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Apr 18, 2017

Ethical Considerations for First Year Counselors

During the last several years I’ve had the amazing opportunity to work in multiple settings alongside new, student, and very experienced counselors. I didn’t set out with the intention of becoming the “counselor whisperer”, but circumstance and perhaps my approachability placed me in the unique position of mentor and advocate, particularly with new and student counselors.

I’ve truly enjoyed the professional relationships I’ve developed with these colleagues and the things they’ve taught me along the way. Despite any school’s diligent effort to fully prepare students for the situations they’ll encounter during practicum or after graduation, there are some circumstances and events that just aren’t things we can train for beyond a familiarity with our code. Perhaps when a problem is in text, it remains two dimensional and therefore unlikely, or it seems less serious. There’s also an underlying belief that most students and new counselors hold that most counselors and counseling agencies will have ethical standards as high as those we in the ACA do.

When you’re in the situation and there are people, who you know and care about affected, things can become a bit overwhelming.

Some issues or circumstances may be specific to a region, local economy, community attitude toward mental health and other situational factors. Others are more universal. About 75% of my networking and interaction with new and student counselors occur in north central Texas. It’s a rural setting with some unique challenges. The other 25% is with colleagues who reach out to me from across the United States and not surprisingly, I hear similar things from counselors in many cases.

Here’s a look at some of the issues that I hear new counselors experiencing most often:

  1. 1.Upcoding. New and student counselors are very likely to find first jobs or internships within publicly funded mental health care. Public funding is great, because it increases access to mental health services for people without regard to income. It’s not so great because it comes with a list of rules about who can receive services and who can’t. Those rules aren’t always based on need, either. They’re often based on the specific diagnosis a person receives during their intake. If a person doesn’t receive a diagnosis that is covered for care (in Texas we call these the “Big 5”, it’s a specific group of disorders) then he or she doesn’t qualify for services. Sometimes to get a person the care they need the in house psychiatrist or intake coordinator “upcodes”; they escalate the diagnosis from what it really is to something that qualifies them for services. This is justified by telling interns or students that without the upcode, the person gets no care.
  2. Upcoding ruffles my ethical feathers because it means that a person’s medical records now contain an inaccurate diagnosis. A person has now received a label that may have a negative impact on their self-worth. The choice to upcode and stick labels in both files and on people for services when the person may have a diagnosis that doesn’t fall within the covered diagnoses is made by the clinician rather than by explaining this to the client and allowing them to choose based on understanding what is happening.

  3. Confidentiality Violations. Regardless of what setting a new counselor finds themselves in they are likely to observe clinicians, secretaries, and other employees in the office talking about clients in the hallway, leaving names on slips of paper in message boxes, searching for clients on social media to scope them out or gather data someone forgot to fill in, and other confidentiality breeches.

    Each of these things is unethical and in some cases in violation of state or federal law governing protected health information or PHI. The sources of this problem are many: overworked staff members, improperly trained support staff, legal loopholes for certain types of agencies that mean they don’t have to comply with HIPAA regulations, loopholes that allow unlicensed (but educated as or similarly educated) counselors people to work directly with clients while simultaneously having no license to protect and no ethics code to uphold.

  4. Unethical or Unprofessional Expectations. If you’re a student in a CACREP program, you must be under faculty AND site supervision to see clients. There are several reasons for this, including, but not limited to, an inability of the school’s insurance policy to cover students not actively enrolled in the event of harm or wrongdoing, inadequate supervision when faculty members are not engaged in your ongoing supervision, and the poor ethics of any agency that receives payment for services you perform (through grant, public funds, insurance, or any other source) to expect you as a student to continue to work for said agency without benefit of log-able hours (because if you’re not in class you can’t log your hours); this is like working for free but in double time, because you already are an unpaid intern, but now you’re not even able to count hours.

    In the nonprofit or public setting as an intern, paid or unpaid, you may be required to work long hours to meet the needs of your agency. You may find that clients that see you at 7p.m. aren’t getting the best of your work because you’ve been at it since 7a.m. with no substantial break.

    You may be asked to schedule appointments for 45 minutes, even though your clinical judgment tells you that an hour is best for your client.

    You may have been to the doctor and received disturbing news, have a death in your non-immediate family, or a sick child to tend you and feel impaired and unable to provide the best service for the time being. You may need a mental health day for yourself, but be unable to take it or receive open criticism for attempting to do so and be intimidated into working when you shouldn’t.

  5. Lack of Licensed Counselors in Supervisory Roles. In the non-profit and public agency settings there are multiple licenses that may end up supervising people who hold different licenses. There are some people who may not even be licensed by any board for anything that work their way into leadership roles. This can be detrimental to the development of new counselors and the integrity of the profession.

When you experience any of the concerns above and take them to your onsite supervisor, he or she may be unable to provide you with appropriate ethical guidance, because they operate under a completely different set of ethical standards. Because other professionals have less to risk, or different sets of rules, different professionals will guide counselors in ways that may not be in keeping with our ethical standards at all. They may even show an open disregard for the standards that we operate under. No one on site may have the expertise, education, or familiarity and dedication to the same standards you do, which leads to a lack of support for new and learning professionals. This issue contributes a great deal to new counselor burn out.

What do you do when these sorts of disasters strike and you’re a new or student counselor?  

Talk to your faculty or license supervisor and make them fully aware of what is happening in the setting you’re in. Follow their instructions on handling these situations. Follow agency procedures for solving ethical issues within the company. Document everything.

If your license supervisor tells you the situation is one you need to leave, leave it. Do not pass “Go”. Do not collect $200. Begin your search for a new site; prepare your letter of resignation. Don’t risk the hard work of your education, the value of your license, your professional integrity, the integrity of the profession itself, or the welfare of the clients by continuing to support an environment that operates questionably.

If more of us did so, fewer agencies would be able to operate “in the gray”, and more would adapt to the reasonable ethical standards of our industry. They would have to adjust - or they would have to stop counseling because there would be no counselors to provide the services they offer.

When and if it still seems fuzzy, ask yourself: Are the clients my agency serves helped by the behaviors the agency staff, counselors, and supervisors exhibit? If the answer isn’t a resounding and definite, immediate, “YES!” then it is time to move on.

While it is easy to argue with yourself about how hard it is to find a site for supervision, how painful it would be to have to complete another term of internship, how if you leave then no one at the agency is going to be looking out for clients, and make sense of staying from that, remember that this speech is the precursor to serious burn out. An entire agency and the wellness of each client it serves can’t rest on the shoulders of a single counselor. That counselor will collapse under the pressure.

You are a counselor. You are not a superhero (even though we all know the work we do is super!).

Seeking supervision, consultation, and help through mentorship for yourself as you complete school required internships and license requirements is vital to your growth, giving people the best possible service, professional success, and your well-being.
Whitney White is a counselor working in Texas in multiple settings with diverse populations. Some of her areas of passion are anxiety, non-suicidal self-injury, and compassion fatigue. With an integrated approach utilizing client strengths, she supports others in achieving their best self. For more information please visit The thoughts expressed in Whitney’s blogs do not represent her employers. 



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1 Comment

  1. 1 Adam Marin 21 Apr
         Hello Whitney, love the article by the way. I am a student counselor that is only 600 hours from achieving my masters in CMHC. I can definitely relate to the issues you discussed, especially upcoding. I recently did a two month internship at a local behavioral health hospital. I observed licensed therapist upcoding a client's true diagnosis in order to get the care that they need. On your point that clinicians make this decision, in my opinion, I think upcoding without having the client make the decision or at least being aware of what is happening is even more unethical than the act itself. Clinicians that do this are breaking a fundamental principle of autonomy. By making these choices without discussing the action to the client is basically controlling the direction of the client's life. Once a diagnosis becomes recorded, it will forever be a part of the client. This means that this inaccurate diagnosis may have a negative impact on the client going forward. As a counseling student and learning quickly in the program that changing diagnoses is unethical. It also made me question the ethical standards at the internship. 


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