VISTAS articles are made available for historical reference only and are presented "as is." ACA does not guarantee or represent that the information is current, accurate or indicative of the original or intended quality. These materials are not maintained or updated and may contain outdated or incomplete information. Readers should exercise discretion and verify information independently before relying on it. We assume no responsibility for the use or interpretation of this content.

Article 32

Content Analysis of Counseling Ethics and Decision Making

Eleni M. Honderich & J. Lloyd-Hazlett

Download PDF

Within the counseling field, acting ethically safeguards clients against harm (Gregoire, Jungers, & White, 2012). Ethical codes tend to be a “salient factor in determining whether clients are physically or psychologically harmed” (Bradley & Hendricks, 2008, p. 261). However, though ethical codes “may be enormously important. . . . we must also be attentive to the shortcomings” (Gergen, 2001, p. 2). Principles and codes alone are insufficient means to ensure ethical behavior among professionals (Linstrum, 2009; Rest, Narvaez, Bebeau, & Thoma, 1999). Counselors disagree on the ethicality of a wide range of behaviors and dilemmas (Cottone, 2001). Contemporary lawsuits in counselor education (Keeton v. Anderson-Wiley, 2010; Ward v. Wilbanks, 2010) highlight divergent interpretation and application across individuals of a singular set of ethical codes. To uphold client welfare and protect the counseling profession, it becomes paramount to understand individuals’ subjective, contextualized understandings of ethicality. Content analysis was used in this pilot study to examine micro-level understandings of counseling ethics and ethical behavior, including the role of formalized codes, personal values, and other professional tools.

Ethical Codes, Behavior, and Decision Making

Acting with ethical intent is an instrumental safeguard against undue client harm. Though definitions of ethicality vary, the ACA Code of Ethics (American Counseling Association [ACA], 2014) represents formalized standards of practice and facilitates monitoring of professional conduct, along with engagement in disciplinary action when necessary. Professional ethical codes set a universal standard and create accountability measures (Bradley & Hendricks, 2008; Gergen, 2001). Furthermore, knowledge of ethical codes promotes enhanced ethical decision making (Welfel, 2012).

Generally, ethical codes outline both specific mandates of ethical behavior (e.g., counselors are not to engage in sexual relationships with current clients) and are also informed by overarching principles (i.e., beneficence, nonmaleficence, justice, fairness, fidelity, veracity; ACA, 2014). Contextual influences of culture, society, time, and history (Evanoff, 2006; Welfel, 2012) influence counselors’ interpretations of more ambiguous ethical domains; ultimately, contributing to varied constructions of ethicality. Neukrug and Milliken (2011) highlighted the magnitude of divergent ethical belief systems with a sample of 535 counselors failing to reach consensus on the ethicality of any of 77 specific counselor behaviors assessed.

Considering divergent ethical beliefs surrounding certain behaviors and that “there is rarely one right answer to a complex ethical dilemma” (Forester-Miller & Davis, 1996, p. 4), the use of professional resources can ground ethical decisions. Specifically, ethical decision-making models support justification of a set course of action, allowing the counselor to holistically examine situational context and make a final decision based on best serving the client and the greater good (Welfel, 2012). Outlined steps within ethical decision-making models may include identifying the problem, applying relevant codes, generating potential courses of action and consequences of these actions, and ultimately, implementing a decision (Forester-Miller & Davis, 1996). Supported by an ethical decision-making model, the counselor acknowledges complexities inherent to ethical decision-making processes. Decisions are not made on a whim, but rather reflect careful consideration of all potential courses of action and ramifications.

Acting ethically represents a core facet of a counseling professional identity and is supported by the use of ethical codes and decision-making models. Nonetheless, the context of a dilemma, life experience, and personal values still appear to affect ethical outcomes (Ametrano, 2014; Cottone, 2001; Welfel, 2012). Thus, micro-level examinations of counselors’ perspectives of macro-level ethical constructs, such as formal codes, values, and decision-making processes, optimally identify areas of disharmony and permit enactment of professional ethical commitments that prioritize client welfare.

Method

Research Design

Counseling research has emphasized objective macro-level examinations of ethics and ethical behavior (Evanoff, 2006). Limited attention has been given to micro-level examinations of ethical constructions and factors influencing individual ethical decision- making processes (Evanoff, 2006). Content analysis entails examining content and themes in written documentation, generally through the use of frequency counting (Hays & Singh, 2012). The use of content analysis permitted a micro-level examination of more macro ethical constructs and also acknowledged diversity between practitioners’ viewpoints (Bradley & Hendricks, 2008; Cottone, 2001).

Participants

Participant inclusion criteria encompassed previous clinical work, completion of a graduate-level course in counseling ethics, and a professional counseling identity (i.e., ACA membership, enrollment/alumni of a graduate-level counseling program). Participants were recruited from a Southeastern CACREP-accredited counseling program. A maximum variation sample was selected based on participants’ years of experience and educational degree level related to counseling, seeking one new-, mid-, and advanced-level professional. Guidelines for appropriate sample sizes in qualitative research vary and are grounded by the specific study’s purpose (Mason, 2010). Generally, pilot studies require fewer participants because data saturation is not the goal (van Teijlingen & Hundley, 2001).

To protect confidentiality, the three participants were given the following pseudonyms: Cassidy, Doc, and Sam. Cassidy, a Caucasian 25-year-old female, was chosen to represent the new-level professional. Currently enrolled in a master’s-level clinical mental health program, she was completing her last semester of studies, while also obtaining a specialization in addictions counseling. Her clinical background included one semester of a practicum course and two semesters of an internship field experience course in counseling. The mid-level professional was Doc, a biracial 29-year-old male. He was a doctoral-level student completing his first year in a counseling program with an already obtained master’s-level degree. Prior to enrollment into the PhD program, Doc worked in a clinical mental health setting with adolescents and adults for 4 years. Lastly, the advanced-level professional was Sam, a Caucasian 47-year-old male. Sam served as a clinical professor in a MEd and PhD counseling program. Along with teaching, Sam was also a Licensed Professional Counselor, a Licensed Marriage and Family Therapist, and had 16 years of experience as an individual, couples, and family counselor.

Procedure

Initial interview questions were developed in consultation with a professional colleague and with reference to current counseling ethics literature. Questions were intended to examine participants’ micro-level conceptualizations of macro-level constructs of ethics, values, and ethical dilemmas, as well as the intra- and interrelationships between these constructs. The initial interview questions were pilot tested among students enrolled in a doctoral-level qualitative research class and amended according to provided feedback. The revised interview protocol included the following questions: (a) How would you define ethical behavior?; (b) What are some specific examples of this definition (ethical behavior)?; (c) In the context of counseling, are there any factors that influence your ethical decision-making process?; (d) If so, what are the factors that influence your ethical decision-making process?; (e) What are some of your personal values?; (f) Do you feel these values affect your understanding of what is or what is not ethical?; (g) If so, how do these values affect your understanding of ethical behavior?; (h) Have you ever been faced with an ethical dilemma in which you felt the ACA ethical codes conflicted with your personal values?; (i) If yes, what was the ethical dilemma and how did you reconcile to overcome the conflict?; and (j) What type of value- conflicted ethical dilemma do you feel would be the most difficult to deal with and why?

Research consent was obtained from participants meeting the aforementioned inclusion criteria who agreed to participate in this voluntary study. Semi-structured 30- minute interviews were conducted and audio-recorded in a private setting; field notes were taken to capture participants’ nonverbal behaviors. The researchers transcribed the interviews and then disseminated them to participants for content verification.

Data Analysis

Conventional content coding analysis was utilized which is a “subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns” (Hsieh & Shannon, 2005, p. 1278). Such analysis allows for the rich emersion of thematic categories without preconceived social definitions. Each interview was first coded independently through the process of word/theme count. Participants’ spoken words were manually counted and associated words/synonyms were themed together (e.g., “bracket values” and “don’t impose values” constituted the same theme) and categorized based on research question relevancy. Words/themes referenced at least three times per participant were deemed individual themes. Member checking of individual themes then occurred with the associated participant, confirming representation of his/her belief system as evidenced by no revisions.

Comparison of the three coded transcriptions then occurred with attention to response similarities across the participants’ identified individual themes. If all three participants made reference to the same individual theme, this theme was then defined as emergent. Upon comparison coding, triangulation of coding analysis occurred with professional peers.

Researcher Bias and Trustworthiness

The researchers are highly vested on subject matter related to ethicality and the protection of client welfare, potentially creating researcher bias. Researcher bias can impede adoption of a neutral stance, thereby impacting the validity of qualitative data. As suggested by Creswell and Miller (2000), the following steps were taken to reduce bias and to increase data trustworthiness: (a) member checking, (b) triangulation of data coding, (c) consultation with peers, and (d) continued self-reflection throughout the research process.

Results

The following section examines this study’s results. Emergent themes are organized by the four research areas/questions. These areas include: (a) ethical behavior constructions, (b) factors influencing ethical decision making, (c) role of ethical codes on decision making processes, and (d) role of personal values on decision-making processes.

Constructions of Ethical Behavior

Two emergent themes resulted in relation to participants’ subjective constructions of ethicality. The first theme identified ethicality as ambiguous and difficult to define. The second theme spoke to a right versus wrong dichotomy existing in the construct of ethicality.

Ambiguous and difficult to define. The concept of ethical behavior was difficult for these participants to define, evidenced through their verbal responses and subsequent multiple pauses when processing their response. For example, Sam described the construct of ethical behavior using 238 words; during this time, he made seven notable pauses that lasted over five seconds each. Similarly, Doc used the following circular definition in describing ethics: “um (pause). . . . Well, kind of like how it sounds. It’s acting and behaving in a way that . . . uh . . . that is (taps fingers on desk) ethical.” Cassidy’s remarks also supported the emergent theme of ambiguity when she stated: “It [ethical behavior] is not a black and white thing. It’s ambiguous.” Though ethicality as a specific construct was difficult to define, participants noted that actions resulting in mental, emotional, or physical risk to the client encompassed unethical behavior; however, what these specific behaviors entailed, in most cases, was deemed situation specific.

Right versus wrong dichotomy. The perception of a right versus wrong dichotomy was a second emergent theme related to participants’ constructions of ethical behavior. For example, when Doc processed an ethical dilemma he faced with a former client, he noted attempting to distinguish the right from wrong course of ethical action. “Right” was defined here as the action most protective of client welfare. Similarly, Cassidy differentiated the “right” course of action in moments of ethical conflict as being “in the best interest of both . . . me and the client.” She defined the “wrong” course of action as any behavior that led to undue harm. Cassidy underscored ethics as either one or the other – either right or wrong. Lastly, Sam identified an aspirational facet existing in the concept of ethical behavior that dictates the right course of action. Using a holistic perspective indicative of higher cognitive complexity (Rest et al., 1999), Sam stated that “you don’t behave ethically just because you are told to behave ethically. You behave ethically because it is the right thing to do.”

Factors Influencing Ethical Decision Making

Participants were asked to reflect on factors influencing their ethical decision making and subsequent actions. Four emergent themes were identified related to this research question. Themes included: (a) ethical codes, (b) personal beliefs and values, (c) the process of engaging in supervision and consultation, and (d) weighing a decisional balance scale.

Ethical codes. Participants noted that ethical codes influenced their decision making process when faced with a potential ethical dilemma. This was evident in Cassidy’s response as she stated that “um . . . well, the code of ethics, obviously” played an important role in helping her choose a course of action in the presence of ethical conflict. Sam referenced ethical codes as the most “concrete” definition of ethical behavior, noting codes “should guide” one’s actions. He reflected when faced with uncertainty about how to proceed in any given ethical situation, “you have to . . . go back to the code, go back to the essence of fairness.” The role of ethical codes was further explored (see emergent theme of “Role of Ethical Codes” below).

Beliefs and values. Participants reported personal beliefs and values as another factor impacting ethical decision-making processes. When discussing the construct of values and its relationship to conduct, Doc remarked, “the influence of the values I was given, being brought up . . . is a huge factor” and “I think the largest influence.” Likewise, Cassidy reported, “my personal beliefs and values come into it [ethical decision-making process] and that is how I interpret it [the situation].” Cassidy and Sam also clarified concern about the detrimental role values could have upon the therapeutic process, such as unmonitored value projection and countertransference. In defining their personal values, the participants noted some of the following core belief systems: honesty, genuineness, accountability, spirituality, and the belief that inherent good exists in others. The role of personal values was further explored (see “Role of Personal Values” section).

Supervision and consultation. Supervision and consultation emerged as a third theme of factors influencing ethical decision making and was described as beneficial to obtaining multiple perspectives, developing sound courses of action, and providing emotional support. Cassidy noted that “consultation . . . is probably the biggest thing that I have fallen back on” when faced with an ethical conundrum. Similarly, Sam reflected that peer consultation helped him feel as if he was not alone in the decision-making process, finding such collaborations imperative when he was “not quite sure which way to go.” In addition, participants associated consultation with the provision of a necessary level of emotional support. Consideration of layered contextual factors, including affect, within consultative relationships facilitated reconciliation of potentially encumbering personal feelings and values. For example, Doc reported that consultative supervision provided him a safe space to process emotions (e.g., fear) and ground his role as a mandatory reporter when faced with an ethical scenario involving potential child abuse/neglect.

While supervision was perceived as an influential factor on ethical decision making, not all supervision engagements resulted in positive experiences. Cassidy reflected on an instance when her supervisor encouraged behavior that Cassidy felt crossed professional boundaries. Wanting to “obey” her supervisor but feeling “uncomfortable” with the situation, Cassidy felt conflicted as the ACA guidelines related to this dilemma lacked specificity. Thus, supervision may assist counselors in navigating ethical dilemmas and associated codes, but may be problematic should individuals’ constructions of the issues conflict.

Decisional balance scale. Finally, relative consideration of benefits and consequences also emerged as influential to ethical decision making. To mitigate interpersonal conflict in the aforementioned dilemma involving mandatory reporting, Doc asked himself: “what if the situation was severe . . . and the report was not made . . . and something really happened to the children? Could I have lived with that? No!” Realizing the children’s welfare was potentially at stake, Doc continued to reflect: “could I have lived with maybe . . . making the report . . . and thus lessening the trust and having the mom mad at me? Yes!” Overall, applying a decisional balance scale helped Doc remain ethically objective, diminishing the influence of contextual factors that potentially muddled his decision (e.g., not wanting to damage therapeutic rapport).

When using a decisional balance scale, Sam reported, “you do sort of a mental cost benefit analysis . . . you weigh the different perspectives . . . you try to look at it from as many different angles as you can . . . and ultimately, try to do the right thing.” According to Cassidy, while assessing identified pros and cons of a situation, “you have to sit there . . . it’s really just a matter of analyzing the content and processing with the client.” Across the participants, continued self-reflection and inclusion of the client’s voice were interconnected with application of the decisional balance scale. Considering benefits and consequences of various courses of ethical action assisted participants to both examine and prioritize inherently layered contexts.

Role of Ethical Codes

When specifically asked about the role of ethical codes on ethical decision- making processes, one theme was identified. This theme entailed the ascription of ethics as rules. Further examination of this theme indicated two branches of delineation: rules were (a) guidelines for proceeding in ambiguous situations or (b) black and white contingent on ethical code specificity.

Ethical codes as rules. The participants described ethical codes as rules. Though these rules were not always clear, Cassidy stated that ethical codes served as a foundation of “what one can or cannot do” within the context of a professional counseling role. Similarly, Sam described the rules as “aspirational in nature . . . but are created to guide (pause) . . . members of the profession.” Distinct dichotomy between right and wrong courses of action was not always prescribed or situational. However, participants agreed that the rules entailed adherence to overarching ethical and moral principles including: doing no harm, serving the best interest of the client, and fairness/equality.

While some areas of ethical code were interpreted fluidly, other codes were conceived as being straightforward. Participants explained that situations such as romantic relationships with current clients and mandatory reporting entailed a clear right or wrong answer. For instance, though Doc was initially torn about making the report to CPS, he also referenced the ethical codes as rules, noting that “I did it. I had to. That was my moral . . . and my, (pause) um . . . my need as a counselor to fulfill . . . as far as being a mandatory reporter.”

Role of Personal Values

The final research question explored the role of personal values in decision- making processes. Participants were asked to discuss subjective constructions of personal values and the influence of values in ethical decision making. Two primary themes emerged. First, participants described (a) personal values as being ambiguous and difficult to define. As such, and captured by the second theme, when making an ethical decision, (b) separation of beliefs from conduct becomes warranted.

Ambiguous and difficult to define. Though participants reported personal values affected their ethical decision-making processes, they also noted a specific definition of what these personal values entailed was difficult to articulate. Generally, participants reflected upon the following core belief systems as a foundation to their value system: honesty, genuineness, accountability, spirituality, and the belief that inherent good exists in others. As general values appeared to result in a plethora of situation-specific instances, participants found it challenging to articulate a specific definition of personal values because they were uncertain of where to begin. For instance, as Doc reported, “that’s hard to capture . . . I think (pause) . . . because there is a lot of them.” Likewise, Sam stated, “Wow . . . I could spend the rest of my life answering that.”

Separation of beliefs from conduct. The final emergent theme reflected the need for a counselor to separate his/her personal beliefs from the therapeutic context. As illustrated by Cassidy, if there “was something that I really believed was not right,” it is a matter of “trying to put aside my personal stuff.” Participants clarified that suspension of values from subsequent behaviors was warranted in instances that the counselor’s personal belief systems conflicted with professional ethical codes or did not uphold the best interest of the client. Ethical codes and consideration of client welfare were utilized as navigational tools in the presence of value conflicts. While discussing special monetary accommodations for individual clients, Sam stated, “to do that would be an ethical violation of fairness . . . and yet . . . part of me says . . personally, why should I not be able . . . to give that gift to this person in order for them to get the treatment that they are seeking.” The moral principle of fairness (i.e., treating all clients equally) was processed from a holistic perspective and Sam reached the conclusion that a payment allocation for the client could jeopardize client welfare. He reflected that professional boundaries could potentially be blurred with the client and other clients might be indirectly affected if payment allocations were not considered for them.

Discussion

Overall, findings from this pilot study were congruent with extant literature supporting that multiple variables can influence ethical constructions, such as codes and personal values (Ametrano, 2014; Cottone, 2001; Welfel, 2012). Participants discussed the pertinence of codes in grounding a collective norm of ethicality and, at the same time, tensions inherent in codes when ambiguity exists. Emergent themes elucidated: (a) ethical construct ambiguity, (b) the use of supplemental professional tools (e.g., codes, decision- making models, supervision), and (c) that personal values can alter or shape individual ethical processes.

Ethical construct ambiguity was evidenced as participants had difficulty defining the term. In general, ethics was linked to moral principles (e.g., beneficence, nonmaleficence). Though moral principles are ubiquitous within the ACA Code of Ethics (2014), serving as pillars for ethical standards, they also lack behavioral specificity. Instead, moral principles are aspirational in nature, serving as a compass that helps guide one to an ethical final decision. As such, reference to specific ethical codes becomes pertinent in grounding ethical outcomes.

Supported by literature (Bradley & Hendricks, 2008) and participants of this study, ethical codes are a pertinent resource that can assist practitioners in navigating ethical conflict. Though imperfect, ethical codes reflect a mutually constructed, “objective” account of counselors’ professional ethical responsibilities, a concept substantiated by this study’s emergent theme that defined ethical codes as rules. Code imperfections speak to indefiniteness inherent within ethical codes (Welfel, 2012). Though, logistically, it would be unfeasible for every potential situation to be identified by a specific code, lack of specificity might be problematic because of the propensity for different subjective interpretation. Divergent beliefs surrounding the construction of ethicality are illustrated by the existence of practitioners’ varied perceptions (Neukrug & Milliken, 2011). Lack of code specificity may increase the difficulty in acknowledging that a potential ethical conflict exists if professional and personal values are not reconciled (Ametrano, 2014).

When faced with code ambiguity, participants turned to professional resources, such as decisional balance scales and peer consultation. When using decisional balance scales, participants reported holistic conceptualizations as both benefits and consequences of actions were considered. Similarly, peer consultation introduced multiple perspectives when processing ethical courses of action. In essence, the use of multifaceted conceptualizations assisted in increasing ethical objectivity. However, peer consultation may become problematic if fundamental differences exist in ethical constructions. In some instances, supervision can lead to miseducative experiences (Nuttgens & Chang, 2013), similar to the situation that Cassidy processed. Cassidy felt uncomfortable with her supervisor’s directives and yet was torn on how to respond, partially due to the inherent power differential. As such, a potential limitation of consultation might exist when instead of engaging in collaborative discussions, individuals are told what to do.

Recent court cases (Keeton v. Anderson-Wiley, 2010; Ward v. Wilbanks, 2010) illustrate how an individual’s values can conflict with moral principles and, in turn, impact ethical interpretation of the codes. To mitigate the potential for detrimental ethical outcomes when dealing with value conflicts, the use of resources that provide holistic interpretations (e.g., peer consultation, decisional balance scale) become quintessential (Kocet & Herlihy, 2014). Reference to professional ethical codes further assists in anchoring ethical outcomes. As Sam noted, despite the influence of one’s values, “you have to . . . go back to the code, go back to the essence of fairness.” Referencing and applying the codes entails interpretation of what is written and also aspirationally implied. Though ethical codes have ambiguity, they still serve as an ethical framework (Welfel, 2012). The results of this study support code specificity as beneficial in defining concepts that are subjected to objective interpretations. For instance, Doc noted that specific code references helped him segregate his values and uphold ethical obligations. Changes to the ACA Code of Ethics (2014) regarding client referrals highlight the necessity of specific revisions when deemed warranted by the profession. Continued micro-level ethics research might assist in understanding the conceptual aspect of ethics, highlighting potential areas of concern that can be addressed, such as discrepancies between individual and collective norms of ethicality.

Limitations

When interpreting this study’s results, it is important to consider transferability limitations produced by sampling protocol and sample size. The use of a maximum variation sample can add a diverse perspective to attained qualitative findings (Creswell & Miller, 2000). However, such demographic variations may have also influenced participants’ ethical constructions (affecting transferability) and encumbered future research replication. In reference to sample size, qualitative research grounds participant numbers based on data saturation (Mason, 2010). However, data saturation is not the goal of pilot studies. Transferability of the findings originating through pilot studies is thereby limited and warrants replication with larger samples. The use of larger sample size would assist with data saturation and validation of micro-level analysis for macro-level constructs (e.g., ethics). Despite the aforementioned limitations, the current pilot study can assist researchers vested in the construct of counseling ethics, providing future research direction. This is congruent with pilot studies’ overarching goals: informing, grounding, and improving future research agendas (van Teijlingen & Hundley, 2001). As such, this pilot study lays the foundation and encourages examination of further qualitative similarities and differences between participants’ ethical perceptions on dimensions, such as years of experience and specialization/environmental difference.

Implications for Future Research

Continued research on micro-level examinations of counseling ethics is suggested by extant literature and the results of this study (Ametrano, 2014; Cottone, 2001; Welfel, 2012). Future researchers might consider a comparative analysis between participants’ constructions (micro-level) and content analysis of ethical codes (macro-level), identifying similarities and incongruities between the two. In addition to qualitative inquiry, researchers might consider mixed methodology methods as to assess quantitative differences between counselors’ ethical perceptions, capturing both breadth and depth. Findings from such research could be used when considering future ethical code revisions and implemented within ethical trainings as to address potential gray and/or conflict areas.

A second research area might encompass interviews with counselors who do not agree with aspects of the ethical codes or have behaved unethically. The participants within this study expressed values congruent with the philosophical underpinnings of the ACA Code of Ethics (2014; e.g., do no harm, protect the better good). Yet, the question remains: why does someone act unethically? Though it is uncertain if participants of this study have ever acted unethically, they had no history of ethical or legal sanctions; setting the participant parameters to entail former/current ethical sanctions might assist the counseling profession in conceptualizing ethical behavior from a different facet, producing pieces of the puzzle that are less understood. Such knowledge could then be used to improve counselor education, supervision practices, and ethical codes within the field.

Summary

Though ethical codes formalize normative ethical behavior, counselors’ micro- level perspectives enrich understandings of ethicality by highlighting inherent ambiguities, factors influencing ethical knowledge and behaviors, and resources that promote multifaceted ethical conceptualizations. Findings from this study (i.e., need to clarify ethical constructs, practice with decisional balance scales, explicit discussion of personal and professional values) may be readily applied to counselor education settings. Continued exploration of areas of overlap and tension among counseling ethics at the macro and micro levels seems particularly relevant. Knowledge from such discourse can ultimately be used to enhance counselor preparation strategies, and professional resources, address disharmonies within a collective norm of ethical practices, and ultimately, improve client services and processional safeguarding.