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The Legal Department articles are not intended to serve as legal advice and are offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in the article.
This article discusses the recent changes to the Code of Ethics, focusing on substantive revisions to sections 1-4 of the Code. It is the first of three articles regarding this topic.
by Michael Griffin, JD, LCSW
The duties of the CAMFT Ethics Committee include, among other things, the responsibility to maintain and review the CAMFT Code of Ethics, and from time to time, to propose revisions, deletions and additions to the Code of Ethics to the Board of Directors for its approval. 1 In December, 2019, the publication of the revised CAMFT Code of Ethics was the culmination of over four years (and hundreds of hours) of intensive work by the CAMFT Ethics Committee, two former Ethics Committee chairpersons serving as consultants, and multiple members of the CAMFT staff.
In revising the Code of Ethics, a fundamental goal of the Ethics Committee was to ensure that the resulting ethical guidelines provide a clear and practical source of guidance to members of the Association. Depending on the particular code section, the revisions may be limited in scope, such as minor changes to Section 1.5, which simply clarifies that termination (if conducted appropriately) is permissible for non-payment of fees. In other instances, the changes are substantial, such as the content of Section 3, which integrates multiple issues applicable to the broad topic of informed consent and disclosure that were previously located in several sections of the Code of Ethics, or the multi-faceted guidance that is now provided in section 4 concerning Dual/Multiple Relationships.
This is the first of a three-part series which focuses on sections of the Code of Ethics that are either new, or, which contain content that has been substantively revised.2 3 The following discussion examines the new and revised content found in sections 1 through 4 of Part I of the Code, (including the new preamble to the Code). Changes to sections 5 through 13 of the Code will be discussed in upcoming issues of The Therapist. (This article does not discuss sections of the Code of Ethics with minor, non-substantive revisions).
PART I - THE STANDARDS
The following preamble was added to the Code of Ethics:
Marriage and family therapists recognize that ethical decision-making principles may be based on higher standards for their conduct than legal requirements and that they must comply with the higher standard. Marriage and family therapists act with integrity and truthfulness, ensure fairness and non-discrimination, and promote the well-being of their clients/patients within the larger society. Marriage and family therapists avoid actions that cause harm and recognize that their clients/patients control their own life choices.
Marriage and family therapists should be familiar with models of ethical decision-making and continuously develop their skills to recognize when an ethical conflict exists. Marriage and family therapists utilize consultation and stay current with the relevant research and literature about these processes. Marriage and family therapists reflect on ethical issues that arise within their practice and within the context of their legal responsibilities, ethical standards, and personal values, and develop congruent plans for action and resolution.
Why Is There A New Preamble to the Code of Ethics? The new preamble to the Code of Ethics, entitled “Ethical Decision Making,” is intended to provide an over-arching aspirational statement, encompassing the core values of the marriage and family therapy profession, as they are expressed throughout the Code of Ethics.
Revised Section 1.1
1.1 NON-DISCRIMINATION: Marriage and family therapists do not condone or engage in discrimination, or refuse professional service to anyone on the basis of race, ethnicity, national origin, indigenous heritage, immigration status, gender, gender identity, gender expression, religion, national origin, age, sexual orientation, disability, socioeconomic status, or marital/relationship status. Marriage and family therapists make reasonable efforts to accommodate clients/ patients who have physical disabilities. (See also sections 3.2 Therapist Disclosures, 3.7 Therapist Professional Background, and 5.11 Scope of Competence.)
What Changed In Section 1.1? Compared to the language of the prior Code of Ethics, this section further clarifies and defines discrimination, including the fact that discrimination or the refusal of professional services may not be based upon a person’s ethnicity, indigenous heritage, or immigration status. In addition, Section 1.1 utilizes “See also,” which alerts the reader to other relevant sections of the Code: (3.2 Therapist Disclosures, 3.7 Therapist Professional Background, and 5.11 Scope of Competence).
The use of “See also,” reminds therapists to be mindful of other sections of the Code of Ethics when they are contemplating the discontinuance of services to a client/patient, or the possible refusal of services to an individual. For example, because therapists do not have identical degrees of competency in working with every possible client/ patient, they must consider whether their “scope of competence,” as determined by their education, training and experience, is appropriate to working with a particular person.
When considering whether their scope of competency may be an issue in working with someone, therapists should not hesitate to consider consultation with a trusted resource.
New Section 1.4
1.4 TERMINATION: Marriage and family therapists use sound clinical judgment when terminating therapeutic relationships. Reasons for termination may include, but are not limited to, the client/patient is not benefiting from treatment, continuing treatment is not clinically appropriate, the therapist is unable to provide treatment due to the therapist’s incapacity or extended absence, or due to an otherwise unresolvable ethical conflict or issue. (See also sections 3.8 Client/Patient Benefit and 5.11 Scope of Competence.)
Why Is There A New Section 1.4? The language of section 1.4 incorporates content from Section 1.3.1 of the prior Code of Ethics and emphasizes that the manner and process involved when terminating a therapeutic relationship should be based upon the clinician’s sound clinical judgment. Furthermore, in contrast to the language of former Section 1.3.1, which stated that termination may occur “in order to avoid” an ethical conflict, the Committee believed that it was clearer, and more instructive, to state that termination may be appropriate “due to an otherwise unresolvable ethical conflict.” Section 1.4 also utilizes “See also,” which alerts the reader to other relevant sections of the Code: (3.8 Client/ Patient Benefit and 5.11 Scope of Competence.)
New Section 1.5
1.5 NON-PAYMENT OF FEES: When terminating client/patient relationships due to non-payment of fees, marriage and family therapists do so in a clinically appropriate manner.
Why Is There a New Section 1.5? Section 1.5 includes content from Section 1.3.4 of the prior Code of Ethics and clarifies that it is permissible for a therapist to terminate a therapeutic relationship for non-payment of fees, if done in a clinically appropriate manner.
New Section 1.10
1.10 TREATMENT PLANNING: Marriage and family therapists work with clients/ patients to develop and review treatment plans that are consistent with client/patient goals and that offer a reasonable likelihood of client/ patient benefit.
Why Is There A New Section 1.10? Section 1.10 incorporates content from Section 1.4.1 of the prior Code of Ethics and includes the use of “Treatment Planning” as the new title, (rather than “Patient Choices”), as this section focuses on the importance of developing treatment plans that are reasonably likely to be beneficial to the client/ patient and which are consistent with the client’s/ patient’s goals. The reason for this change is that the Ethics Committee wanted to emphasize the importance of treatment planning in general, and the need for the therapist and their client/patient to collaborate in creating treatment plans. The client’s/patient’s treatment record ought to reflect the therapist’s assessment of the client’s/patient’s needs and concerns, and their effort to work with the client/patient in determining appropriate goals and objectives.
New Section 2.4
2.4 EMPLOYEES—CONFIDENTIALITY: Marriage and family therapists take appropriate steps to ensure, insofar as possible, that the confidentiality of clients/patients is maintained by their employees, supervisees5, assistants, volunteers, and business associates.
Why Is There A New Section 2.4? Section 2.4 incorporates content from Section 2.5 of the prior Code of Ethics and includes the use of the term “business associates.” Under the Health Insurance and Portability Act of 1996 (HIPAA), therapists who engage in certain transactions with third-party payers are considered to be “covered entities.” A “covered entity” may disclose confidential information to a business associate (a person or entity) that performs functions or activities that involve the use or disclosure of protected health information on behalf of that entity.
New Section 3 and Preamble
3. INFORMED CONSENT AND DISCLOSURE: (New Preamble)
Marriage and family therapists respect the fundamental autonomy of clients/patients and support their informed decision-making. Marriage and family therapists assess their client’s/patient’s competence, make appropriate disclosures, and provide comprehensive information so that their clients/patients understand treatment decisions.
Why Is There A New Section 3 and Preamble? The preamble to Section 3 is intended to underscore the fundamental importance of providing sufficient information to clients/patients in order to support and facilitate their informed participation in therapy. This section integrates relevant information that was located in multiple sections of the prior Code of Ethics in order to provide a cohesive discussion of informed consent and disclosure.
New Section 3.1
3.1 INFORMED DECISION-MAKING: Marriage and family therapists respect the rights of clients/patients to choose whether to enter into, to remain in, or to leave the therapeutic relationship. When significant decisions need to be made, marriage and family therapists provide adequate information to clients/patients in clear and understandable language so that clients/patients can make meaningful decisions about their therapy.
Why Is There A New Section 3.1? Section 3.1 incorporates content from Section 1.5 of the prior Code of Ethics, with revisions. The title of Section 3.1 was changed from “Therapist Disclosures,” to “Informed Decision-Making,” to emphasize that it is a fundamental right of clients/patients to make meaningful decisions about their therapy.
New Section 3.2
3.2 THERAPIST DISCLOSURE: When a marriage and family therapist’s personal values, attitudes, and/or beliefs are a prejudicial factor in diagnosing or limiting treatment provided to a client/patient, the marriage and family therapist shall disclose such information to the client/patient or facilitate an appropriate referral in order to ensure continuity of care.
Why Is There A New Section 3.2? Section 3.2 incorporates content from Section 1.5.1 of the prior Code of Ethics, with revisions. The language of this new section clarifies that a therapist is only expected to provide disclosures to a client/patient regarding the therapist’s personal values, attitudes and/or beliefs, (or to facilitate an appropriate referral), if the therapist believes that their values, attitudes and/or beliefs are a prejudicial factor in diagnosing or limiting treatment to the client/patient.
New Section 3.4
3.4 EMERGENCIES/CONTACT BETWEEN SESSIONS: Marriage and family therapists inform clients/patients of the extent of their availability for emergency care between sessions.
Why Is There a New Section 3.4? Section 3.4 addresses the issue of providing emergency services to clients/patients in-between sessions, and incorporates content from Section 1.5.3 of the prior Code of Ethics. Although former Section 1.5.3 referred to circumstances where the therapist “is not located in the same geographic area as the patient,” such content is now addressed in Section 6 of the Code of Ethics, which concerns the topic of Telehealth.
New Section 3.11
3.11 TREATMENT ALTERNATIVES: Marriage and family therapists discuss appropriate treatment alternatives with clients/ patients. When appropriate, marriage and family therapists advocate for the mental health care they believe will benefit their clients/patients. Marriage and family therapists do not limit their discussions of treatment alternatives to what is covered by third-party payers.
Why Is There A New Section 3.11? Section 3.11 incorporates language from Sections 1.12 and 1.13 of the prior Code of Ethics, including content which concerns the issue of advocating for mental health care on behalf of client/patients. It clarifies that therapists are not ethically obligated to advocate for mental health care on behalf of clients/patients, but may engage in such advocacy, as they are often in a position to determine whether such services may benefit the client. This new section also emphasizes the importance of discussing treatment alternatives with client/patients.
New Section 3.12
3.12 DOCUMENTING TREATMENT RATIONALE/CHANGES: Marriage and family therapists document treatment in their client/patient records, such as major changes to a treatment plan, changes in the unit being treated and/or other significant decisions affecting treatment.
Why Is There A New Section 3.12? Section 3.12 reminds therapists that major changes to a client’s/patient’s treatment plan, and significant decisions affecting a person’s treatment, such as changes in the unit of treatment, should be appropriately documented in the treatment record.
In light of the fact that documentation of treatment is a legal and an ethical duty, language that was located in Section 1.15 of the prior Code of Ethics (“Documenting Treatment Decisions”), which merely encouraged marriage and family therapists to carefully document treatment was not included in this new section. The Committee also decided not to carry over language from the prior Code of Ethics regarding the documentation of suspected child abuse, or elder or dependent abuse, in order to clarify that mandated reporters have discretion whether to document their decisions related to mandatory reporting. The Child Abuse and Neglect Reporting Act provides protection to mandated reporters by stating that the identity of the mandated reporter must be kept confidential and may only be disclosed as specified in the law, unless authorized by the mandated reporter or by a court order.
New Section 4 and Preamble
4. DUAL/MULTIPLE RELATIONSHIPS: (Preamble) Marriage and family therapists establish and maintain professional relationship boundaries that prioritize therapeutic benefit and safeguard the best interest of their clients/patients against exploitation. Marriage and family therapists engage in ethical multiple relationships with caution and in a manner that is congruent with their therapeutic role.
Why Is There A New Section 4 and Preamble? The new preamble to Section 4 underscores that it is important for therapists to carefully consider the best interests of their clients/patients, and to exercise due care, when contemplating the possibility of involvement in dual/multiple relationships with clients/patients. This section is devoted to the broad topic of dual/ multiple relationships. It was created to provide an expanded, and better integrated discussion of various issues that are relevant to this topic. This new section is also intended to provide ethical standards that are more specific and which offer improved guidance to therapists, compared to the prior Code of Ethics.
New Section 4.1
4.1 DUAL/MULTIPLE RELATIONSHIPS: Dual /multiple relationships occur when a therapist and his/her client/patient concurrently engage in one or more separate and distinct relationships. Not all dual/ multiple relationships are unethical, and some need not be avoided, including those that are due to geographic proximity, diverse communities, recognized marriage and family therapy treatment models, community activities, or that fall within the context of culturally congruent relationships. Marriage and family therapists are aware of their influential position with respect to clients/ patients, and avoid relationships that are reasonably likely to exploit the trust and/or dependence of clients/patients, or which may impair the therapist’s professional judgment.
Why Is There A New Section 4.1? In an effort to provide further guidance on the topic of dual/multiple relationships, and to dispel the common misconception that all dual/ multiple relationships are unethical, Section 4.1 incorporates, and expands upon content that was located in Sections 1.2 and 1.2.1 of the prior Code of Ethics. 6 As an example, Section 4.1 clarifies that, in some circumstances, a dual/ multiple relationship may be unavoidable, or permissible, including those that are based upon: Geographic proximity, (where engaging the client/patient in the community may be unavoidable by virtue of residing or working in the same location); Diverse communities, (where therapists and clients/patients engage in close-knit activities based upon their mutual affiliation with a particular group or community); Recognized marriage and family therapy treatment models that require activities outside of the traditional therapist role (such as a therapist who assumes a supervisory role while working in a substance abuse treatment setting, or, who works in a community mental health treatment model which incorporates therapists into activities that are outside of the treatment setting. Examples of the latter may include, accompanying the client/patient to court, to seek health care or to secure social services); Community activities (where the therapist participates in an activity that the client/ patient happens to be involved in, such as a food drive, or a clean-up effort at a local beach), and, activities which fall within the context of culturally congruent relationships, (such as instances where the therapist’s participation in an activity is important or meaningful to the client/patient, such as attending an adolescent’s Quinceañera or similar event).
New Section 4.2
4.2 ASSESSMENT REGARDING DUAL/ MULTIPLE RELATIONSHIPS: Prior to engaging in a dual/multiple relationship, marriage and family therapists take appropriate professional precautions which may include, but are not limited to the following: obtaining the informed consent of the client/patient, consultation or supervision, documentation of relevant factors, appraisal of the benefits and risks involved in the context of the specific situation, determination of the feasibility of alternatives, and the setting of clear and appropriate therapeutic boundaries to avoid exploitation or harm.
Why Is There A New Section 4.2? Therapists may encounter, or contemplate engaging in a wide range of dual/multiple relationships. Depending on the situation, and the needs of the client/patient, therapists are expected to take appropriate professional precautions to avoid the possibility of exploitation or harm to the client/patient. Section 4.2 provides guidance to therapists regarding these issues, by providing examples of precautions for therapists to consider when assessing whether it may be appropriate to enter into a dual/multiple relationship with a client/patient.
As an example, obtaining informed consent from the client/patient can help that person make an informed decision regarding their relationship with the therapist; Consultation or supervision may provide a therapist with objective input from a colleague or other professional regarding relevant clinical, legal or ethical issues; Thorough documentation by the therapist may help to clarify the therapist’s rationale, justification and appraisal of risks, benefits, and alternatives, and illuminate their efforts to establish clear and appropriate boundaries in order to avoid exploitation or harm to the client/patient.
New Section 4.3
4.3 UNETHICAL DUAL/MULTIPLE RELATIONSHIPS: Acts that could result in unethical dual relationships include, but are not limited to, borrowing money from a client/ patient, hiring a client/patient, or engaging in a business venture with a patient, or engaging in a close personal relationship with a client/ patient. Such acts with a client’s/patient’s spouse, partner or immediate family member are likely to be considered unethical dual relationships.
Why Is There A New Section 4.3? Section 4.3 incorporates content from Section 1.2.1 of the prior CAMFT Code of Ethics with clarification that unethical dual/multiple relationships (such as those defined in this section) between a therapist and a client/patient’s spouse, partner or immediate family member are likely to be considered unethical. The Committee believed that it was appropriate to clarify that the application of this standard to immediate family members was reasonable and that therapists should not be restricted from engaging in a relationship with a person merely because that individual is related to the client/patient.
New Section 4.4
4.4 NON-PROFESSIONAL RELATIONSHIPS WITH FORMER CLIENTS/PATIENTS: Prior to engaging in a non-sexual relationship with former clients/ patients, marriage and family therapists take care to avoid engaging in interactions which may be exploitive or harmful to the former client/patient. Marriage and family therapists consider factors which include, but are not limited to, the potential continued emotional vulnerability of the former client/patient, the anticipated consequences of involvement with that person, and the elimination of the possibility that the former client/patient resumes therapy in the future with that therapist.
Why Is There A New Section 4.4? Section 4.4 was written to address various issues which specifically apply to dual/multiple relationships with former clients/patients. First of all, the Committee believed that it was necessary to provide clearer language and improved guidance on this topic than that which was provided by Section 1.2 of the prior Code of Ethics, which stated that a dual relationship was a separate or distinct relationship with the client/patient which was entered into “either simultaneously with the therapeutic relationship, or during a reasonable period of time following the termination of the therapeutic relationship.” Because such language may have caused some confusion, due to the ambiguous meaning of what constitutes “a reasonable period of time,” it was not included in the new Section 4.4.
The Committee believed that a primary consideration for a therapist who is contemplating a relationship with a former client/patient, is whether the relationship may lead to exploitation or harm to the former client/patient. Section 4.4 therefore provides therapists with a number of factors to consider when making such a determination, including: The potential continued emotional vulnerability of the former client/patient and the anticipated consequences of entering into a post-therapy relationship with that individual, including, but not limited to, the possibility that a post-therapy relationship may preclude the resumption of therapy with that person in the future. The fact that it is not uncommon for former clients/patients to request services from their therapist at some point in time after termination occurs, should be a significant consideration for therapists when deciding whether to enter into a post-therapy relationship with a former client/patient.
New Section 4.5
4.5 SEXUAL CONTACT: Sexual contact includes, but is not limited to sexual intercourse, sexual intimacy, and sexually explicit communications without a sound clinical basis and rationale for treatment. Sexual contact with a client/patient, or a client’s/patient’s spouse or partner, or a client’s/patient’s immediate family member, during the therapeutic relationship, or during the two years following the termination of the therapeutic relationship, is unethical. Prior to engaging in sexual intimacy contact with a former client/patient or a client’s/patient’s spouse or partner, or a client’s/patient’s immediate family member, following the two years after termination or last professional contact, the therapist shall consider factors which include, but are not limited to, the potential harm to or exploitation of the former client/patient or to the client’s/patient’s family, the potential continued emotional vulnerability of the former client/patient, and the anticipated consequences of involvement with that person. (See also section 7.2 Sexual Contact with Supervisees and Students.)
Why Is There A New Section 4.5? Section 4.5 includes, and expands upon content expressed in Section 1.2.2 of the prior Code of Ethics. This new section requires therapists to assess certain factors prior to engaging in a sexual relationship with a former client/patient, a client’s/patient’s spouse or partner, or a client’s patient’s immediate family member, as opposed to former Section 1.2.2, which stated: “Should a marriage and family therapist engage in sexual intimacy...” Also, Section 4.5 requires therapists to undertake the same professional precautions that are applicable to non-professional relationships with former clients/patients, (as expressed in Section 4.4), by requiring therapists to avoid the potential harm to, or exploitation of, the former client/patient, or their spouse or immediate family member, by assessing the potential continued emotional vulnerability of the former client/patient, and the anticipated consequences of involvement with that person.” In addition, a significant addition to Section 4.5, is language which clarifies that sexual contact includes, “sexually explicit communications without a sound clinical basis and rationale for treatment.” This added language takes into consideration that sexual intimacy may include electronic communications with a person that convey sexually explicit content. However, this ethical standard is not meant to preclude the use of sexually explicit communications by a therapist when there is a sound clinical basis for such communications, such as circumstances where a therapist is discussing sexual behaviors with a client/patient, as an appropriate part of that person’s treatment plan.
Section 4.5 also utilizes “See also,” which alerts the reader to other relevant sections of the Code: (7.2 Sexual Contact with Supervisees and Students.)
New Section 4.6
4.6 PRIOR SEXUAL RELATIONSHIP: A marriage and family therapist does not enter into a therapeutic relationship with a person with whom the therapist has had a sexual relationship or knowingly enter into a therapeutic relationship with a partner or immediate family member of a person with whom the therapist has had a sexual relationship.
Why Is There A New Section 4.6? Section 4.6 recognizes that there may be circumstances where a therapist is not aware of the fact that they are treating the partner or immediate family member of someone with whom they have had a sexual relationship. This section therefore clarifies that a therapist is prohibited from knowingly entering into a therapeutic relationship with someone with whom the therapist has had a sexual relationship.
New Section 4.8
4.8 NON-THERAPIST ROLES: Marriage and family therapists when engaged in professional roles other than treatment or supervision (including, but not limited to, managed care utilization review, consultation, coaching, adoption service, child custody evaluation, or behavior analysis), act solely within that role and clarify, as necessary in order to avoid confusion with consumers and employers, how that role is distinguished from the practice of marriage and family therapy.
Why Is There A New Section 4.8? Section 4.8 contains language from Section 1.16 of the prior Code of Ethics, with the addition of “child custody evaluation” to the list of non-therapist roles. This change is in recognition of the fact that marriage and family therapists often assume the role of child custody evaluators.
The Code of Ethics is a Valuable Resource
To be sure, the Code of Ethics contains an enormous amount of information, and it would be understandable if a therapist felt a bit intimidated when reading the various sections. But it is important to remember that the Code is not a simple document: It is intended to serve as a guide to therapists who work with clients of all types, in an array of professional settings.
Therapists should not hesitate to refer to the Code of Ethics to clarify the application of ethical standards, and to resolve ethical questions as they arise. Because circumstances vary, it may be difficult at times to ascertain whether, and how, to apply the ethical standards to a given situation. When this occurs, it is strongly recommended that therapists seek appropriate consultation from a knowledgeable colleague, consultant, supervisor, instructor, or a member of the CAMFT legal staff.
Michael Griffin, JD, LCSW, is a staff attorney at CAMFT. Michael is available to answer member calls regarding legal, ethical, and licensure issues.
1 CAMFT Bylaws, Art. VII, Section (B)(3)
2 The term “client/patient,” as used in the Code of Ethics is synonymous with such words as “consumer,” and “counselee.” It is worth noting that the Committee adopted the use of the term “client/patient” throughout the Code instead of interchanging “client” and “patient,” as witnessed in prior versions of the Code.
3 The Introduction to the Code of Ethics includes the updated title for MFT Registrants (”Registered Associate Marriage and Family Therapists”) and a clarification that all members of CAMFT (including MFT’s as well as non-MFT’s) are expected to be familiar with the requirements expressed in the ethical standards.
4 The term “marriage and family therapist,” as used in the Code of Ethics, is synonymous with the term “licensed marriage, family and child counselor,” and is intended to cover registered associate marriage and family therapists and trainees performing marriage and family therapy services under supervision and is meant to apply to all other mental health providers in all membership categories of the Association
5 The term “supervisee,” as used in the Code of Ethics, includes registrants, trainees, and applicants for the license. 6 The issue of dual relationships with students and supervisees is located in Section 4.1 of the prior Code of Ethics. That topic is now addressed in Section 7 of the Code of Ethics, which concerns supervisee, educator, and student responsibilities.
This article is not intended to serve as legal advice and is offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in this article.