Ethics Consultation in Rehabilitation Counseling

Advisory Opinions

Serving 2-year terms, the CRCC Ethics Committee comprises six members, including a chair who is appointed by the president elect of the CRCC Board. The remaining members are elected through an open Call for Applications process. Although CRCC is committed to maintaining diverse committee composition with regard to age, gender, ethnicity, and geographical location, an even greater emphasis is placed on encouraging a diverse composition with regard to work setting. Also considered, but not required, is prior experience with ethics such as having taught a course in ethics or participated on other committees or taskforces where ethics was a component of the issues discussed.

In line with the mission of the CRCC Ethics Committee, which is to educate and to prevent violations that are detrimental to the safety and welfare of clients, the CRCC Ethics Committee provides consultation in the form of advisory opinions to inform its members. Formal requests for an advisory opinion must be made in writing and submitted to CRCC headquarters. Once received, the request is reviewed by the Ethics Committee at the next quarterly meeting. After a careful analysis of the information provided, if the Ethics Committee determines that the Code does not provide clear guidance on its own, then an official advisory opinion is provided to clarify the ethical duties and responsibilities. The advisory opinions are rendered in response to limited, unverified information provided to the Ethics Committee and are therefore not to be construed as direct or legal advice. Rather than offering a solution to a specific problem, the intent of an advisory opinion is to provide more general clarification and/or guidance regarding how to interpret specific ethical standards. Furthermore, the Ethics Committee does not offer opinions regarding requests in which there appears to be a violation of the Code. In such cases, the Ethics Committee recommends the filing of a formal complaint to allow a full adjudication of the potential violation. Further information is available on the CRCC website (www.crccertification.com/pages/advisory_opinions/129.php).

Present Study

As the Code is a “living document” that must continually evolve in anticipation of emerging ethical issues (Tarvydas et al., 2010), an in-depth inquiry into the content of advisory opinions may provide insights into sections and standards within the Code that have required the most clarification over time (Koch, Niesz, & McCarthy, 2014). Whereas Shaw and Lane (2008) focused on requests as well as formal advisory opinions, the present study explored only the content of the actual advisory opinions rendered by the CRCC Ethics Committee, which are available on their website. As such, the guiding research question was “What sections, standards, and topical descriptors were most often addressed in the advisory opinions?” Considering that the current 2010 Code includes new and enhanced requirements, standards, and sections, a companion study to Shaw and Lane’s work is timely. Focused on the advisory opinion archive over the 17-year period from March 1996 to October 2013, the purpose of the present study was to explore the nature of all CRCC advisory opinions historically as well as more recently.

Method

Using an “inductive” approach to qualitative analysis, data analysis began with a coding template in mind with data organized according to an existing, though alterable structure (Hsieh & Shannon, 2005; Zimmer, 2006). Alterability was important as one aim of this study was to adapt, expand, and in general, improve on our understanding of the content of the advisory opinions with respect to emerging patterns. Pre-established by the CRCC Ethics Committee itself, data for this study were extracted from the CRCC advisory opinion archive that is categorized by section, standard, and topical descriptor. The topical descriptors specified the issue involved in the requests (e.g., disclosure, legal, confidentiality, forensic and indirect services, and informed consent). In addition to a manual analysis, the NVivo10 software program (QSR International Pty Ltd., 2012) was utilized to systematically inspect the data. A text search summary was then used to analyze word frequencies. In analyzing the data, the researchers identified the sections of the Code, specific standards, and topic descriptors most commonly referenced in the advisory opinions as the source classification and organized them into nodes. As a follow-up to the descriptive analysis, the researchers examined trends within the topic descriptors of the individual advisory opinions. Specifically, content analysis traced repeated trends in the structural categories of language and terminology. For instance, Figure 1 illustrates the coding scheme used to further analyze the larger structural category of Disclosure. Through this iterative process, recurring sub-codes were nested within the larger structural categories (Saldaña, 2013). Finally, to confirm the validity of structural categories and to heighten trustworthiness (Hsieh & Shannon, 2005), the researchers triangulated patterns across the referenced sections and standards of the Code for each advisory opinion.

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Figure 1.

Text search query.

Most of the advisory opinions cited more than one standard and topical descriptor, so the overall number of sections, standards, and topical descriptors is higher than the actual number of advisory opinions. Furthermore, over time, the structure and standards of the Code have evolved; the present study used the current 2010 Code standards. As a companion article to the Shaw and Lane (2008) study, comparisons were made between trends over the 10-year period from 1996 to 2006 as well as trends since that study over the 7-year period of 2007 to 2013.

Results

Over the 17-year period from March 1996 through November 2013, a total of 127 advisory opinions were provided by the CRCC (2013) Ethics Committee. Of these, 91 (71.6%) were provided during the 10-year period between March 1996 and November 2006, whereas 26 (20.5%) were provided during the 7-year period between March 2007 and November 2013. Of these, the majority of opinions (n = 104, 81.9%) were in response to requests submitted by CRCs, whereas 23 (18.1%) responded to requests from other stakeholders (i.e., employers, practitioners providing direct services, attorneys, clients, and students). A close inspection of the content of the opinions may reveal insights into what types of ethical issues have required the most clarification.

Sections of the Code

Overall, the 127 advisory opinions referenced a total of 470 citations to specific sections of the Code (see Table 1). To begin, the most referenced section was Section A: The Counseling Relationship as cited in 135 of 470 (28.7%) opinions, followed by Section B: Confidentiality, Privileged Communication, and Privacy as cited in 89 of 470 (18.9%) opinions. Taken as a whole, these two sections accounted for slightly less than half (47.6%) of the citations to sections of the Code.

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Table 1.

Sections of the Code.

Section	n	%
Preamble	5	1.1
A. The Counseling Relationship	135	28.7
B. Confidentiality, Privileged Communication, and Privacy	89	18.9
C. Advocacy and Accessibility	5	1.1
D. Professional Responsibility	52	11.1
E. Relationships With Other Professionals	33	7.0
F. Forensic and Indirect Services	44	9.4
G. Evaluation, Assessment, and Interpretation	17	3.6
H. Teaching, Supervision, and Training	6	1.3
I. Research and Publication	2	0.4
J. Technology and Distance Counseling	12	2.6
K. Business Practices	12	2.6
L. Resolving Ethical Issues	58	12.3
Total	470	100

Source. Commission on Rehabilitation Counselor Certification (2010).

Section L: Resolving Ethical Issues was the next most common with 58 of 470 citations (12.3%). In many ways, the high number of opinions addressing the resolution of ethical issues suggests that one tenth of the advisory opinions are in response to current ethical dilemmas, and the advisory opinion is intended to clarify the CRCs’ ethical duties and responsibilities. For instance, in many of the opinions, CRCs were reminded of the importance of consulting the laws and statutes in the jurisdiction in which they practiced to determine reporting requirements and action steps necessary to fulfill their professional and ethical responsibility. Relatedly, Section D: Professional Responsibility was another frequent section with 52 of 470 citations (11.1%), indicating that many of the advisory opinions clarified CRCs’ scope of practice as well as their ethical responsibilities and duties with respect to addressing ethical issues.

Finally, Section F: Forensic and Indirect Services was cited in 44 of the 470 (9.4%) opinions. In addition, the related Section G: Evaluation, Assessment, and Interpretation was cited another 17 (3.6%) times. As found by Shaw and Lane (2008), there continues to be a high number of advisory opinions related to forensic rehabilitation, one of the fast-growing areas of rehabilitation practice (Barros-Bailey, Carlisle, & Blackwell, 2010). The rest of the citations were spread out across the remaining sections of the Code.

Specific Standards

In addition to sections of the Code, the most frequently referenced standards were examined (see Table 2). Among the most common standards, there were 310 total citations. Of these, the most commonly cited standard was A.3.a. Professional Disclosure Statement with 79 of the 310 (25.5%) citations, accounting for approximately a quarter of the most frequent standards. When analyzed over time, professional disclosure was noted in 49.5% of the advisory opinions from March 1996 to November 2006 compared with 55.5% of the advisory opinions from March 2007 to November 2013, which is relatively consistent.

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Table 2.

Most Frequent Standards.

Standard	Title	n	%
A.3.a	Professional Disclosure Statement	79	25.5
L.2.c	Conflicts Between Ethics and Laws	37	11.9
A.1.a	Primary Responsibility	23	7.4
F.1.a	Primary Obligations	23	7.4
F.1.d	Indirect Service Provision	23	7.4
B.1.b	Respect for Privacy	20	6.5
E.1.c	Employer Policies	20	6.5
A.3.b	Informed Consent	17	5.5
D.1.a	Boundaries of Competence	16	5.2
B.2.d	Minimal Disclosure	15	4.8
A.1.c	Employment Needs	14	4.5
B.1.d	Explanation of Limitations	12	3.9
E.1.b	Questionable Conditions	11	3.5
Total		310	100

After professional disclosure, L.2.c: Conflicts Between Ethics and Laws was the next most referenced standard as cited 37 (11.9%) times. Relative to the absolute number of advisory opinions, the percentage that addressed conflicts between ethics doubled from March 1996 to November 2006 compared with March 2007 to November 2013, from 23.1% to 50.0% of advisory opinions. Thus, there was a relative increase in consultation requests clarifying the impact of laws and legislation on the profession and practice of rehabilitation counseling.

The remaining most frequently cited standards were relatively spread out. Rather than examining each one separately, related standards were examined collectively. To begin, several of the standards related to the primary roles and responsibilities of CRCs with respect to their clients. Specifically, the following standards were frequently cited across all of the advisory opinions: A.1.a. Primary Responsibility (n = 23; 7.4%), A.3.b. Informed Consent (n = 17; 5.5%), F.1.a. Primary Obligation (n = 23; 7.4%), and F.1.d. Indirect Service Provision (n = 23; 7.4%). Sharing a common characteristic of defining the primary roles and responsibilities of CRCs across different employment settings, individually each of these standards was cited more frequently in recent years, in part, because the standard did not exist in previous versions of the Code. Taken as a whole, the four standards listed above were cited in 44.0% of the advisory opinions from March 1996 to November 2006 compared with 84.6% from March 2007 to November 2013, which is almost doubled.

In addition to clarifying that the CRCs’ primary responsibility is to their client, a second group of related standards involved Section B: Confidentiality, Privileged Communication, and Privacy. In terms of the most commonly cited standards, the following standards were mentioned across all of the referenced advisory opinions: B.1.b Respect for Privacy (n = 20; 6.5%), B.2.d. Minimal Disclosure (n = 15; 4.8%), and B.2.d Explanation of Limitations (n = 12; 3.9%). As a percentage of the absolute number of advisory opinions over time, the number of advisory opinions addressing these standards decreased. Indeed, when compared with November 2006 to March 2007, the absolute number of advisory opinions addressing one of these three standards decreased from 37.4% to 26.9% from March 2007 to November 2013, indicating a decrease in the number of advisory opinions addressing confidentiality. The decrease is surprising given the heightened questions around security, especially with respect to the safe transfer of confidential client information in the age of information technology.

Finally, there was also a decrease in the absolute number of advisory opinions that addressed employer policies. Among the most frequently cited standards, the following were common across all of the advisory opinions: E.1.c. Employer Policies (n = 20; 6.5%) and E.1.b. Questionable Conditions (n = 11; 3.5%). Similar to confidentiality, the percentage of these standards decreased from 22.0% to 15.4% from March 1996 to November 2006.

Topical Descriptors

Although analysis of the most frequently cited sections of the Code as well as specific standards is an important consideration for future Code revisions, the topical descriptors of the advisory opinions are perhaps more important for practitioners. Given the most frequently standards cited described above, topical descriptors ranked in a descending order are shown in Table 3. Topical descriptors addressing the area involved with disclosure of clients’ rights in the counseling relationship were the most frequently assigned in 56 (30.4%) of the advisory opinions. The next frequently assigned topical descriptors addressed legal (n = 40; 21.7%) and confidentiality (n = 38; 20.7%) issues. The topical descriptors addressing questions regarding dual roles and the provision of indirect services were denoted next (n = 26; 14.1%). Finally, topical descriptors related to informed consent between counselors and clients were found in 24 (13%) of the advisory opinions. Each of the most frequent topical descriptors is discussed in the following sections.

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Table 3.

Most Frequent Topical Descriptors.

Topical descriptor	n	%
Disclosure	56	30.4
Legal	40	21.7
Confidentiality	38	20.7
Forensic and indirect services	26	14.1
Informed consent	24	13.0
Total	184	100

Disclosure

Standards related to disclosure have evolved considerably across the 1987, 2002, and 2010 Code revisions. For instance, today disclosure must be written and address specific information, including (a) an explanation of the knowledge, credentials, and expertise relevant to the services to be provided; (b) identification of role and role changes; (c) scope and limits of information and services among treatment team members, attorneys, employers, and other involved responsible parties; (d) consequences of deferring, refusing, and participating in services; (e) risks associated with social networking and other electronic means; and (f) legal issues affecting services. In addition, standards within the Code have evolved to explicitly note CRCs’ obligation to engage in full disclosure at the outset with reiteration or expansion throughout the counseling relationship. Finally, ethical practices in rehabilitation have evolved to the point where case documentation is encouraged, and in many instances, there is a need to document both verbal and written disclosures. Related to informed consent, disclosure has become a standardized procedure that is required in virtually all rehabilitation work settings.

The following example represents an opinion rendered involving professional disclosure:

The Committee considered a request for an advisory opinion regarding several questions related to informed consent and professional disclosure within the workers’ compensation setting where the carrier or accreditation standards mandate the use of certain documents in relation to informed consent and disclosure. The Committee responded first by clarifying that CRCs are now mandated to use written disclosure statements in accordance with Section A.3.a of the Code. Further, that this response will address a CRCs obligation with respect to the Code as opposed to any requirements established by an accrediting agency.

Importantly, this advisory opinion reaffirms that written disclosure is a requirement. Furthermore, the advisory opinion reinforces the obligation of written informed consent, even in situations in which an agency does not have that requirement.

Legal

Emerging from the state–federal vocational rehabilitation system, the profession of rehabilitation counseling has always been affected by federal legislation and laws. However, given the increasing complexities surrounding healthcare reform as well as the corresponding access to legal information, requests for consultation involving legal issues may continue to increase. An opinion appearing in the archive involving conflicts between ethics and laws is demonstrated in the following example:

The Committee considered a request for an advisory opinion with regard to whether CRCC’s Code of Professional Ethics for Rehabilitation Counselors precludes the provision of services to undocumented workers. The Committee responded that CRCC’s Code requires that individuals comply with legal requirements in the jurisdiction in which they practice and observe legal limitations of services they offer to clients. Should such legal requirements or limitations prohibit the provision of services to undocumented workers, the Code would require that a CRC does not engage in any such service provision.

In this advisory opinion, the Ethics Committee is noting that CRCs must comply with legal requirements in the jurisdiction in which they practice, including instances of undocumented workers, which is a larger political and social discussion in the United States (Correales, 2003; Thomas, 2010).

Confidentiality

As the cornerstone of the counseling relationship, confidentially remains a perennial concern. As demonstrated in the following example of an opinion appearing in the archive that involved confidentiality and respect for privacy, rehabilitation counselors do not share confidential information without consent from clients or without sound legal or ethical justification. Furthermore, CRCs must obtain written permission from clients to disclose records to legitimate third parties:

The Committee considered a request for an advisory opinion as to whether it was appropriate to furnish reports for clients other than those in the case in question. The Committee responded that the request appears to be a simple request from an attorney where the certified individual has no obligation to respond.

Forensic and indirect services

As a growing area of practice, advisory opinions addressing forensic and indirect services have become more and more common, a trend that is likely to continue into the future. An example below is an opinion rendered in the archive involving forensic and indirect services:

The Committee considered a request for an advisory opinion with regard to the obligation to a client in disclosing information, writing reports, and making recommendations without the client’s participation, knowledge, input or consideration when the client was initially interviewed and evaluated by the rehabilitation counselor. The Committee responded that the obligation is dependent upon the reason for the referral, which should have been disclosed to the client at the outset of services.

This advisory opinion reinforces an understanding that CRCs who engage in the provision of forensic and indirect services have an obligation to disclose the rights and responsibilities of both counselors and clients at the onset of services.

Informed consent

Related to disclosure, the concept of informed consent has evolved considerably over the course of the Code revisions. Becoming much more explicit in what informed consent truly means, including a differentiation between consent and assent for individuals who have legal guardians, the notion of informed consent is much larger than just providing information. In fact, it is the ability to help clients synthesize the overwhelming amount of information available on the Internet. With so much information available, it is relatively easy for rehabilitation professionals to provide a one-sided argument for a type of service or treatment. Thus, it is becoming more and more important to provide at least two good options for clients and then help them to navigate the virtually limitless amount of information available in today’s digital age.

A request for an advisory opinion with regard to several questions about electronic communications was found in the archive. The questions and the Committee’s response to one such request are detailed as follows:

Q:

How does CRCC review electronic sharing of case notes? What is the CRCs obligation to inform our clients of confidentiality limitations in this situation? Is it inappropriate to share some or all of typical case notes recorded in the vocational counseling process electronically? What does CRCC view as minimal disclosure?

A:

Disclosure and informed consent are critical in every situation, but come to the forefront given this method of recording data. Furthermore, it is necessary that CRCs understand what is essential and vocationally relevant in a matter. The organization may need to provide additional training to staff members so that they understand these concepts.

This advisory opinion makes it clear that CRCs are held to the same level of expected behavior and competence regardless of the technology or its application, specifically in regard to disclosure and informed consent.

Discussion

Taken as a whole, an absolute number of 127 advisory opinions over the 17-year period indicates that the CRC membership as well as the CRCC Ethics Committee is actively involved in viewing the Code as a “living document” that requires narration and interpretation (Tarvydas et al., 2010). In addition to the analysis of trends in the sections, standards, and topical descriptors of the advisory opinions, it may be useful to consider broader themes, which may inform future Code revisions.

Future Directions

In sum, the results of the present study suggest some trends with respect to the content of advisory opinions historically and more recently. As part of the purpose of the present study, these findings are particularly useful in considering directions for future Code revisions. Importantly, the identification of perennial issues, such as disclosure and confidentiality, must be reexamined with respect to anticipating changes in society, as well as the practice of rehabilitation counseling. As such, it is important to consider the potential implications for rehabilitation counseling professionals.

First and foremost, it is critical that all CRCs read through the advisory opinion archive from time to time as a complement to periodically reviewing the Code itself. Rather than a static set of universal, impartial ethical rules, the Code is a “living document” that requires narration and interpretation (Tarvydas et al., 2010, p. 195). Thus, the advisory opinion archive is an excellent resource for students and professionals in the field to become more comfortable with applying ethical standards to practice. Furthermore, as a source of consultation, the opinions are intended to be much broader than for an individual situation, but rather intended to illuminate and provide additional guidance to all CRCs. Thus, educational courses on ethics can use the archive to examine the ways in which ethical standards are situated within a particular employment context. Thus, the advisory opinion itself may be an excellent resource for future educational initiatives.

In addition to designing educational outreach, the CRCC Ethics Committee periodically reviews the advisory opinion archive as a way to note historic and more recent trends. Providing a lens to identify the topical descriptors and specific standards that have required the most clarification, the CRCC Ethics Committee can use the results of the present study to inform future Code revisions. In addition to noting the most common areas, such as disclosure and conflicts between ethics and the law, it is important to note the relative decrease in consultation requests addressing confidentiality and privileged communication, especially in today’s digital age. The absence of advisory opinions may mean that the Code provides enough guidance. At the same time, it may mean that the Code simply does not address emergent areas, such as social media, in which guidance would be particularly helpful. For example, digital technology is clearly an emerging ethical issue (Chapin & Byrne, 2013); however, the current Code does not address the use of social media. As social media continue to evolve, we are likely to see more explicit oversight regarding the use of social media in rehabilitation counseling. As a glimpse into the future, the Code of Ethics of the American Counseling Association (ACA; 2014) was recently revised and now contains specific standards addressing the use of social media in counseling. The standards established in the ACA revision focused primarily on the nature of the virtual presence of both the counselor and client, as well as protecting the privacy and confidentiality of the client. In addition, these new standards do require that counselors clearly explain to clients “the benefits, limitations, and boundaries of the use of social media” (ACA, 2014, p. 17) as part of the informed consent process. Similarly, in the near future, revisions to the CRCC Code may include specific ethical standards regulating the use of social media in rehabilitation counseling. In the future, there may be an increase in advisory opinions addressing Section J: Technology and Distance Counseling as it intersects with Section A: The Counseling Relationship and Section B: Confidentiality, Privileged Communication, and Privacy, which historically have been the most commonly addressed sections of Code across the advisory opinions.

Limitations

There were limitations to this study that may restrict the interpretation but do not negate the findings. First, the study analyzed the content of the advisory opinions provided by the CRCC Ethics Committee, which may or may not reflect the most common ethical dilemmas in the field. Furthermore, the present study was descriptive in nature and the interpretation of the trends was limited. In addition, as with all analyses involving textual content, the building of thematic categories involved an interpretative process, which does not allow for generalizability (Merriam, 1998). Finally, as an evolving document, the Code has changed over time, which makes it difficult to identify trends in the nature of violations over time.

Conclusion

The aim of the present study was to provide a content analysis of the advisory opinions provided by the CRCC Ethics Committee from 1996 to 2013. Overall, the study found that the CRCC Ethics Committee has been in regular dialogue with CRCC members with respect to ethics consultation that resulted in 127 advisory opinions over a 17-year period. Although the absolute number of advisory opinions is good news, further discussion in the field is needed to ensure that the Code remains relevant to practice. Thus, it is not enough to consider the content of the advisory opinions, but we must also use the knowledge of the past to anticipate future ethical problems within the profession and practice of rehabilitation counseling.