Medical Ethics in Mental Health Counseling: Interview Analysis

Introduction to Professional Counseling and Mental Health

Healthcare providers include nurses, doctors, social workers, and a number of other professions that exist on the periphery of the helping field. One of those on the outside — one that many do not consider when looking at the healthcare profession — is the professional counselor. Since the term "counselor" has been diluted by everyone from friends to lawyers, it is often unclear what one is talking about when using such a generic occupational title. Nevertheless, professional counselors are vital members of the healthcare field. These individuals work in hospitals, nonprofits, and private offices, serving couples, individuals, and groups.

Interview: Ethics in Practice

Among the many specialties within the professional counseling field is that of mental health counselor. As the number of individuals diagnosed with a mental illness has risen in recent years, so too has the demand for mental health counselors. Alongside other healthcare professionals, counselors work with people who have a mental illness to help them live successful lives in the larger society. This paper presents an interview with a mental health and substance abuse counselor who has 14 years of experience working in hospitals and nonprofits, and who is currently employed at a hospital-alternative, short-term residential facility for individuals with acute mental illness.

I first started as an intern at two facilities while completing my master's degree. I worked with teenage boys who had some form of acquired brain injury, and also in a residential facility for individuals with acute mental illness. During college I also worked with young men involved with the Department of Corrections because of drug convictions — the program was a rehabilitation alternative to jail or prison. After college, prior to my present job, I worked as a counselor in a hospital setting for patients in a locked facility, as a case manager for high-functioning individuals who needed some degree of advocacy, and as assistant director of a residential program for children and teens whose parents were, for various reasons, involved with the Department of Child and Family Services. Currently I direct a program that houses individuals on a very short-term basis — usually about a two-week stay. The clients have some previous, acute mental health diagnosis that has been active just prior to their admittance to the program (Arnold, 2011).

Primarily, I believe that respect is the most important ethic that anyone can have. The people I work with have generally been on the fringes of society. Because of their persistent diagnoses, they have not been able to function successfully in society for the most part, and many times they have little chance of doing so. They receive many different reactions from the people they encounter on a daily basis, but not many are accorded even rudimentary respect for who they are as a person. Most of the time, all anyone sees is the diagnosis — and in most cases it is readily apparent that something is very different about my average client. However, every single one of these individuals has the same need to be accepted and respected as a member of society. That is what I hope to give them (Arnold, 2011).

Analysis: The ACA Code of Ethics and Business Pressures

Far too many to mention. As a director, I also have to look at the good of the organization I represent. Unfortunately, even a nonprofit is constrained by money, and there are certain requirements to maintain the government assistance we depend on. The reputation of the organization must also be maintained. These two factors mean that I need to keep the facility safe and operating efficiently. In one such case, we had a client who had been at the facility multiple times and was asking for re-admittance due to an increase in psychotic symptoms. Company policy is that an individual may not return to the same facility within a year of their last admittance date. Since there are five other programs of the same type operating, this is usually not a problem — but at this particular time, none of the other facilities had a bed available. We were forced to turn him away. We asked that the requirements be relaxed just this once, but the beds in our facilities are at such a premium that it could not be done (Arnold, 2011).

I work with around 40 other counselors in my facility, as well as a team of three or four nurses and three psychiatrists who visit on certain days. Whenever a situation arises that has an ethical component, I always seek the advice of one or several of these professionals. I have long believed that it is wise to seek counsel, and unwise to try to make a decision on my own. Although I realize that I often have the ultimate responsibility for a decision, I want to consider every possible option (Arnold, 2011).

There are many times that I should have advocated for a client that I did not, because I did not wish to "rock the boat," so to speak. During my college years, I was hesitant to counter what a nurse, doctor, or licensed counselor said regarding a client, even if I knew better based on having spent more time with that individual. Now, I try to always think about the client and that person's needs first. I have no problem questioning what another team member says with regard to treatment, and I always seek the advice of junior staff — even interns — who have more face-to-face dealings with specific clients (Arnold, 2011).

The counseling code of ethics is similar to most of the other codes that helping professions follow (ACA, 2005). Drawn from the original Hippocratic Oath, the first and most important tenet seems to be to do no harm (MedTerms, 2011). The first section of the ACA Code of Ethics addresses "The Counseling Relationship" (ACA, 2005), and everything else in the code appears to stem from that foundational principle. In looking at how counselors view ethics, Ponton and Duba (2009) noted that counselors seem to be increasingly engaged in the business of counseling rather than the care of clients — and this tension is evident throughout the interview conducted here.

Research has identified a trend toward business-oriented care rather than client-centered care, and this shift has multiple causes and consequences. The main reason that nonprofits are drawn to a business model is that it helps them stay in business. With increasing competition within the industry, organizational success appears more tied to sound financial practices than to clinical outcomes. Reputation is built as much on financial performance as on client welfare. There is also increased pressure from funding agencies to ensure that nonprofits are running their operations as efficiently as possible, and since funds are at a premium, efficient management of available resources has become essential.

The primary negative consequence of this trend is that client-centered care can take a back seat to efficiency. This is also, very clearly, an ethical problem, because it means that people are not always the primary concern of managers — and sometimes not even of direct service staff. Clinicians must weigh the needs of current clients against the sustainability of the organization that serves future clients. The ethical implications are twofold: first, the current client deserves the best care possible, and the agency is bound by an ethical contract to treat that person to the best of its ability. At the same time, the agency has a duty to future clients to remain in operation. Providing for the needs of future clients is just as valid an ethical obligation as providing for the clients currently being served.

Conclusion: Navigating Ethical Dilemmas

This exercise has proven that there is no easy solution to an ethical dilemma, and that there are often two very compelling cases to be made on opposite sides of the issue. The interview with this experienced mental health counselor demonstrates that ethical practice in counseling requires constant vigilance, collegial consultation, and a willingness to advocate for clients even when doing so is uncomfortable. The tension between business efficiency and genuine client care is unlikely to disappear, but awareness of that tension — and a firm grounding in professional ethical codes such as the ACA Code of Ethics — provides counselors with a framework for navigating it as thoughtfully as possible.