Informed Consent, Confidentiality, and Diagnosing: Ethical Guidelines for Counselor Practice

By Kress, Victoria E.; Hoffman, Rachel M. et al. | Journal of Mental Health Counseling, January 2013 | Go to article overview

Informed Consent, Confidentiality, and Diagnosing: Ethical Guidelines for Counselor Practice


Kress, Victoria E., Hoffman, Rachel M., Adamson, Nicole, Eriksen, Karen, Journal of Mental Health Counseling


Informed consent and confidentiality are discussed in the context of counselors' use of the DSM diagnostic system. Considerations that can facilitate counselor diagnostic decision-making related to informed consent and confidentiality are identified in a case application. Suggestions that can enhance ethical diagnostic practices are provided.

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The Council for the Accreditation of Counseling and Related Educational Programs (CACREP, 2009) requires that all trainees be instructed in ethical principles (CACREP, Section II.G.l.j). The CACREP standards also require that clinical mental health counselors and addictions counselors be trained in the use of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, hereafter DSM; American Psychiatric Association [APA], 2000; CACREP Standards for Clinical Mental Health Counseling Section K. 1 and Standards for Addiction Counseling Section K.1). With regard to the intersection of ethics and diagnosis and in relation to informed consent, the American Counseling Association (ACA) Code of Ethics (2005) states "Counselors take steps to ensure that clients understand the implications of diagnosis" (A.2.b.). The American Mental Health Counselors Association (AMHCA) Code of Ethics (2010) asserts that "Informed consent is ongoing and needs to be reassessed throughout the counseling relationship" (B.2.d.).

The DSM contains 297 diagnoses (APA, 2000), which will be explored with generally equal breadth and depth in the next DSM iteration (APA, 2011). It may therefore be difficult for counselors to fully understand the myriad ethical considerations that need to be addressed when applying DSM diagnoses (Eriksen & Kress, 2005). Calley (2009) stated that because they are elusive aspects of counselors' personal and professional behavior, ethics must be explicitly addressed if they are to be fully integrated into professional practices. Explicit discussions of DSM ethics-related issues are thus important if counselors are to be deliberate and ethical in their practice (Calley, 2009).

There is a need for context-specific applications of ethics related to informed consent, confidentiality, and the DSM (Eriksen & Kress, 2005; Kress, Hoffman, & Eriksen, 2010). A lack of professional exchange about this topic could give the impression that it is not of importance. Conversely, more detailed discussions should facilitate ethical practices related to the DSM, confidentiality, and informed consent (Calley, 2009). Although professional codes of ethics focus on appropriate use of the DSM (ACA, E.5.a.-E.5.d.; AMHCA, D.1.-D.3.) and CACREP requires counselor training in its use, the literature offers minimal guidance on how to use the DSM ethically. Only a few articles have touched specifically on the topic of client-informed consent and confidentiality as related to the DSM (e.g., Bassman, 2005; Kress et al., 2010; Walker, Logan, Clark, & Leukefeld, 2005).

Client diagnosis has risks, and clients are often not fully apprised of them. This lack of transparency compromises the counseling values of beneficence and nonmaleficence (because client well-being may be jeopardized), and autonomy (because the client is not given all the information needed for an informed decision). Calley (2009) suggested that counselors consider complex ethics issues comprehensively, explicitly identifying problems and relating them to the principles of beneficence, nonmaleficence, justice, and fidelity. Calley suggested there is value in examining all ethical codes that apply to a particular dilemma and identifying how the standards are being executed.

According to Calley (2009), if upon consideration a counselor is unable to conclude that ethical codes are being upheld, it is necessary to explore the issue in greater depth. Calley suggested consulting resources to help identify desirable ethical standards and how they can be applied to a given ethical dilemma. …

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