5320- U5 D1: Professional Development

Please see attached.

5320- U5 D1:

Professional Development

Your textbook discusses multiple stages of development, starting with formal
educational training, then continuing education, and on through practices of
supervision and consultation. The stages of development could be compared
to those of an apprentice, journeyman, and a master of a trade.

In your initial post to this discussion, identify at least two practices an
ethically focused practitioner would engage in for each of these stages of
practice. What are some potential challenges a practitioner might encounter
at each stage of his or her professional journey? Cite sources from at least
one of the professional codes of ethics and from the course text to support
your post.

NOTE: Minimum of 350 words and 1 scholarly journal

267

CHAPTER 11

Efficacy of Treatment

Michelle: Hi, Lynn. Do you have a minute?

Lynn: Sure, Michelle. What’s up?

Michelle: I’ve been working with this girl, Maria, and we have a real
good working relationship, but I just don’t feel like I have a true
grasp of what is going on or that I am approaching this situation
the best way. I explained this to Maria, and she has given me written
permission to speak with you about the case. I know you are really
busy, but I was hoping that you could provide some supervision
around this case to see if you feel like I’m on the right track and using
the best approach.

W hile our counselor, Ms. Wicks (Michelle), is certainly skilled and
trained professionally, her real interest and concern for her client
and her own self-awareness of the limits of her expertise have

led her to seek consultation from a colleague. Approaching helping with the
essential training and experience is an ethical must. However, beyond this
initial training, ongoing professional development, consultation, and supervi-
sion are the hallmark of the ethical professional.

The ethical responsibility to be competent extends beyond the basic
credentialing of a helper and includes the helper’s ability to employ treat-
ment strategies that are efficacious. It is these issues of treatment efficacy
and helper competency that serve as the focus for the current chapter.

Parsons, Richard D., and Karen L. Dickinson. Ethical Practice in the Human Services : From Knowing to Being, SAGE Publications, Incorporated, 2016.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/capella/detail.action?docID=5945468.
Created from capella on 2023-02-08 17:24:26.

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268–●–ETHICAL PRACTICE IN THE HUMAN SERVICES

The chapter will review the ethics and legality surrounding the issue of
competent practice and efficacy of treatment. The value of professional train-
ing, action research, and referral as elements of competent practice will be
highlighted.

After reading this chapter you should be able to do the following:

• Describe what is meant by the term competence.

• Discuss the role of continuing education, ongoing supervision, and con-
sultation in the continuous development of professional competence.

• Describe the value of approaching practice from a reflective, action
research orientation.

• Discuss the conditions under which referral would appear to be the
most efficacious treatment decision.

• Describe legal considerations and concerns in relation to the issue of
helper competence, standard of care, and treatment efficacy.

● OBJECTIVES

● PRACTICING WITHIN THE REALM OF COMPETENCE

The ethical professional is called upon to accept responsibilities and employ-
ment on the basis of competence and professional qualification. Table 11.1
provides the position taken by a select group of professional associations on
the issue of professional practice and competency. What should be evident
by reviewing Table 11.1 is that each of these organizations supports the
notion that one should not engage in practices that require skills beyond
those possessed. To be ethical as a helper requires that competency be
developed and maintained and that the helper’s competence level be repre-
sented accurately to clients, employers, and the general public.

Competence

Being competent means that the helper has the knowledge, skills, and
abilities needed to perform those tasks relevant to that profession. To sug-
gest one is competent implies that the individual is capable of performing
a minimum quality of service that is within the limits of his or her training,
experience, and practice, as defined in professional standards or regulatory
statutes.

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Chapter 11. Efficacy of Treatment–●–269

Table 11.1 Ethical Codes Addressing Helper Competence

Professional
Organization Ethical Principle/Standards

American Counseling
Association (2014)

C.2.a. Boundaries of competence

Counselors practice only within the boundaries of their
competence, based on their education, training, supervised
experience, state and national professional credentials, and
appropriate professional experience. Whereas multicultural
counseling competency is required across all counseling
specialties, counselors gain knowledge, personal awareness,
sensitivity, dispositions, and skills pertinent to being a culturally
competent counselor in working with a diverse client population.

American
Psychological
Association (2010)

2.01. Boundaries of competence

a. Psychologists provide services, teach, and conduct research
with populations and in areas only within the boundaries of
their competence, based on their education, training, supervised
experience, consultation, study, or professional experience.

American Association
for Marriage and
Family Therapy
(2015)

3.10.

Marriage and family therapists do not diagnose, treat, or advise on
problems outside the recognized boundaries of their competencies.

National Association
of Social Workers
(2008)

4.01. Competence

c. Social workers should base practice on recognized knowledge,
including empirically based knowledge, relevant to social work
and social work ethics.

Ethical principle: Social workers practice within their areas of
competence and develop and enhance their professional expertise.
Social workers continually strive to increase their professional
knowledge and skills and to apply them in practice. Social workers
should aspire to contribute to the knowledge base of the profession.

1.04. Competence

a. Social workers should provide services and represent themselves
as competent only within the boundaries of their education,
training, license, certification, consultation received, supervised
experience, or other relevant professional experience.

b. Social workers should provide services in substantive areas or use
intervention techniques or approaches that are new to them only after
engaging in appropriate study, training, consultation, and supervision
from people who are competent in those interventions or techniques.

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270–●–ETHICAL PRACTICE IN THE HUMAN SERVICES

Competence is defined in relative terms; that is, rather than having
one clear, objective standard against which to judge a professional’s level
of performance as competent or incompetent, competence is most often
defined using the conduct of others within the profession as the compara-
tive standard. Thus, one might ask, what would a reasonable person do in a
similar situation?

● PROFESSIONAL DEVELOPMENT:
KNOWING THE STATE OF THE PROFESSION

Competence can be developed from formal training as might be found in
graduate training or training for certification and licensure. Further, one’s
own ongoing continuing education, professional reflective practice, and
supervision may serve as additional resources for developing and maintain-
ing competence.

Formal Training

Formal training occurs both at the undergraduate and graduate levels of
study. Foundations of general knowledge of helping theory and skills along
with research supporting intervention strategies may be acquired through
undergraduate and graduate course work. However, in addition to these cog-
nates, the competent practitioner must have guided practice in the applica-
tion of this knowledge. In many disciplines (e.g., psychology), the doctorate
along with supervised field and intern experiences is considered essential to
competent independent practice.

For most of the helping professions, professional organizations and/
or certifying and licensing bodies have identified both aspirational levels
and mandatory levels of training as a way of defining competence. Each
of these levels of governance monitor the development and application
of professional practice. Colleges and universities often offer programs of
training that have been shaped by the professional standards under the
review of professional accrediting organizations. Professional accrediting
bodies (e.g., American Psychological Association, Council for the Accredi-
tation of Counseling and Related Educational Programs [CACREP]) qualify
educational programs as meeting standards beyond those demanded for col-
leges or universities to offer degrees and certify that these programs meet
high professional standards, thus establishing the foundation for ethical
practice. Beyond these school-based programs, professional organizations

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Chapter 11. Efficacy of Treatment–●–271

(e.g., American School Counseling Association, American Rehabilitation
Counseling Association, Academy of Certified Social Workers) often develop
aspirational codes of ethics, which while not having any internal mandatory
enforcement mechanism, call their members to perform at the highest level
of professional practice.

Beyond the professional organization level, the professional regulatory
bodies at the state and national level promulgate and enforce standards of
practice through the establishment of certification and licensure standards.
Often these requirements exceed those demanded for entrance into the pro-
fession, requiring additional post degree experience and supervision. The
definition of minimum professional training for entry-level helpers as well
as the mandate to remain up-to-date on the state of the profession through
continuing education varies from state to state. It is essential for the ethical
helper to be knowledgeable about these standards (see Exercise 11.1).

Being an ethical, competent practitioner requires not only a basic level
of initial training but also the development and maintenance of this knowl-
edge and these skills via continuous professional growth. The ethical helper
continually strives for increased competence. The ethical helper strives to
increase his or her competence by continuing to develop his or her skills and
understanding of the helping process.

Exercise 11.1

Licensing and Certification Requirements

Directions: Since the requirements defining minimum requirements
for competent practice vary from profession to profession and in many
instances from state to state, it is helpful for you to be aware of the
specific requirements for entrance into your particular field of practice.

Step 1: Identify two arenas for professional practice (e.g., school
counselor, psychologist, marriage counselor, clinical social worker,
etc.).

Step 2: Identify two states, one in which you intend to practice and
a neighboring state.

Step 3: Contact each state’s department or bureau of professional
license and practice.

Step 4: Complete the following grid.

(Continued)

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272–●–ETHICAL PRACTICE IN THE HUMAN SERVICES

Practice Specialty 1 Practice Specialty 2

State

Home
State

Neighboring
State

Home
State

Neighboring
State

Minimum
Education
(bachelor’s,
master’s, master’s +
doctorate)

Supervised
Experience
(internship,
practice, etc.)

Post Degree
Requirements
(course work, field
experience, etc.)

Other
Requirements

(Continued)

Continuing Education

All the codes of conduct call for practitioners to be current with emerg-
ing knowledge relevant to their professions (see Table 11.2). It is incumbent
upon the ethical practitioner to upgrade knowledge and skill by participat-
ing in continuing education experiences. Continuing education may be in
the form of trainings through a professional conference or additional course
work at the local university or courses taught through qualified associations
and organizations.

While the call for ongoing education and professional development
is clear, the specifics are still lacking. Does this suggest a certain number
of courses? Credits? Hours of supervision? Many organizations and state
licensing and certifying bodies require that a number of continuing edu-
cation hours be completed within a number of years. For example, in
Pennsylvania, all licensed marriage and family therapists seeking renewal of
their licenses are directed to gain 30 hours of continuing education every

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Chapter 11. Efficacy of Treatment–●–273

Table 11.2 Maintaining Professional Development

Professional Ethical Standards Statement on Professional Development

American Association for
Marriage and Family Therapy
(2015)

3.1.

Marriage and family therapists pursue knowledge of new
developments and maintain their competence in marriage
and family therapy through education, training, and/or
supervised experience.

American Counseling
Association (2014)

C.2.f.

Counselors recognize the need for continuing education
to acquire and maintain a reasonable level of awareness
of current scientific and professional information in their
fields of activity. Counselors maintain their competence
in the skills they use, are open to new procedures, and
remain informed regarding best practices for working with
diverse populations.

American Psychological
Association (2010)

2.03. Maintaining competence psychologists undertake
ongoing efforts to develop and maintain their competence.

National Association of
Social Workers (2008)

4.0.l.b.

Social workers should strive to become and remain
proficient in professional practice and the performance
of professional functions. Social workers should critically
examine, and keep current with, emerging knowledge
relevant to social work. Social workers should routinely
review the professional literature and participate in
continuing education relevant to social work practice and
social work ethics.

two years (http://pamft.com/for-professionals/licensure/faq/). Similarly,
the State Board of Licensing for Psychologists in Pennsylvania requires
psychologists to complete 30 hours of approved continuing education every
two years in order to maintain and/or renew their licenses. While the spe-
cific requirements vary across professions (e.g., marriage counselor, school
psychologists, clinical social worker) and from state to state, similar demand
for maintaining competence is built into all certification and licensing
requirements. It is important for each practitioner to be aware of the stan-
dards set by his or her own professional organization or those required for
relicensing or recertification within the state where they intend to practice.

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274–●–ETHICAL PRACTICE IN THE HUMAN SERVICES

Supervision and Consultation

Practicing within the realm of competence starts with a practitioner
operating within the scope of practice. Practitioners are ethically bound
to restrict their professional activities to the professions and specialties for
which they have been trained and supervised. When required, they must
possess the appropriate certification and licensure. Practicing within the
realm of competence also means knowing when it is essential to consult
and/or refer to another professional who has more experience and training
with this particular type of client and or problem.

The use of peer consultation, in which specific concerns can be shared
with an experienced colleague, is a valuable means for maintaining compe-
tence. Peer consultation may be useful in enhancing the clinical care of the
client as well as acting as a risk management tool for the helper by provid-
ing trusted resources (Gottlieb & Younggren, 2009). Peer consultation can
provide mutual support for problematic cases. However, when consulting
with colleagues regarding a client, the ethical practitioner needs to balance
the need for his or her own continued support with the client’s right to
maintain confidentiality. The American Psychological Association’s (APA)
ethical standards, for example, state:

When consulting with colleagues, (1) psychologists do not disclose
confidential information that reasonably could lead to the identifi-
cation of a client/patient, research participant, or other person or
organization with whom they have a confidential relationship unless
they have obtained the prior consent of the person or organization or
the disclosure cannot be avoided, and (2) they disclose information
only to the extent necessary to achieve the purposes of consultation.
(APA, 2010, 4.06)

Even with this sensitivity to the requirements of confidentiality, the ethi-
cal helper can employ a peer consult to formulate the problem, review the
decisions made, and tap a different point of view on the process. Often a
colleague with more experience can provide some clarity about the helping
process and may even assist the practitioner to develop additional insights
or adjustments in the treatment process.

Consulting with a professional peer not only provides the helper a
valuable resource for expanding his or her knowledge and skill but also
can also serve as a valuable check and balance for the helper when the
boundaries of competence may be exceeded. This is especially true when
the helper’s own objectivity may be blurred (see Chapter 10). Under these

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Chapter 11. Efficacy of Treatment–●–275

conditions, the peer consultation can provide a mechanism for examining
the ethical and professional issues involved (Gottlieb & Younggren, 2009).

For those working within certain clinical settings, formal peer review
may be incorporated as a way of maintaining professional competence and
standards of care. For those serving in an independent practice, it would be
valuable to develop a network of colleagues who can continue to serve as
peer consultants.

THE STANDARD OF CARE: APPROPRIATE TREATMENT

●

Most malpractice cases turn on the question of negligence (Bennett, Bryant,
VandenBos, & Greenwood, 1990). Negligence implies that the practitioner
failed to meet the relevant standard of care. According to Bennett and col-
leagues (1990), the question of negligence will be determined by the debate
over the clinical connectedness and efficacy of the treatment that was given,
along with the practitioner’s judgment in choosing it (p. 33).

While there is no single prescribed way to conduct “helping,” ethi-
cal guidelines establish some standards of care that must be followed. For
example, sexual intimacies with clients are prohibited. Further, innovative
therapy involving physical contact with clients can be the basis for malprac-
tice suits, particularly when the contact is extreme (e.g., hitting, choking).
While these are extreme examples that most mental health providers will
not encounter, failure to properly administer and interpret tests and inven-
tories, failure to warn to take appropriate steps in the face of homicide and
suicide, and failure to employ appropriate methods and forms of treatment
may be areas in which helpers are more likely to fall short of recognized
standards of care, failing to provide appropriate treatment.

Defining an Appropriate Treatment

Standards of practice have not specifically been identified. There are
no preordained directives for what must be done under each condition of
helping. The standard of care and the definition of appropriate treatment
are typically determined by comparing the practitioner’s performance with
that of other professionals in the same community with comparable training
and experience.

There is an evolving sense of what should prevail, and it is the standard
of what a reasonable and prudent practitioner may do in situations like this
that sets the standard of care (see Exercise 11.2).

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276–●–ETHICAL PRACTICE IN THE HUMAN SERVICES

Exercise 11.2

Standard of Care: A Reasonable, Prudent Response

Directions: Below you will find two clinical scenarios. Read each situa-
tion and contact two mental health providers in your local community
and ask them what they would do in this situation.

Situation 1: You are treating an individual diagnosed with AIDS.
This individual has informed you that he is in and has been in a
long-term relationship. The client also has informed you of the
name of his partner, with whom he lives. In your most recent
session, your client informs you that not only is he engaging in
unprotected sex with his lover but that he has not informed his
lover that he has AIDS. What do you do? Do you inform the lover?

Situation 2: You have been seeing a couple for marriage counseling.
You receive a subpoena for your records on the case from one partner’s
lawyer. What do you do? Do you respond to the subpoena? How?

Reflections:

● Did the two practitioners essentially agree on the steps to be taken?

● Did their responses seem to be in line with what you have read
about confidentiality, duty to warn, informed consent, and so forth?

● Share your findings with a classmate/colleague who may have
performed the exercise. Does there seem to be consistency in
practitioner response that could be interpreted as a definition of
standard of care?

Share your findings with your classmates or colleagues.

Employing Effective Treatments

Beyond a generic standard of what a reasonable and prudent practitioner
may do, attention has been drawn to the importance of employing tried-and-
true techniques and strategies of intervention. A number of professionals
and professional organizations have called for use of effective treatments,
as have consumer groups. The ACA Code of Ethics, for example, notes,
“Counselors have a responsibility to the public to engage in counseling
practices that are based on rigorous research methodologies” (ACA, 2014,

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Chapter 11. Efficacy of Treatment–●–277

Introduction Section C). Or even more specifically, “When providing ser-
vices, counselors use techniques/procedures/modalities that are grounded
in theory and/or have an empirical or scientific foundation” (ACA, 2014,
Principle C.7.a). A similar directive is found within in the National Associa-
tion of Social Workers’ (NASW) Code of Ethics, which notes, “Social workers
should base practice on recognized knowledge, including empirically based
knowledge, relevant to social work and social work ethics” (NASW, 2008.
Principle 4.01.c). Thus, it is firmly rooted in our codes of ethics that coun-
selors use techniques that are empirically based. It is clear that the ethical
helper needs to be aware of the current research on treatment effectiveness
and employ these strategies when and where appropriate.

Defining Efficacious

Providing the most effective treatment available requires professionals
to keep current on the research on treatment effectiveness for their particu-
lar client populations. In line with this need to identify and employ effective
treatment strategies, the Task Force on Promotion and Dissemination of
Psychological Procedures (1995) from the division of clinical psychology
within the APA, developed criteria for determining whether a treatment should
be considered empirically valid. The task force also established a list of inter-
ventions that have been “well established” and a list that are “probably effica-
cious,” citing the literature that supports this claim (Chambless et al. 1998).

A review of those treatments that prove effective suggest that they
share the following characteristics: These interventions are targeted to spe-
cific problems, incorporate continuous monitoring and assessment, involve
client skill development, and are generally brief, requiring 20 or fewer ses-
sions (O’Donohue, Buchanan, & Fisher, 2000).

As the professions and the research identify specific strategies with dem-
onstrated effectiveness, these interventions become the standard of care. As
such, it is essential for the ethical practitioner to not only be aware of this
research and these techniques but to develop the competency required for
the ethical application of these strategies.

Managed Care: Compounding the Standard of Care Issue

The issue of treatment efficacy is of special consideration when a prac-
titioner is operating within a managed care situation (Cohen, Marecek, &
Gillham, 2006). With managed care pushing for brief, more cost-effective

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278–●–ETHICAL PRACTICE IN THE HUMAN SERVICES

forms of treatment, the ethical practitioner must be able to identify for
whom these services are appropriate and which form of service is required.
Discerning for whom brief therapy is appropriate and advocating for those
clients for whom such an approach may not be appropriate becomes an
essential role of the ethical, competent practitioner operating within a
managed care environment. Further, competence to perform short-term
models of treatment, when appropriate, requires that the practitioner be
prepared and able to focus on achievable, specific treatment goals and to
be active and more directive in conducting the treatment. Short-term models
are not simply long-term therapy models condensed in time. Utilization of
these short-term models requires the ethical practitioner to possess unique
understanding and skills. Thus, the ethical practitioner will not only know
for whom such treatment is appropriate but will also have been trained in
this approach. If the practitioner is not trained in the area that is specified,
it is the responsibility of the practitioner to receive the appropriate training,
at times before accepting an offer for employment (Daniels, 2001).

● EMPLOYING AN ACTION RESEARCH APPROACH
TO PRACTICE

In areas for which there is not solid research to direct best practice or in
which the standard of the profession is not clearly articulated, service needs
to be predicated on theoretical and technical ideas that are held by a substan-
tial portion of the profession. Thus, knowing the recognized models, theories,
and schools of thought is as essential as having the ability to assess the validity
and reliability of a particular strategy for one’s own practice. In speaking of
psychology, for example, Chambless and colleagues (1996) noted:

Psychology is a science. Seeking to help those in need, clinical psychol-
ogy draws its strength and uniqueness from the ethic of scientific valida-
tion. Whatever interventions that mysticism, authority, commercialism,
politics, custom, convenience, or carelessness might dictate, clinical
psychologists focus on what works. They bear a fundamental ethical
responsibility to use, where possible, interventions that work and to
subject any intervention they use to scientific scrutiny [emphasis
added]. (p. 10)

This last point suggests subjecting any intervention to scientific scru-
tiny is a directive to all ethical practitioners and not just those interested in

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Chapter 11. Efficacy of Treatment–●–279

performing large empirical research. The ethical helper will approach his or
her practice as a reflective professional, integrating research and practice.

In order to be effective in their practice, human service providers must
blend the method and findings of research with the realities of their profes-
sional practice. As practitioner-researchers, they will need not only to interact
in the moment but also to reflect, inquire, and critique their own interac-
tions. Further, for their observations to provide meaningful data and useful
guidance, they must be systematic and valid. Action research methodology
provides practitioners with the means of acquiring these valid, useful data
and results in the development of effective strategies of professional practice.

Action Research Defined

As presented here, action research is applied research in which the
researcher-investigator is also the practitioner (e.g., a counselor, psycho-
therapist, social worker) attempting to use research as a methodology for
identifying the “what” they do and for making decisions on doing it better.
Action research provides practitioners with the method for viewing their
professional decisions systematically and deciding on them rationally. It is
the opportunity to blend theory with practice, becoming true practitioner-
researchers. Action research has a circular nature (plan-act-observe-reflect
and then start all over again), which supports a reflective practitioner and
guides increased awareness of effectiveness.

Action Research: An Ethical Consideration

Viewed as a frame of mind, action research calls us to a continued inter-
est in serving our constituencies better and providing increased accountabil-
ity for our service. As such, action research is not simply a good idea, rather
it becomes an ethical responsibility for monitoring the effectiveness of our
practice and increasing the competency of our service. No one professional
can guarantee success in each and every encounter or situation. However,
ethical practitioners need to assess the degree to which their practices are
both valid and effective. Action research provides a mechanism for monitor-
ing the efficacy and adequacy of practice decisions and methods.

Table 11.3 provides a brief review of one model of action research that
has application to the mental health professional. While presented as a linear
set of steps to be taken, in practice it is a recurring, recycling process that
continually takes shape in and gives shape to practice.

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280–●–ETHICAL PRACTICE IN THE HUMAN SERVICES

Table 11.3 Steps in the Action Research Process

Step Description

1. Identification
of the research
question

Three types of questions seem to emerge. First, what are our
practice decisions? Second, what specifically about our practice
is effective? And finally, what can we do to enhance our
effectiveness as practitioners?

2. Problem
relevance, problem
significance

The goal is to be able to answer questions such as, why study it?
What do I expect will happen as a result of this investigation?
How is the problem and the study significant to my practice?

3. Definitions The practitioner–action researcher needs to begin to more
concretely identify and define the concepts, the constructs,
the variables involved. When and where possible, the action
researcher needs to define these by his or her actions or
operations performed (i.e., operational definitions).

4. Review of related
literature

Reviewing the professional literature for evidence of similar
investigation may prove a valuable step to intervention planning.

5. Developing
hypotheses

With action research, it should be remembered that these are
truly “working hypotheses.” As data is collected and decisions
are made, the hypotheses may be reshaped. In fact, true to the
qualitative nature of the action research, new hypotheses can
emerge from the data as the study progresses.

6. Outcome
measures

If the action researcher seeks to increase his or her understanding
of the operations of his or her professional practice or the
impact of specific practice decisions, then measurement of those
decisions and their impacts needs to take place. One should
employ outcome assessment that measures change from multiple
perspectives (i.e., the subject/client, the practitioner-researcher,
and others) and through multiple approaches.

7. Methods: creating
a design

As with any study, for our conclusions to be valid we must
consider the use of an approach or a design that provides validity
of data collection and interpretation.

8. Data collection The types of data collected and the method of collection will clearly
be situation, researcher, and problem specific. But the information
gathered needs to be as detailed and as informative as possible
so that as an action researcher, you will know what is happening
in ways that you previously did not know. The action researcher
needs to remember that he or she is a practitioner as well as a
researcher and that he or she has a professional responsibility for
those involved. There are ethical considerations, especially those
regarding informed consent, that need to be considered.

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Chapter 11. Efficacy of Treatment–●–281

Step Description

9. Data analysis At a minimum the data needs to be organized and grouped by
themes, with trends and characteristics noted. When appropriate,
visual presentation and descriptive and inferential statistics should
also be employed.

10. Interpretation In reviewing the data, the action researcher needs to balance
research significance with practical relevance. Having answered
the question what happens if, the researcher now needs to answer
questions such as these: What does knowing what happens if mean
for my clients, my students, and for those whom I service? To me? To
my professional decision-making? To my current practice decisions?

THE USE OF REFERRAL ●

The ethical helper provides only those services for which he or she is
trained, experienced, and credentialed (e.g., certified or licensed). Compe-
tence refers not only to the degree to which the professional possesses the
knowledge, skills, and abilities required to perform the various tasks and
procedures relevant to that profession but also to the ability to discern when
it is appropriate to provide the services and when it is desirable to refer.

In the private confines of a helper’s office, however, where a practi-
tioner is free from direct supervision or teacher scrutiny, it may be all too
easy to be seduced into engaging in problem solving in areas for which
one is ill prepared. Consider the following case of Mrs. Robinson (see Case
Illustration 11.1).

Even if we assume the best intent on the part of Dr. Hansen, the truth
of the matter is that he lacks the training and appropriate experience to
work with Mrs. Robinson’s clinical depression. Further, his lack of experi-
ence and training is more evidenced by his willingness to serve as both
Mrs. Robinson’s therapist and marital counselor.

If one were to assume that Dr. Hansen was qualified to work with a
depressed client, it might be easy to believe the transition from working
with the distraught Mrs. Robinson to couple-marriage counseling was a logi-
cal extension of the helping contract. However, suppose Dr. Hansen has not
had the specialized training that may be required.

The American Association for Marriage and Family Therapy highlights the
unique training necessary to be a clinical member, training that includes spe-
cific graduate training in marriage and family therapy and two years of super-
vised practice. Given the special training necessary, assuming expertise and
competence with a couple, even when competent working with individuals,

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282–●–ETHICAL PRACTICE IN THE HUMAN SERVICES

Case Illustration 11.1

Moving From Individual to Couple Counseling

Dr. Hansen received a call from Mrs. Alice Robinson, who described
herself as “a little down” and unclear about the direction she wanted to
go with her career. Dr. Hansen, a certified vocational counselor, sched-
uled to meet with Mrs. Robinson to begin the process of a vocational
career assessment.

Following the initial intake, Dr. Hansen concluded that Mrs. Robinson,
while interested in vocational and career counseling, was doing this in
reaction to what she “perceived to be a failing marriage.” Dr. Hansen saw
Mrs. Robinson three more times with the intent of more clearly identifying
Mrs. Robinson’s goals for counseling. Through these three sessions,
Dr. Hansen came to realize that Mrs. Robinson was seriously depressed.
She revealed a long-standing history of depression and self-medicating
alcohol consumption. She also described considering committing suicide
on more than three occasions in the past month. Further, Mrs. Robinson
noted that she is unable to eat, has lost approximately 20 pounds in
a one-month period, and is having difficulty sleeping. The root of this
depression, according to Mrs. Robinson, is the fact that “she cannot
communicate” with her husband, and she knows unless something is
done, they will get a divorce. And according to Mrs. Robinson, she simply
“would not, could not live without him!”

Mrs. Robinson described how long she has been wanting to seek
counseling for herself (her depression) and for she and her husband. But
according to Mrs. Robinson, she just didn’t feel comfortable seeking
help since there are so many “wacko doctors” out there. Mrs. Robinson
expressed her comfort and trust with Dr. Hansen and asked if he would
help her and her marriage.

Dr. Hansen, while being trained and supervised in career/vocational
counseling, agreed to work both individually with Mrs. Robinson in
order to assist her with her depression and also to set up an arrangement
to see her and her husband as a couple to start “communications
training.”

invites unethical behavior and a failure to provide appropriate standard of
care. Thus, Dr. Hansen needs to reflect not only on his own training (formal
and informal) and supervised experience working with clinically depressed
individuals but also on the extent of his preparation in systemic-relational

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Chapter 11. Efficacy of Treatment–●–283

treatment before proceeding to treat if the couple. This would be essential for
ethical, competent practice.

Helpers, regardless of their knowledge and skill, cannot provide every
service needed by every client. Ethically, therefore, a helper needs to know
not just the when and how of applying helping skills but also when the situ-
ation is beyond his or her capabilities or when the boundaries of his or her
competence have been exceeded.

Knowing When to Refer

Knowing when to refer is not always easy. At a minimum, the ethical
helper will refer anytime it is determined that she or he is unable to pro-
vide the professional, competent services required. The ethical, competent
helper needs to be aware of his or her areas of expertise, the kinds of sup-
port and supervision available, and an accurate sense of his or her own time,
energy, and availability to take on a particular case. When any of these areas
are in question, referral should be considered.

If Dr. Hansen (see Case Illustration 11.1) reflected on his own decision-
making, he might have concluded that a trained, experienced marriage
relational counselor might more competently provide the services that
Mrs. Robinson and her husband currently need. As such, he would have
made a referral rather than attempted to provide those services himself.

Each practitioner can provide competent service, but no one practitioner
can be a master of all the knowledge and skills required to competently address
the myriad of situations and clients presented. As each profession develops
its knowledge base and refines the skills required, it will become increasingly
incumbent on the practitioner to recognize the limits of his or her own com-
petency and the richness of resources available through the use of referral.

Knowing Where to Refer

In making a competent referral, the practitioner needs to understand the
nature of the specific support and services requested. As such, the ethical,
competent helper will have a cadre of available referral sources whose char-
acter and capacities are known (Zhang & Parsons, 2016). Building a referral
system, branching through the surrounding geographic area, is essential.
This referral network should include a variety of professional and indigenous
helpers, including psychologists, psychiatrists, social workers, ministers,
physicians, clinics, social service agencies, hospitals, and so on.

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284–●–ETHICAL PRACTICE IN THE HUMAN SERVICES

Exercise 11.3

Developing a Referral Network

Directions: You can begin developing a referral network by contacting
local agencies and human service providers by phone, letter, or e-mail
and gathering the following information:

Name: ___________________________

Address: ___________________________

Phone: ___________________________

1. What is the purpose or mission of your professional service or
practice?

2. What population (age, gender, socioeconomic position, ethnic-
ity, etc.) is best served by your service?

3. What type of difficulty, problem, or concern is most often
addressed by you/your service?

4. What resources are available (e.g., 24-hour hotlines, medical
facilities, educational materials, housing, job placement, etc.)?

5. What is the procedure or process for gaining access, making an
appointment, or seeking assistance?

6. What is the general therapeutic theory or model employed?

Being fully versed on the resources available not only enables the ethical
helper to select the service(s) that most effectively meet the client’s needs
but also allows the helper to explain the reason for and the process of referral
to the client. Being familiar with the services available allows the helper the
opportunity to highlight the unique qualifications of the person or program
to which the client is being referred, along with other information needed to
make for a smooth and comfortable referral and transition for the client.

While a listing of various human services agencies and providers may
be obtained by contacting the local county government or mental health/
(mental retardation) intellectual disability agencies listed in your phone book
or on a webpage, more personalized knowledge is required for adequate
referral. Exercise 11.3 is offered as a guide for developing this personalized,
referral network.

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Chapter 11. Efficacy of Treatment–●–285

Making the Referral

Recognizing the need or value of referral is only the first step. In
addition to recognizing the need and having available resources to whom
to refer, the competent helper will also have the skill to assist the client to
accept and embrace this referral. It is not unusual for a client to interpret the
suggestion of a referral as a sign of rejection or as evidence of the hopeless
nature of his or her condition.

The competent, ethical helper will present the idea of referral in a way
that it is seen as a continuing, productive step in the helping process that,
far from being evidence of rejection, it is evidence of the helper’s concern.
And rather than evidence of the hopelessness of the situation, it is evidence
of the clarity of the nature of the problem and the reality of the existence of
a resource with a record of success in these situations. Consider the dialogue
presented in Case Illustration 11.2.

7. What are the training levels of the helpers who provide these
services?

8. Are there fees? How much? Payment plans? Sliding scales? Insur-
ance? Other?

9. Who is the contact person?

10. Is there a waiting list?

11. Other information (e.g., special services, general impressions,
etc.).

Case Illustration 11.2

Preparing Margaret for Referral

Linda is a master’s-level mental health counselor working for an
Employee Assistance Program (EAP). Her training is in counseling
psychology, and she has experience working with individual, solution-
focused approaches to counseling. As a counselor in an EAP, she is
contracted to provide a maximum of six sessions of direct service,
while overseeing and case managing all clients whom she refers for

(Continued)

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286–●–ETHICAL PRACTICE IN THE HUMAN SERVICES

ongoing assistance. Margaret, her client, has come to her because
her husband “kicked her out” of their house and is filing for divorce.
Margaret, in addition to being depressed about the situation with her
marriage, is in crisis over her current living conditions. The exchange
occurs near the end of the first session.

Linda: Margaret, you have certainly been open and honest with
me. And I know that speaking about the marriage and your
relationship with Tom has at times been very upsetting.

Margaret: It has been easier than I thought. You are a very kind person
and a good listener.

Linda: Thank you. But as we’ve talked, it has become clear to me
that of the things you are concerned about, the one thing
that seems to need immediate attention, is helping you with
your housing problem.

Margaret: Yeah, I don’t have any money to go and get a new apartment
right now and last night I slept in the car. I know I have enough
money to go to a motel for a night or two, but I don’t know
what I can do (starts to cry). Where can I go?

Linda: You are correct in saying that you can’t continue to sleep in
the car, and finding an answer to your question of, where can
you go? should be our primary concern. Do you agree?

Margaret: Yes (crying).

Linda: Housing or social service support for displaced women is
not something that we provide here at the EAP or that I am
very experienced with.

Margaret: (interrupting): Oh, NO! You have to help me . . .

Linda: It is going to be all right. I am going to help. Even though
I do not work with these types of situations, I know someone
who can really help us, who has a lot more experience
in these situations. So what I would like to do is call
Ms. Anderson over at the Women’s Center and see if she has
the time to talk with us and see you today. The Women’s Center
is right around the corner from here and it provides ongoing
counseling for women who are in situations just like yours.

(Continued)

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Chapter 11. Efficacy of Treatment–●–287

As evident in the exchange (see Case Illustration 11.2), presenting
the client with a referral needs to be done as a hopeful, positive step in
the helping process. The helper needs to convey to the client that this is not
an abandonment but an extension and refinement of the helping process. In
making a referral the helper should

• Be clear and direct about the goal and expectation for seeking referral

• Confront what referral is NOT, that is, it is not a rejection or a state-
ment of hopelessness

• Share information about the referral source, nature of service, costs,
location, and so forth

• Discuss the client’s feelings and concerns

• Answer all client questions regarding the referral

• Reassure the client about the value of the referral

• Assist the client in making the initial contact

• Establish a mechanism for follow-up with each other. Encourage
the client to let the helper know how the initial visit went

They also have resources for temporary housing and even
help women find low-cost housing. Plus, once they help you
get settled, they can help you with some of the job training
we started discussing.

Margaret: But how about you . . . ? I like you . . .

Linda: And I like you. In fact, I really want you to get the best help
you can get and I think the Women’s Center is the answer.
But I can still help, by talking with Ms. Anderson and telling
her some of things you have shared with me, especially
things about your current concerns and some of your goals.
I could also work with you and Ms. Anderson, if that makes
sense after talking with her. And if you want to come back
to talk with me, or if we want to look into another referral
source, we could do that as well. So how do you feel about
me calling and seeing if we can set up an appointment for
you?

Margaret: Okay . . . but I can still call you if I need to?

Linda: Absolutely, and I will call you to see how things are going
after you have had a chance to work with the Women’s
Center.

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288–●–ETHICAL PRACTICE IN THE HUMAN SERVICES

If you are requesting special services for a client from a colleague, it
is important to provide the colleague with the information about the case
that is necessary to support the goals of the referral. Needless to say, it is
essential to gain the client’s consent for such collaboration prior to speaking
with the professional to whom you are referring. Once the referral contract
has been established, it is important for the referring helper to back off from
case involvement unless specifically requested by the attending professional.

● RECENT LEGAL DECISIONS

Malpractice or professional liability lawsuits are quite often based on the issue
of therapist negligence. A client, who in legal proceedings is the plaintiff,
would assert that the helper has breached the standard of care. A simple way
of looking at negligence is to think of it as the failure to do something that a
reasonable person in ordinary circumstances would do or something a reason-
able person in ordinary circumstances would not do. When viewed through
the lens of the professional helper, negligence would be a failure to do that
which the typical clinician would do or not do in that same situation. While
malpractice requires a demonstrating of injury even when such proof of injury
is absent, complaints to professional ethics committee or regulatory agencies
(e.g., licensing boards) can result in sanctions.

The legal concept of negligence is based on the premise that all members
of society owe to one another the duty to exercise a certain inherent standard
of care. In most cases, the courts will look to the profession itself to define
which standard should be used. The standard of care has been described as the
qualities and conditions that prevail, or should prevail, in a particular mental
health service, and that a reasonable and prudent practitioner follows (Zur,
2007). The standard is based on community and professional standards and, as
such, professionals are held to the same standard as others of the same profes-
sion or discipline with comparable qualification in similar localities.

Case law on the standard of care question varies around the country.
Some courts will put the emphasis on “accepted” practice, others on what is
“customary.” In this latter case, an attorney will develop evidence to define
the customary standard applied by others in the field, with “field” defined in
the most specific sense possible. For example, when a clinical psychologist
who has been trained in cognitive techniques offers this orientation explic-
itly to his or her clients, when he comes to the courtroom, the standard for
his or her performance is predefined. The cognitive school is recognized
by the community of psychologists as a distinct and viable orientation,
with well-defined standards for training and clinical guidelines. Should this

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Chapter 11. Efficacy of Treatment–●–289

While the threat of malpractice can certainly motivate one to perform within
the boundaries of his or her training, it is not insurance in and of itself that
such ethical, competent performance of duty will occur. As with all of the
ethical standards and practice guidelines, directives to provide competently
within the standard of care are or can be a mere statement of expectation
rather than an operative schema guiding practice decisions.

As ethical practitioners, we need to move the concepts and principles
discussed within this chapter from levels of comprehension to incorporation
as personal values and moral imperatives. Once assimilated as a personal
value and moral response, acting competently will be a simple consequence
of being competent in the broadest sense of the term. The final exercise
(Exercise 11.4) is provided to assist you in adding the affective, personal
component to this theoretical, conceptual discussion.

psychologist be operating without the appropriate training or outside the
customary procedures for a cognitive therapist, he or she may be vulnerable
to negligence and malpractice. Therefore, not only do helpers need to legally
perform within their scope of training, but they also must perform in ways
that are typically or customarily associated with that form of service. Help-
ers who develop or subscribe to innovative therapies might find themselves
having to prove that a “respectable minority” in their profession concurs in
their techniques or treatment strategies.

An alternative approach to negligence, malpractice, and the issue of
standard of care is that derived not from one’s own training but from the
clinical imperatives of the client’s condition. In Hammer v. Rosen (1960)
the court ruled that a therapist’s (psychiatrist) decision to beat his patient
as part of therapy was a prima facie case of malpractice. The court noted
that some acts are so obviously unacceptable that expert testimony is not
needed to justify the conclusion of malpractice. If a nontraditional therapy
is employed, documentation of the reasons for its choice rather than a more
traditional approach, along with expert testimony showing the efficacy of
the therapy in a similar situation and/or its theoretical and scientific bases,
may be needed should a malpractice action be filed (Dickson, 1998). It could
be assumed that the same logic may be applied to the situation in which a
practitioner used a traditional but less than effective strategy of intervention.
The theoretical and empirical base for that decision may be essential should
a malpractice action be filed.

BEYOND PROFESSIONAL STANDARDS:
A PERSONAL MORAL RESPONSE

●

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290–●–ETHICAL PRACTICE IN THE HUMAN SERVICES

Exercise 11.4

Personalizing the Importance of Competence

Part 1: Below you will find a list of presenting concerns. As you read
the list, place a check mark under the column indicating whether
you would work with the person and provide service or refer the
person to another helper. If you are currently in a formal degree/
training program, answer the question as if you had just completed
that training.

Presenting Concerns
Provide
Service

Refer to
Another
Helper

A person with anxiety about making
a career decision

A person grieving the recent death of her
parent

A person thinking about leaving his
partner

A person concerned about the possibility
of having a drinking problem

A person who has questions about her
sexual orientation

A person having academic difficulties in
college

A person who feels extremely depressed

A person who is experiencing headaches
and muscle tensions as a result of job-
related stress

A person who is concerned about his
explosive temper

A person who is having conflict with
her adolescent child, which at times has
exploded into physical confrontations

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