggerated or false claim; or false, deceptive, or fraudulent statement made
by another, the licensee shall take immediate and reasonable action to correct
the statement.
(e) A licensee shall inform
an individual in writing before services are provided of the following:
(1) fees and
arrangements for payment;
(2) counseling
purposes, goals, and techniques;
(3) any
restrictions placed on the license by the board;
(4) the limits
on confidentiality;
(5) any intent
of the licensee to use another individual to provide counseling treatment
intervention to the client; and
(6) supervision
of the licensee by another licensed health care professional including the name
and qualifications of the supervisor.
(f) A licensee shall inform
the client in writing of any changes to the items in subsection (e) of this
section prior to initiating the change.
(g) A licensee shall
provide counseling treatment intervention only in the context of a professional
relationship. Interactive long distance counseling delivery, where the client
resides in one location and the counselor in another may be used as part of the
therapeutic counseling process. Counselors engaging in interactive long
distance counseling must adhere to each provision of this chapter.
(h) A licensee shall not
intentionally or knowingly offer to pay or agree to accept any remuneration
directly or indirectly, overtly or covertly, in cash or in kind, to or from any
person, firm, association of persons, partnership, corporation, or entity for
securing or soliciting clients or patronage for or from any health care
professional.
(1) In
accordance with the provisions of the Act, §503.401(4), a licensee is subject
to disciplinary action if the licensee directly or indirectly offers to pay or
agrees to accept remuneration to or from any person for securing or soliciting
a client or patronage.
(2) A licensee
employed or under contract with a chemical dependency facility or a mental
health facility shall comply with the requirements in the Texas Health and
Safety Code, §164.006, relating to soliciting and contracting with certain
referral sources. Compliance with the Treatment Facilities Marketing Practices
Act, Texas Health and Safety Code, Chapter 164, shall not be considered as a
violation of state law relating to illegal remuneration.
(i)
A licensee shall not engage in activities for the licensee's personal gain at
the expense of a client.
(j) A licensee shall not
promote the licensee's personal or business activities to a client unless the
licensee informs the client of the licensee's personal or business interest in
the activity.
(k) A licensee shall set
and maintain professional boundaries. Dual relationships with clients are
prohibited. A dual relationship is considered any non-counseling activity
initiated by either the licensee or client for the purpose of establishing a
non-therapeutic relationship.
(1) The
licensee shall not provide counseling services to previous or current:
(A)
family members;
(B)
personal friends;
(C)
educational associates; or
(D)
business associates.
(2) The
licensee shall not give or accept a gift from a client or a relative of a
client valued at more than fifty dollars, or borrow or lend money or items of
value to clients or relatives of clients or accept payment in the form of goods
or services rendered by a client or relative of a client.
(3) The
licensee shall not enter into a non-professional relationship with a client,
client's family member or any person having a personal or professional
relationship with a client, if such a relationship could be detrimental to the
client.
(l) The licensee shall not
knowingly offer or provide counseling treatment intervention to an individual
concurrently receiving counseling treatment intervention from another mental
health services provider except with that provider's knowledge. If a licensee
learns of such concurrent therapy, the licensee shall take immediate and
reasonable action to inform the other mental health services provider.
(m) A licensee may take
reasonable action to inform medical or law enforcement personnel if the
professional determines that there is a probability of imminent physical injury
by the client to the client or others or there is a probability of immediate
mental or emotional injury to the client.
(n) In individual and group
counseling settings, the licensee shall take reasonable precautions to protect
individuals from physical or emotional harm resulting from interaction within a
group or from individual counseling.
(o) For each client, a
licensee shall keep accurate records of the dates of counseling treatment
intervention, types of counseling treatment intervention, progress or case
notes, intake assessment, treatment plan, and billing information.
(p) Records held by a
licensee shall be kept for seven years for adult clients and seven years beyond
the age of 18 for minor clients.
(q) Records created by
licensees during the scope of their employment by educational institutions; by
federal, state, or local governmental agencies; or their political subdivisions
or programs are not required to comply with subsections (o) and (p) of this
section.
(r) A licensee shall bill
clients or third parties for only those services actually rendered or as agreed
to by mutual understanding at the beginning of services or as later modified by
mutual written agreement.
(1)
Relationships between a licensee and any other person used by the licensee to
provide services to a client shall be so reflected on billing documents.
(2) On the
written request of a client, a client's guardian, or a client's parent (sole
managing, joint managing or possessory conservator) if the client is a minor, a
licensee shall provide, in plain language, a written explanation of the types
of treatment and charges for counseling treatment intervention previously made
on a bill or statement for the client. This requirement applies even if the
charges are to be paid by a third party.
(3) A licensee
may not knowingly or flagrantly overcharge a client.
(4) A licensee
may not submit to a client or a third payor a bill
for counseling treatment intervention that the licensee knows was not provided
or knows was improper, unreasonable, or medically or clinically unnecessary,
with the exception of an unkept appointment.
(s) A licensee shall
terminate a professional counseling relationship when it is reasonably clear
that the client is not benefiting from the relationship. When professional
counseling is still indicated, the licensee shall take reasonable steps to
facilitate the transfer to an appropriate referral or source.
(t) A licensee shall not
evaluate any individual's mental, emotional, or behavioral condition unless the
licensee has personally interviewed the individual or the licensee discloses
with the evaluation that the licensee has not personally interviewed the
individual.
(u) A licensee may not
persistently over treat a client.
(v) A licensee shall not
aid and abet the unlicensed practice of professional counseling by a person
required to be licensed under the Act.
(w) A licensee or an
applicant for licensure shall not participate in any way in the falsification
of applications for licensure.
(x) A licensee shall comply
with the requirements of Texas Health and Safety Code, Chapter 611, concerning
the release of mental health records and confidential information.
(y) A licensee shall establish a plan for the custody and control
of the licensee's client mental health records in the event of the licensee's
death or incapacity, or the termination of the licensee's counseling practice.
A licensee shall inform each client of the plan.
End of text. You may now take the course quiz
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End of text. Now take the course quiz.
