Ethical Decision Making: In Practice
As a mental health therapist, it’s not uncommon to encounter complex clinical situations that challenge your ethical judgment. One common dilemma arises when a trusted client discloses an issue outside your area of expertise. Do you refer them out and risk rupturing the therapeutic relationship—or continue care and risk practicing beyond your scope?
First I want to call attention to the American Counselors Association (ACA) and the American Mental Health Counselors Association (AMHCA). These are the two professional organization’s codes of ethics that govern my license.You will see the content is similar, but the order in which it is listed is different. The National Association of Social Workers (NASW) and American Association for Marriage and Family Therapy (AAMFT) ethical decision making models are very similar to the ACA and AMHCA. The most important thing is to utilize an ethical decision making model when faced with an ethical dilemma.
In this blog post, we’ll walk through this situation using the ACA’s Ethical Decision-Making Model and the AMHCA Ethical Decision Making Model and explore how to make a responsible, client-centered choice. This framework is especially helpful for counseling professionals, graduate students, and clinical supervisors seeking to balance ethics with real-world challenges.
Scenario: A New Disclosure Outside the Therapist’s Scope
You’ve been working with a client for six months. Progress has been strong, and the therapeutic alliance is solid. Then, during a session, the client discloses a significant issue that they withheld during the intake process—one that falls outside your current scope of practice. You learned about the topic in graduate school, but you don’t have clinical experience or specialized training to treat it effectively.
You gently explain this to the client and suggest a referral to a therapist with more expertise in this area. However, the client refuses. They’ve had multiple negative therapy experiences in the past and explain that they will not seek care from another therapist.
Now what?
Applying the ACA and AMHCA Ethical Decision-Making Models
The ACA Ethical Decision-Making Model is an eight-step framework and the AMHCA decision-Making Model is a six-step framework designed to help counselors address difficult ethical situations with clarity and care. Let’s apply it to this case:
Step 1: Identify the Problem (both ACA and AMHCA)
The central issue is a conflict between:
C.2.a. Boundaries of Competence – Counselors must practice only within the boundaries of their training and experience.
A.1.a. Primary Responsibility – The counselor’s primary responsibility is to promote the client’s welfare.
A.11.b. Values Within Termination and Referral – Counselors must avoid causing harm through abandonment.
This dilemma pits competence against continuity of care, particularly in light of the client’s strong therapeutic alliance and prior negative experiences.
Step 2 ACA: Apply the ACA Code of Ethics
Relevant standards include:
C.2.a. Boundaries of Competence: Requires counselors to practice only within the areas they are qualified.
A.4.a. Avoiding Harm: Counselors act to avoid both intentional and unintentional harm.
A.11.a. Competence Within Termination and Referral: Counselors terminate relationships when it becomes reasonably clear that the client no longer needs assistance or would be better served elsewhere.
A.11.b. Values Within Termination and Referral: Counselors should make appropriate referrals and avoid abandonment.
Together, these codes require the counselor to balance client well-being with professional competence. The situation is ethically complex—no matter what choice the therapist makes, there's a potential risk.
Step 3 ACA: Determine the Nature and Dimensions of the Dilemma
This dilemma is both ethical and clinical. While continuing care may help avoid emotional harm and preserve client progress, there is a risk of practicing beyond one’s scope—potentially leading to ineffective treatment or liability. I suggest writing out the answers to these questions. Then go back and re-read your answers. You may find you need to add or clarify things.
It’s important to ask:
What harm could come from continuing treatment?
What harm could come from referring the client away?
Is there a safe, ethical compromise?
Factors to consider:
The client is benefiting from the current therapeutic relationship.
The therapist has foundational knowledge but lacks specialized training.
A referral could result in treatment termination if the client refuses to engage elsewhere.
Step 4 (ACA and AMHCA): Generate Potential Courses of Action
After you have fully explored the ethical dilemma, start creating a list of possible courses of action. In this scenario, here are four potential options:
Refer the client to a provider with the appropriate expertise.
Continue therapy while:
Seeking ongoing consultation with a specialist,
Participating in targeted professional development,
Fully informing the client of the limits of your competence.
Engage in co-treatment with a specialist (if available).
Temporarily continue care, while helping the client emotionally prepare to transition, if referral becomes unavoidable.
Step 5 (ACA): Consider the Potential Consequences of Each Option and Determine Your Course of Action
Step 3 (AMHCA): Consult with colleagues, an ethics committee or other competent sources
Step 4 (AMHCA): Deliberate and Decide on your course of action.
Step 5 (AMHCA): Document your decision-making process
Consultation is strongly encouraged during ethical dilemmas. I would suggest starting with your closest supervisor/mentors. In the age of Facebook, there are tons of groups that can point you in the direction of individuals/agencies that would be helpful to consult with. The counselor should:
Consult with a clinical supervisor or mentor
Reach out to colleagues or professionals with relevant expertise
Contact the ACA Ethics Committee or a professional association for guidance
Consider legal consultation, depending on the severity of the issue
This protects both the counselor and the client while promoting ethical integrity.
After receiving consultation and exploring potential consequences, make, and document, your course of action.
Create a clear plan for moving forward..
Use informed consent to communicate limitations and next steps with the client. Make sure your client understands the informed consent and the course of action.
Document everything, including the rationale, steps taken, and supervision received/needed.
Step 6 (AMHCA): Evaluate
Step 6 (ACA): Evaluate the selected course of action (taken from ACA ACA Ethical Decision Making Model
Review the selected course of action to see if it presents any new ethical considerations.
Apply three simple tests to the selected course of action to ensure that it is appropriate: justice, publicity, and universality (Stadler, 1986).
Justice: In applying the test of justice, assess your own sense of fairness by determining whether you would treat others the same in this situation.
Publicity: For the test of publicity, ask yourself whether you would want your behavior reported in the press.
Universality: The test of universality asks you to assess whether you could recommend the same course of action to another counselor in the same situation.
If the course of action you have selected causes any new ethical issues, then you’ll need to go back to the beginning and reevaluate each step of the process. Perhaps you have chosen the wrong option or you might have identified the problem incorrectly.
If you can answer in the affirmative to each of the questions suggested by Stadler (1986; thus passing the tests of justice, publicity, and universality) and you are satisfied that you have selected an appropriate course of action, then you are ready to move on to implementation.
Step 7: Implement the Best Course of Action
Follow through with your “best course of action”
Ongoing: Evaluate the Effectiveness of the Plan
Ethical decision-making is an ongoing process. The therapist must:
Monitor the client’s progress and well-being.
Reevaluate their ability to effectively treat the presenting issue.
Be willing to refer out later if the situation becomes too complex or outside their growing expertise.
Evaluation is an ongoing process and must be reviewed at each stage of the clinical work.
Conclusion: Balancing Ethics and Compassion in Counseling
Using the ACA Ethical Decision-Making Model allows counselors to thoughtfully explore complex clinical scenarios with compassion, structure, and integrity.
While every situation is unique, grounding decisions in the ACA Code of Ethics and maintaining transparency with clients ensures that both ethical standards and client welfare are upheld.
Conclusion: Ethics in Action
This scenario reflects the gray areas mental health professionals often face. While ethical codes provide structure, real-world situations demand flexibility, consultation, and self-awareness.
As counselors, our goal is to serve the client’s best interest without overstepping our competence. With thoughtful decision-making, supervision, and transparency, it is possible to navigate this delicate balance with integrity.
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ACA Ethical Decision Making Model
AMHCA Ethical Decision Making Model
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