Ethical counseling flows from informed consent. As a counseling professional, it is your job to make sure clients, students, and parents understand and consent to the rules and parameters of counseling—including the limits of confidentiality.
Informed consent is a clinical process that involves written documentation, an oral description, and an opportunity for questions and discussion. The process and documentation capture the professional background, the theoretical orientation(s), agency or school policies, emergency policies and procedures, and other matters specific to your setting, but in this text we only provide guidance for the portions related to potential suicidality.
If you are currently working with clients, students, or patients without a standard informed consent process, we highly recommend you develop one and use it. Both you and your clients are at risk without a clear informed consent document and process. There are three distinct but related components to informed consent. We cover these components here, with examples that may need fine-tuning depending on your setting.
Confidentiality and Its Limits
When clients, students, or others in distress talk with mental health or school counseling providers, they usually assume that what they say will be held in confidence. This is mostly true, but confidentiality exists only when a formal professional relationship has been established. For example, if teachers contact you about student behavior or parents contact you and offer information about their child, you may or may not be required to hold that information confidential. These are situations when you should spell out limits of confidentiality in advance, before inaccurate assumptions take hold.
It is up to you to explain what you can and will keep confidential and what you cannot keep confidential. Intent to harm oneself or others is an almost universal reason for mental health, health, and school professionals to break confidentiality. Some professional ethics codes directly or indirectly allow for maintaining confidentiality when clients are terminally ill and may be considering ending their lives (Werth et al., 2002). Technically, such plans and considerations would be labeled “suicidal,” but this is a vastly different situation than the ones we are writing about in this book. State laws, ethics codes, agency policies, and school rules dictate or influence what can and cannot be held in confidence. You should practice presenting information about confidentiality and its limits accurately, in understandable language, to clients, parents, teachers, administrators, and other community or school professionals (e.g., police officers). Here is an example aimed at an adolescent population:
As your counselor, I will keep nearly everything you tell me private. We call this confidentiality. This is important for a trusting relationship. For example, if we see each other in public, I’ll be careful not to greet you unless you greet me first, because the fact that you’re seeing me for counseling is nobody else’s business. That’s how private this relationship is. But there are a few exceptions we should talk about.
1 Your parents. Your parents have a right to ask for my counseling records. That doesn’t mean I’m going to tell them everything you say, but they can ask to see my notes. Most parents don’t ask to see my notes because they agree that what you and I talk about should be just between us. We will work together on reaching an understanding with your parents so we both know what to expect. If your parents, friends, or others tell me things about you that will help in our counseling, I will let you know. They’re important people in your life, but they’re not my clients. I won’t keep secrets for them, and I’ll make that clear to them if they speak with me.
2 Danger. If what we talk about leads me to believe you’re in danger of hurting yourself or someone else, by law I have to act to keep you or others safe. But the first thing I would do is talk directly with you about how to do that. If I believe it’s necessary to call someone, I will make every effort to tell you first. My most important priority is to help you. If you’re in danger, I may need to contact others to help keep you safe.
3 Abuse. If I suspect that you, or anyone, is being abused, the state requires that I make a report to child protective services. This could involve sexual abuse, physical abuse, or neglect. If I suspect this, I’ll ask you about it directly and then I’ll tell you if I need to make a report.
4 Questions. Do you have any questions about your privacy or confidentiality with me?
There are other reasons why counselors breach confidentiality, such as for insurance paperwork or court orders, but these details are typically addressed in written informed consent documents.
Social Media and After-Hours Contact
Social media is now so ubiquitous that school and mental health professionals must address it within the informed consent process (Wheeler & Bertram, 2019). In some cases the messaging can be simple, as in an informed consent form that reads “Please note that because of ethical issues, I don’t socialize with clients outside of scheduled professional appointments, including through social media.” A specific statement such as the following might be useful:
In my counseling work, I do not use Facebook, Instagram, Twitter, or other such platforms to interact with clients. I have a Facebook page that I use for personal and social reasons, but I don’t friend my clients and I don’t accept friend requests from them. My goal is to keep our relationship professional.
Again, there are individual, agency, and professional variations in how clients or students can interact with professionals within the frame of social media. In some cases, it may be an important clinical tool to be used to extend care, but if so, it should be used for specific purposes and professional/personal boundaries should be clear. In other cases, it can be both invasive and worrying to have clients reach out to you via social media.
Emergency Procedures
Emergency procedures should be described in your informed consent document. Your description may be as simple as “In cases of emergency, you should call 911 immediately.” When discussing emergency procedures with youth, you might say something like the following:
If you’re feeling suicidal, it’s important to have a positive plan for what to do. Of course, you can call 911 or go to the nearest emergency room. You can also call the National Suicide Prevention Lifeline (1-800-273-TALK—a new 988 number for mental health emergencies will be available in 2022) or text the Crisis Text Line (text HOME to 741741 to connect with a crisis counselor). I’m also interested in your ideas about what you would like to do if you’re in a crisis. We can talk more about that today.
Creating a collaborative safety plan is an essential clinical skill. We provide guidance on this in Chapter 9.
Ethical Issues Pertaining to Suicide in Online and Other Distance Counseling Formats
Coronavirus-related economic shutdowns, social distancing, and other contemporary factors have quickly increased the use of counseling online and in other distance formats. Going by the names telehealth, telemental health, and telebehavioral health, these counseling platforms follow the same ethics codes and state and federal regulations as face-to-face counseling. However, attention to specific details with regard to informed consent, confidentiality and privacy issues, and emergency procedures is particularly salient when working with clients who are suicidal (Stoll et al., 2020).
Most online, telephonic, or text-based ethical issues in counseling are best addressed by counselor preparation and a clear and thorough informed consent process. Before engaging clients in distance counseling, address the following issues in writing and, when possible, via oral or text-based discussion:
Before meeting, do a preparation and competence check, including the following:Learn to use a counseling platform that is compliant with the Health Insurance Portability and Accountability Act of 1996 and has adequate data security and storage.Establish a clear and secure online payment