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Current and emerging ethical issues in counseling: a Delphi study of expert opinions.

A Delphi study was conducted to ascertain the opinions of panel experts regarding the most important current and emerging ethical issues facing the counseling profession, Expert opinions on ethical issues in counselor preparation also were sought, Eighteen panelists responded to 3 rounds of data collection interspersed with feedback. Themes that emerged as important ethical issues were ensuring that counselors practice ethically and abide by the American Counseling Association (2005) ACA Code of Ethics, dealing with social justice and diversity issues, strengthening the professional identity of counselors, and ensuring competence in providing services within a climate of change.

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The environment in which counseling is practiced is complex and ever changing, and new ethical issues are constantly emerging. This makes it difficult for even the most ethically conscientious practitioners to keep current. Counselors look to the American Counseling Association (2005) ACA Code of Ethics (hereinafter referred to as the Code), which represents the consensus of the profession regarding ethical behaviors, as a primary source of guidance when they are confronted with ethical dilemmas. However, the Code may be of limited value when counselors seek guidance regarding new and emerging issues. Published codes cannot keep up with the pace of change; the Code typically is revised only once every 7 to 10 years (Herlihy & Corey, 2006) and may not address cutting-edge issues around which no consensus has been achieved (Mabe & Rollin, 1986). As a result, counselors need to rely on other resources in order to maintain best standards of ethical practice.

Published research in ethics can be "particularly helpful for professionals trying to cope responsibly with new and emerging areas of practice" and can "provide an opportunity to consult with the most knowledgeable and experienced scholars in the profession" (Welfel, 2006, p. 13). The purpose of this study was to obtain consensus of a Delphi panel of experts on what they believe to be the most important current and emerging ethical issues facing the counseling profession. The timing for such a study seemed to be fortuitous, because the current iteration of the Code has been in place for 4 years now and further revisions are unlikely to occur before 2012 at the earliest. We hoped that results of this study might point to areas of needed research, which might in turn provide knowledge that would assist counseling practitioners and inform future code revisions.

Three research questions guided this study:

Question 1: What do experts believe are the most important ethical issues currently facing the counseling profession?

Question 2: What do experts believe are the most important emerging ethical issues that the counseling profession will need to address during the next 5 years?

Question 3: Do experts identify social justice concerns as important current and emerging ethical issues?

The last question was included in the study because counseling for social justice has risen to a place of prominence in the profession and is evident throughout the current Code. The ACA Ethics Code Revision Taskforce recommended changes to the previous code, ACA's (1995) Code of Ethics and Standards of Practice, with a special focus on multiculturalism, diversity, and social justice (Kocet, 2006).

Method

The Delphi technique, which has long been supported in the literature as a consensus-building method (Young & Jamieson, 2001), relies on the informed intuitive judgment of a panel of experts. Using multiple rounds of data collection and analysis, the experts collect opinions on problems or issues that are difficult to quantify (Helmer, 1983). Through a series of questionnaires interspersed with controlled feedback on opinions derived from earlier rounds of responses, a consensus is generated (Davis, 1997). The number of rounds of data collection can vary, although a three-round Delphi is typical (Skulmoski, Hartman, & Krahn, 2007). The number of participants is determined by the number of individuals who have the required expertise and are willing to participate; the number can range from as few as four to more than 170 (Skulmoski et al., 2007).

The Delphi technique uses written responses rather than bringing individuals together for discussions and therefore is useful for engaging participants who cannot come together physically. This format reduces potential bias because participants are separate and unknown to each other. No two Delphi studies are alike, and the method can be modified to respond to the needs of the individual researcher (Davis, 1997). Because we were seeking the opinions of experts regarding current and future ethical issues in counseling, the Delphi technique seemed ideally suited for our purposes.

Participants

In a Dephi study, the decision-making population, or Delphi panel, must consist of individuals who are recognized as having high levels of relevant expertise in the area being considered (Davis, 1997). To identify potential expert participants, we compiled a list of individuals who met at least one of the following criteria: (a) served on the 2005 ACA Ethics Code Revision Taskforce, (b) served as chair of the ACA Ethics Committee within the past 5 years, (c) authored or coauthored major texts in counselor ethics, and (d) had established a record of published research in counselor ethics across a range of ethical issues. We believed that individuals with these specific types of experiences would have given in-depth consideration to a wide spectrum of ethical issues. We identified 22 individuals, most of whom met more than one of the criteria, who might serve as Delphi panelists.

Procedure

After obtaining institutional review board approval, we sent an invitation to participate in the study to the 22 potential participants by e-mail. Twenty individuals responded to the invitation, all who agreed to participate in three rounds of data collection.

In Delphi studies, the initial questions typically are broad and open-ended so as to "widely cast the research net" (Skulmoski et al., 2007, p. 10). For Round 1, participants were contacted by e-mail and asked to identify what they believed to be the most important ethical issues facing the counseling profession today, and to identify the emerging issues they believed the profession will need to address over the next 5 years. These broad questions were used to capture as many issues as possible. Participants were instructed that they could include short, explanatory narratives for issues they identified, or they could simply name issues they believed were self-explanatory. Informed consent was obtained from each participant, and brief instructions were provided. Participants returned their responses by e-mail correspondence.

Round 1 generated a wealth of data. Although some panelists simply listed issues they deemed important, other respondents wrote lengthy narratives. To organize the data in preparation for Round 2, we separated the responses into current issues and future issues categories. We then reduced the data by creating themes within each category, merging responses under a single theme when multiple participants described the same issue in differing words. For example, four responses under the first category, current issues ("how multiple relationships can be managed rather than avoided," "managing boundaries in the counseling relationship," "avoiding personal relationships that are harmful to clients," and "understanding potentially beneficial relationships"), composed the theme of managing boundaries/ multiple relationships. Within the second category, future issues, three responses ("duty to warn issues with adolescents," "individuals who are at risk for suicide or violence," and "students engaging in suicidal or para-suicidal behaviors") composed the theme dealing with clients who pose a danger to self or others. Some themes included as many as nine individual responses, whereas other themes reflected a single response. We noted that a number of the responses named ethical issues that were specific to counselor preparation and training. This may have occurred because most of the panelists were counselor educators. Therefore, we created the third category, counselor preparation issues.

We then created a survey instrument that listed the themes within the three categories, with participant responses in their own words presented under each theme. This detailed feedback was given so that participants would have the full benefit of each other's thinking and so that participants would have the opportunity to correct any misinterpretations of their meanings. We formatted Round 1 responses into SurveyMonkey for ease of responding. Participants were asked to rate each of the themes based on a 5-point Likert scale ranging from strongly agree (5) to strongly disagree (1), indicating their extent of agreement that the item was an important current ethical issue, an emerging ethical issue, or a counselor preparation issue.

To prepare a survey instrument for Round 3 after the Round 2 responses were received, we calculated the means for each item (based on the 5-point Likert scale) and arranged them in order from highest to lowest mean score in each of the three categories. Because there were a large number of items in the first two categories of current issues and future issues (28 and 24, respectively) after Round 2, we reduced the number of themes. Within the current issues category, 14 items were retained, with mean scores ranging from 4.00 to 4.56 (see Table 1). Fourteen items were also retained in the future issues category, with means ranging from 3.88 to 4.53 (see Table 2). Within counselor preparation issues, the number of items was smaller (seven); the five items with a mean score of 4.00 or higher were retained (see Table 3). This reduction process created a more efficient survey instrument without losing those themes considered most important by the Delphi panelists.

In Round 3, participants were contacted again by e-mail. A Microsoft Word document attachment was sent that contained the 14 themes under current issues, 14 themes under future issues, and five counselor preparation issues. Participants were asked to identify the four most important themes in each of the three categories, and to rank order them in the order of their importance, with I = most important and 4 = fourth most important. Participants were instructed to return the Microsoft Word attachment by e-mail.

Results

Eighteen expert panelists responded to all three rounds of data collection. As was noted earlier, responses from Round 1 were organized into 59 themes: 28 themes for the current issues category, 24 themes for the future issues category, and seven themes for the counselor preparation issues category. For Round 2, participants were asked to rate the extent of their agreement, using a 5-point Likert scale, that each theme was an important issue within each of the three categories. Descriptive statistics, including mean scores, were calculated for all 59 themes. For the final round, the number of items was reduced to include only those that had the highest mean scores after Round 2. In Round 3, the final round of data collection, participants ranked the top four themes in each of the three reduced categories.

For the final round, the four most important themes for each category were calculated. To facilitate readability and understanding of the results, we reverse-scored the rankings. For example, an item ranked by participants as 1, most important, was reverse-scored to a 4. To derive the sum score for each item, each ranking was multiplied by the number of respondents who gave the item that rank, and the scores were then totaled. For example, for Theme 5 in the current issues category ("working with clients who pose a danger to self or others"), the total was calculated as follows: 1st ranked = zero responses (0 x 4 = 0), 2nd ranked = three responses (3 x 3 = 9), 3rd ranked = two responses (2 x 2 = 4), and 4th ranked = one response (1 x 1 = 1) for a total score of 14 for the six responses (see Table 1).

Current Issues

Ensuring that counselors practice ethically and abide by the code was the current ethical issue deemed most important by the experts. More than half (n = 11, 61%,) of the participants ranked this item; eight of the 11 experts who selected this theme ranked it "most important," which contributed to its high sum score of 38 (see Table 1). Sum scores for the remaining three of the top four current issues ranged from 21 to 18, indicating that the panelists viewed these issues as being similar to each other in importance. Strengthening the professional identity of counselors was ranked 2nd; this theme was ranked by seven of the 18 participants (39%) and had a sum score of 21. Determining boundaries of competence was ranked 3rd; seven participants (39%) ranked this item, and its sum score was 19. Finally, practicing with multicultural competence was ranked 4th most important; 50% (n = 9) of the participants selected this item, which had a sum score of 18.

Three other themes had mean scores among the top four after the second round and continued to receive relatively strong endorsements in the final round. These three themes were working with clients who pose a danger to self or others, managing confidentiality, and managing boundaries/multiple relationships, with sum scores of 14, 14, and 13, respectively (see Table 1).

Future Issues

Dealing with social justice and diversity issues emerged in the final round as the most important future issue, with 10 (56%) of the participants ranking this theme as one of the four most important for a sum score of 28 (see Table 2). As was found in the current issues category, the sum scores for the second, third, and fourth most important themes were closely clustered (20, 20, and 18, respectively), indicating that the experts viewed these issues as being similar in relative importance. Being accountable for measuring the effectiveness of counseling, and serving emerging populations and dealing with issues created by medical advances were tied for second ranking with seven participants (39%) and eight participants (44%) ranking these two themes as important, respectively. The fourth most important theme, ranked by 50% (n = 9) of the participants, was managing diagnosis and changing concepts of mental health. Other future issues that also retained relatively strong endorsements through the third round included dealing with new and emerging technologies, ensuring continuing professional growth, dealing with licensure issues, and working with clients who pose a danger to self or others, with sum scores of 16, 15, 14, and 12, respectively.

Counselor Preparation Issues

After the final round, there was consensus that teaching ethical decision making is the most important issue in counselor preparation; all 18 experts assigned it a ranking resulting in a sum score of 57. The theme ranked second most important, by 16 (89%) of the participants, was gatekeeping for the profession, with a sum score of 38 (see Table 3). Other themes that were strongly endorsed were defining counselors' professional identity (n = 13, 72%) and modeling appropriate relationships in counselor education programs (n = 14, 78%), with sum scores of 37 and 28, respectively.

Discussion

Several themes were rated by the panelists as important ethical issues in more than one of the three categories. These recurring themes were ensuring ethical practice, addressing social justice and diversity, strengthening the professional identity of counselors, and ensuring competence in providing counseling services. An overarching theme that seemed to encompass most of the issues identified by the experts across all three categories was a concern for maintaining best practices within a climate of change.

Ensuring Ethical Practice

According to the panelists, "ensuring that counselors practice ethically and abide by the code" is the most important ethical issue currently faced by the counseling profession. In the initial round, this issue was identified by four panelists who expressed concerns that our profession is not doing a good job of helping counselors understand ethical behavior and demonstrate it in practice and that most violations are not addressed by licensing boards, professional associations, or colleagues. This latter issue has been discussed in the literature. Most violations go unreported (Welfel, 2006), and counselors generally are reluctant to confront or report the unethical behaviors of their peers (Bernard & Jara, 1986; Lowman, 2006). These findings are worrisome not only because of the continuing harm that may be caused to clients but also because public trust is based on a belief that counselors hold their fellow professionals to acceptable standards of ethical behavior (Herlihy & Corey, 2006; Remley & Herlihy, 2010).

The panelists did not identify specific ethical behaviors they believed counselors may fail to understand and demonstrate in practice; however, researchers have investigated the types of ethical violations that have been reported most frequently to state counselor licensure boards (Neukrug, Healy, & Herlihy, 1992; Neukrug, Millikin, & Walden, 2001). Neukrug et al. (2001) found that the most frequent complaints made to state licensing boards were (in descending order of frequency) inappropriate dual relationships, incompetence, practicing without a license or misrepresenting one's qualifications, sexual relationships with clients, and breach of confidentiality. The Delphi panelists identified issues related to these behaviors, including managing boundaries/multiple relationships, determining boundaries of competence, and maintaining confidentiality, as important ethical concerns both in current practice and in the future.

Given the high priority assigned to ensuring ethical practice, it is not surprising that the panelists selected "teaching ethical decision making" as the most important issue in counselor preparation. The importance of professional judgment when confronted with ethical dilemmas has been underscored (Cottone & Tarvydas, 2007), and numerous ethical decision-making models have been described (see Cottone & Claus, 2000). However, it appears that little research has been conducted to determine how professional judgment is taught or which models (if any) practitioners actually are using or whether they find these models to be helpful. Despite the energy expended in designing ethics courses, the effects of instruction on ethical development of students and counselors have not been documented. A large amount of research has been generated regarding counseling students' and professionals' perceptions of ethical dilemmas, but even the most recent studies have relied on self-report questionnaires or surveys (Bodenhorn, 2006; Helbok, Marinelli, & Walls, 2006; Zakrzewski, 2006). Hill (2004) suggested that counselor educators first assess their "baseline of information" (p. 183) regarding curricula and current ethics teaching methods.

When our experts looked to the future, they ranked "dealing with social justice and diversity" as the most important emerging ethical issue with which counselors will need to deal with over the next 5 years. This future issue was given a high priority by the experts consistently throughout the three rounds of data collection: It was named by more panelists than any other future issue in the initial round, remained among the top three issues in Round 2, and emerged as the top ranked issue in the final round. Participants expressed a need for counselors to participate more fully in advocacy and social justice efforts, both globally and within our own demographically changing society. They were concerned about issues such as discrimination against gay, lesbian, bisexual, transgender, and queer clients and the potential for more value clashes with clients as societal diversity increases.

Social justice was also present as a current issue, although it did not receive as high a ranking in that category. In the current issues category, "practicing with multicultural competence" (ranked 4) and "addressing issues of social justice and advocacy" (ranked 8) were presented as separate themes. If the two themes had been merged and presented as a single option, a higher ranking might have resulted for social justice/multicultural counseling as a current issue. Although social justice was not ranked in the final round as a counselor training issue, it was one of the seven themes that were present in Rounds 1 and 2. Recent literature has begun to identify issues that inform the development of ethical understanding from a social justice perspective and that need to be included in counselor training curricula (Pack-Brown, Thomas, & Seymour, 2008).

Strengthening Professional Identity

Concerns related to defining and strengthening the professional identity of counselors emerged as both an important current issue (ranked 2) and as an issue in counselor preparation (ranked 3). In Round 1, professional identity issues were named by only one panelist as a current issue, and by one panelist as an issue in counselor preparation. One expert wrote about the need for counselors to "strengthen our professional identity so that we can confidently take our place at the table with other mental health professions." A second panelist emphasized the importance of training counselors who provide "positive, developmentally sensitive, wellness-oriented services and interventions" and of defining our unique identity rather than competing for the rights to do psychological testing or prescribe medications. The high rankings assigned to this issue in the final round demonstrate the consensus-building process that can occur in a Delphi study, when rounds of controlled feedback inform panelists of each other's perspectives and provide them with opportunities to change their views (Skulmoski et al., 2007).

Competence in counseling is difficult to define, because it is a complex concept with many possible levels along a continuum (Remley & Herlihy, 2010). Evaluating competence of counselor trainees, or "gatekeeping for the profession," was ranked 2nd among the ethical issues in counselor preparation. In the initial round, panelists highlighted some of the difficulties inherent in the gatekeeper role, such as evaluating trainee competence/incompetence, lack of appropriate oversight in counselor education programs that leads to incompetent graduates, and dealing with students who lack the personal and interpersonal competencies to become effective counselors. Multiple models for gatekeeping and dismissing students from counselor education programs are available (Dufrene & Henderson, 2009). These models conform to the requirements of the Code but have not yet provided details on exactly how remediation should occur.

Counselor educators and supervisors are responsible for evaluating competence of trainees, but professional counselors are responsible for determining their own boundaries of competence (Remley & Herlihy, 2010). "Determining boundaries of competence" was ranked the third most important current issue in the final round. Counseling practitioners struggle with balancing their dual responsibilities to practice only within the boundaries of their competence (ACA, 2005, Standard C.2.a.) and at the same time to stretch those boundaries of competence. Counselors are obligated to develop skills in new specialty areas including skills pertinent to working with a diverse client population, but they must ensure the competence of their work as they develop and practice these new skills (ACA, 2005, Standards C.2.a. & C.2.b.). The panelists noted the challenges for counselors of accurately assessing their level of competence and of being asked in their work settings to perform tasks they do not feel competent to perform.

Maintaining Best Practices in a Climate of Change

The reality that counseling is a relatively new and evolving mental health profession is reflected in our experts' judgments regarding the importance of establishing our professional identity and of increasing our ability to ensure that counselors practice ethically and abide by the Code. The emergence of advocating for social justice as a priority in the profession adds new dimensions to ethical issues that have long been a focus of concern and research. For example, practicing with multicultural competence becomes a more challenging mandate as the diversity of our society increases, and traditional injunctions against shifting boundaries and engaging in multiple relationships need to be revisited when working with diverse populations (Herlihy & Corey, 2006).

The changing climate in which counseling is practiced raises some new ethical questions that were identified by our experts. According to the panelists, important issues the profession will need to address over the next 5 years are serving emerging populations and dealing with issues created by medical advances (tied for ranking 2), being accountable for demonstrating the effectiveness of counselors (also tied for ranking 2), and managing diagnosis and changing concepts of mental health (ranked 4).

Biomedical advances in areas such as genetic testing, life-sustaining technologies, and HIV and AIDS care raise new ethical issues for counseling practitioners (Cottone & Tarvydas, 2007; Remley & Herlihy, 2010). The Delphi panelists noted that as the U.S. population continues to age, counselors will be called on to assist clients with end-of-life decision making and other longevity-related issues. They also predicted that there will be an increased need for services to emerging populations, such as immigrants; veterans and their families; people affected by war, the economic crisis, and addictions; and other types of trauma, crisis, and catastrophe. These phenomena affect mental well-being and family stability, and they present challenges to maintaining cultural competence that counselors will need to address in coming years (Arredondo, Tovar-Blank, & Parham, 2008).

As reported by Schmacher (as cited in Rollins, 2007), the issue of accountability today and in the future is at the forefront of professional dialogue. As a result of increased state and federal legislation and regulation of health care and managed care, more accountability is being required. Issues identified by Schumacher reflected the types of knowledge that are needed to help counseling professionals adapt to accountability requirements. Increasingly, it will be important for counselors to evaluate how counseling outcomes (particularly client outcomes) are affected by the implementation of counseling interventions. As one expert panelist stated in this study, counselors need to know what interventions are effective and how they work, and how this knowledge affects practice.

Participating in diagnosis continues to be an arena fraught with ethical quandaries for counselors, whose orientation to wellness and social justice can create conflicts with the prevailing values of managed mental health care (Danzinger & Welfel, 2001; Herlihy, Watson, & Patureau-Hatchett, 2008; Kress, Eriksen, Rayle, & Ford, 2005; Zalaquett, Fuerth, Stein, Ivey, & Ivey, 2008). The Delphi panelists noted the difficulties of reconciling the wellness orientation of counselors with Diagnostic and Statistical Manual of Mental Disorders diagnosis and of dealing truthfully with third party payers. They also expressed concern about the consequences of diagnosis on client development and treatment.

Implications and Recommendations for Further Research

Some limitations to this study should be noted. First, expert panelists who did not participate in this study might have identified other ethical issues and might have ranked them differently. We attempted to minimize the effects of this potential limitation by choosing appropriate and multiple criteria for eligibility to participate. Additionally, the trustworthiness of our findings is strengthened by the fact that all 18 expert panelists participated in all three rounds of data collection. Second, a greater consensus of the experts might have been achieved if additional rounds of data collection had been conducted. It was evident that panelists did change their views after reviewing the input of their colleagues. However, as Helmer (1983) has noted, complete convergence of opinions cannot be expected because of the uncertainties of predicting the future and because results are based on the intuitive judgments of experts rather than verifiable facts. We were also aware that response rates decrease when the number of rounds increases (Skulmoski et al., 2007).

Kaplan et al. (2009) discussed specific new mandates that were added to the Code to assist counselors with managing ethical dilemmas that arise in difficult areas of practice. Future researchers might investigate whether these new provisions in the Code are indeed providing useful guidance to counselors as they encounter ethical quandaries in their work. For example, does the Code's increased attention to cultural sensitivity provide useful advice to counselors in dealing with social justice and diversity, which the Delphi panelists identified as the most important ethical issue that counselors will confront over the next 5 years? Has the requirement that treatment modalities must have a scientific basis helped counselors to be more accountable for measuring the effectiveness of counseling (ranked 2 among future issues)? Are the new standards on end-of-life care helping counselors better serve emerging populations and deal with issues created by medical advances (ranked 3)? Do the additional standards on diagnosis clarify counselors' responsibilities related to managing diagnosis and changing concepts of mental health (ranked 4)? Does the expanded section on technology applications assist counselors as they deal with new and emerging technologies (ranked 5)? The term dual relationships was eliminated from the Code's language, and the standards now allow counselors to interact with clients outside of counseling sessions under certain conditions. Does this change in language clarify a confusing issue so that counselors are better able to manage boundaries/ dual relationships (ranked 7)? Finally, according to the Code, confidentiality may be broken in cases when there is serious or foreseeable harm to a client or others. Is this standard proving useful to counselors as they work with clients who pose a danger to self or others (ranked 8)?

Results of this study suggest several additional questions that might be addressed by future researchers: How well do consumers understand the unique professional identity of counselors? How well do practicing counselors understand the appropriate procedures (as recommended in the Code) for dealing with unethical behaviors of a colleague? What are the factors that discourage them from taking action? To what extent are counseling practitioners engaging in advocacy for their clients and for the profession? What are the ethical issues inherent in international/global counseling? As the complex climate in which counseling is practiced continues to change, are new and unforeseen types of ethical violations occurring? The Neukrug et al. (2001) study might be updated to investigate what types of complaints state counselor licensure boards are receiving in the 21st century.

The results of this study suggest several implications for counselor educators. Counselor educators need to continue to explore how ethical decision making is being taught, what models are being promoted, and how effective these models are in helping prospective counselors reason through ethical dilemmas. Given the importance assigned by the Delphi panelists to addressing issues of social justice and to strengthening our professional identity, we need to ensure that counselor education graduates know how to advocate for their clients and for the profession and that counselor educators are teaching advocacy skills across the curriculum. Finally, we suggest that counselor educators can provide leadership by partnering with practitioners to produce more rigorously designed outcome studies that demonstrate the effectiveness of counseling.

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Barbara Herlihy and Roxane L. Dufrene, Department of Educational Leadership, Counseling, and Foundations, University of New Orleans. Correspondence concerning this article should be addressed to Barbara Herlihy, Department off Educational Leadership, Counseling, and Foundations, University of New Orleans, 348 Education Building, 2000 Lakeshore Drive, New Orleans, LA 70148 (e-mail: bherlihy@uno.edu).
TABLE 1
Current Issues: Results for Rounds 1, 2, and 3

                                Round 1           Round 2    Round 3
Category 1: Current
Issues Themes               n      M      SD      n    Sum    Rank

 1. Ensuring that
    counselors practice
    ethically/abide by
    the code                4#   4.44#   0.62#   11#   38#     1#
 2. Strengthening the
    professional identity
    of counselors           1#   4.17#   0.79#   7#    21#     2#
 3. Determining
    boundaries of
    competence              3#   4.33#   0.69#   7#    19#     3#
 4. Practicing with
    multicultural
    competence              3#   4.33#   0.77#   9#    18#     4#
 5. Working with clients
    who pose a danger to
    self or others          2    4.56    0.62     6    14
 6. Managing
    confidentiality         4    4.39    0.92     5    14
 7. Managing boundaries/
    multiple
    relationships           4    4.50    0.71     6    13
 8. Addressing issues of
    social justice and
    advocacy                4    4.00    0.97     5    11
 9. Dealing with
    diagnosis and third
    party payments          4    4.11    0.47     4     9
10. Ensuring access to
    care                    2    4.11    0.76     3     8
11. Dealing with advances
    in technology and
    cybercounseling         7    4.06    0.73     4     6
12. Committing to
    counselor self care     1    4.06    1.00     3     5
13. Managing
    confidentiality with
    minor clients           3    4.22    0.88     1     1
14. Dealing with issues
    related to informed
    consent                 2    4.22    1.00     1     2
15. Dealing with
    conflicts between law   2    3.94    1.11
    and ethics
16. Dealing with the
    changing nature of      1    3.89    0.90
    the family
17. Helping counselors
    understand that
    ethics is meant to
    guide their own
    behavior, rather than
    judging the behavior
    of other counselors     1    3.78    1.11
18. Managing
    relationships with
    other mental health
    professionals and
    paraprofessionals       3    3.72    0.83
19. Counseling clients
    on end of life
    decision making         1    3.72    1.18
20. Addressing religious/
    spiritual issues with
    clients and each
    other                   2    3.67    1.03
21. Child custody issues    1    3.59    1.02
22. Managing conflicts
    with business goals     1    3.56    0.86
23. Conflicts of interest   1    3.50    0.79
24. Issues raised when
    services are
    delivered in
    nonoffice, off-site
    settings                1    3.50    0.86
25. Generational
    differences in how
    clients want to
    access and
    participate in
    counseling              1    3.39    0.98
26. Decline of membership
    in ACA                  1    3.33    1.14
27. Counseling
    researchers may be in
    conflict about the
    cultural validity of
    their sampling,
    assessment, and
    design                  1    3.28    0.96
28. Use of sliding fee
    scales                  1    3.00    1.14

Note. N = 18. Round 1: n = the number of participants who endorsed
the theme in Round 1. Round 2: the first five themes were selected
for Category 3. Round 3: n = number of participants who endorsed
the theme at any ranking. Boldface indicates themes with the four
highest rankings. Sum = sum of each rankings, where 4 = most
important to 1 = fourth most important, Rank = ranking of theme
based on the largest sum score; ACA = American Counseling Association.

Note: Themes with the four highest rankings indicated with #.

TABLE 2
Future Issues: Results for Rounds 1, 2, and 3

                                 Round 1          Round 2     Round 3

Category 2: Future
Issues Themes               n      M      SD      n    Sum     Rank

 1. Dealing with social
    justice and diversity
    issues                  9#   4.29#   1.05#   10#   28#   1#
 2. Being accountable for
    measuring
    effectiveness of
    counseling              1#   4.12#   0.96#    7#   20#   2 (tie)#
 3. Serving emerging
    populations and
    dealing with issues
    created by medical
    advances                6#   4.06#   0.83#    8#   20#   2 (tie)#
 4. Managing diagnosis
    and changing concepts
    of mental health        2#   3.88#   0.60#    9#   18#   4#
 5. Dealing with new and
    emerging technologies   7    4.00    0.71     7    16
 6. Ensuring continuing
    professional growth     1    3.88    0.78     4    15
 7. Dealing with
    licensure issues        2    3.94    0.66     5    14
 8. Working with clients
    who pose a danger to
    self or others          3    4.53    0.62     4    12
 9. Maintaining
    confidentiality         3    4.18    1.02     3    10
10. Dealing with issues
    related to the
    globalization of
    counseling              4    4.06    0.97     5     8
11. Responding to needs
    created by the
    economic crisis         5    3.94    1.03     4     8
12. Promoting counselor
    self care               1    4.12    0.93     2     6
13. Dealing with
    complexities of
    supervision             1    4.18    0.73     2     4
14. Managing boundaries/
    dual relationships      4    4.35    0.79     2     3
15. Planning for code
    revisions               1    3.76    0.97
16. Educating consumers     1    3.76    0.97
17. Dealing with changing
    family systems          1    3.76    0.90
18. Maintaining ethical
    research practices      2    3.71    0.77
19. Dealing with child
    custody issues          1    3.65    1.00
20. Coping with business
    demands                 2    3.59    0.87
21. Differentiating
    between coaching and
    counseling              1    3.53    1.13
22. Dealing with
    counselor involvement
    in legal system         2    3.41    0.87
23. Promoting social
    consciousness           1    3.29    1.11
24. Determining ethics of
    brief therapy           1    3.06    0.93

Note. N = 18. Round 1: n = the number of participants who endorsed
the theme in Round 1. Round 2: the first five themes were selected
for Category 3. Round 3: n = number of participants who endorsed
the theme at any ranking. Boldface indicates themes with the four
highest rankings. Sum = sum of each rankings, where 4 = most
important to 1 = fourth most important, Rank = ranking of theme
based on the largest sum score.

Note: Themes with the four highest rankings indicated with #.

TABLE 3
Counselor Preparation Issues: Results for Rounds 1, 2, and 3

                                 Round 1          Round 2    Round 3
Category 3: Counselor
Preparation Issues Themes   n      M      SD      n    Sum    Rank

1. Teaching ethical
   decision making          2#   4.56#   0.62#   18#   57#     1#
2. Gatekeeping for the
   profession               6#   4.72#   0.46#   16#   38#     2#
3. Defining our
   professional identity    2#   4.39#   0.78#   13#   37#     3#
4. Modeling appropriate
   relationships in
   counselor education
   programs                 1#   4.44#   0.71#   14#   28#     4#
5. Fostering the personal
   development of
   students                 2    4.00    0.84    11    20
6. Training for counselor
   educators in social
   justice and advocacy     1    3.78    1.11
7. The burgeoning of
   online training
   programs                 1    2.78    1.06

Note. N = 18. Round 1: n = the number of participants who endorsed
the theme in Round 1. Round 2: the first five themes were selected
for Category 3. Round 3: n = number of participants who endorsed
the theme at any ranking. Boldface indicates themes with the four
highest rankings. Sum = sum of each rankings, where 4 = most
important to 1 = fourth most important, Rank = ranking of
theme based on the largest sum score.

Note: Themes with the four highest rankings indicated with #.
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Author:Herlihy, Barbara; Dufrene, Roxane L.
Publication:Counseling and Values
Date:Oct 1, 2011
Words:6852
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