Reading C

The question of values permeates the therapeutic process. In this chapter we ask you to think about your values and life experiences and the influence they can have on your work. We ask you to consider the possible impact of your values on your clients, the effect your clients’ values may have on you, the possible conflicts that can arise if you and your clients have different values, and the importance of learning to manage these conflicts in an effective way. We also hope to bring attention to the central role culture plays in determining the values we hold, both personally and professionally.

Can therapists keep their values out of their counseling sessions? The belief that practitioners can be completely objective and value-free is no longer a dominant perspective in the field of psychology (Shiles, 2009). Levitt and Moorhead (2013) contend that values not only enter the counseling relationship but can significantly affect many facets of the relationship. Counselors need to understand how their own values can permeate their work with clients for good or ill, perhaps unconsciously and unintentionally. Francis and Dugger (2014) emphasize that counselors are ethically responsible to monitor the various ways they may communicate their values to clients “and be aware of how the power differential that exists within each counseling relationship may result in the imposition of their values” (p. 132). Hancock (2014) cautions therapists about letting personal beliefs assume priority: “When the therapist’s personal beliefs—no matter how deeply held—interfere with the ethical obligations of the profession, the beliefs become more important than the client” (p. 7). Hancock argues that “personal beliefs can and do inform the lives of practitioners; however, they cannot trump the ethical principles and standards of the profession—not when serving the welfare of the client” (p. 8).

Although clinicians may not agree with the values of some clients, mental health practitioners are expected to respect the rights of clients to hold their own views. By demonstrating a nonjudgmental attitude toward clients with different values, we can remain invested in the work our clients are doing. For example, a counselor can help a client who is deciding whether or not to leave a committed relationship by exploring the client’s motivations and the possible consequences of either decision, but pressuring the client to choose a particular outcome would be unethical. By honoring the client’s self-determination, we help to empower the client.

Counselors must develop the ability to manage their personal values so that they do not unduly influence the counseling process. Kocet and Herlihy (2014) describe this process as ethical bracketing: “intentional setting aside of the counselor’s personal values in order to provide ethical and appropriate counseling to all clients, especially those whose worldviews, values, belief systems, and decisions differ significantly from those of the counselor” (p. 182). Setting aside our personal values does not mean that we must give up or change our values (Kaplan et al., 2017). Counselors do not have to like or agree with their clients’ choices to fulfill their ethical obligation to help those seeking their assistance. Many clients will have a worldview different from that of the counselor, and clients bring to us a host of problems. They may have felt rejected by others or suffered from discrimination. Clients should not be exposed to further discrimination by counselors who refuse to render services to them because of differing values.

In our ethics courses, students sometimes ask, “Can I put a values statement in my informed consent document that communicates the nature of my personal values so prospective clients can make an informed decision about whether to enter a professional relationship with me?” If you were to incorporate a personal values statement in your informed consent materials, what would you include? Would you identify specific areas you have difficulty maintaining objectivity about because of the values you hold? Would you include your position on any of the value areas we address in this chapter? Although perhaps well intentioned, such disclosures put the emphasis in the wrong place—on the counselor’s values. This can easily convey a judgmental attitude to clients about issues with which they may be struggling. Clients often come to therapy in search of a safe and supportive environment in which they can share secrets and unburden themselves of shame or guilt. Clients are in a vulnerable position and need understanding and support from a counselor, not judgment.

In counseling, your clients struggle to make changes in their lives. We question the underlying assumption that counselors have greater wisdom than their clients and can prescribe better ways of being happier. Unquestionably, psychoeducation is a part of counseling, and counselors do facilitate a process of helping clients gain a fuller understanding of their problems. However, the process of counseling is meant to help clients discover their own resources for dealing with problems rather than listening to advice from others. Counseling is a dialogue between therapist and client that is meant to further the client’s goals and empower the client to make choices that are in his or her best interest.

The following questions may help you begin to think about the role your values will play in your work with clients:

• Do you think it is ever justified to influence a client’s set of values? If so, when and in what circumstances?
• In what ways could discussing your values with clients unduly influence the decisions they are making?
• Can you interact honestly with your clients without making value judgments?
• If you were convinced that your client was making a self-destructive decision, would you express your concerns?
• Do you think therapists are responsible for informing clients about a variety of value options?
• How are you affected when your clients adopt your beliefs and values?
• Are you able to allow your clients to select their own values and live by their beliefs, even if they differ from yours?
• Do you think a referral is ever justified on the basis of a conflict of values between a counselor and client? If so, in what instances?
• Do you believe certain values are inherent in the therapeutic process? If so, what are these values?
• How does exposing your clients to your viewpoint differ from subtly influencing them to accept your values?
• What are some potential advantages and disadvantages in having similar life experiences with your client?
• In what ways are challenging clients to examine their values different from imposing values on them?

Because your values can significantly affect your work with clients, you must clarify your assumptions, core beliefs, and values and the ways in which they may influence the therapeutic process. If counselors have a strong commitment to values they rarely question, whether these values are conventional or unconventional, may they be inclined to promote these values at the expense of their clients’ exploration of their own attitudes and beliefs? If counselors rarely reflect on their own values, it is unlikely that they can provide a climate in which clients can examine their values. Exploring values is at the heart of why many counselor education programs encourage personal therapy for counselors in training. Personal therapy sessions provide an opportunity to examine your beliefs and values and to explore your motivations for wanting to share or impose these beliefs. Clinical supervision sessions are another arena in which the impact of values when working with clients can be examined. Ongoing clinical supervision throughout one’s professional career is also encouraged.

In the following sections we examine some sample cases and issues to help you clarify what you value and how this might influence the goals of counseling and the interventions you make with your clients. As you read these examples, keep the following questions in mind:

• What is my position on this issue?
• Where did I develop my views?
• Am I open to being challenged by others?
• Under what circumstances would I disclose my values to my clients? Why? What are my reasons for wanting to reveal my values to a client?
• Do my actions respect the principle of clients’ self-determination that is consistent with their culture?

The imposition of values by the counselor is an ethical issue in counseling individuals, couples, families, and groups. Value imposition refers to counselors directly attempting to influence a client to adopt their values, attitudes, beliefs, and behaviors. It is possible for mental health practitioners to do this either actively or passively, and with or without awareness. Jadaszewski (2016) contends that mental health practitioners and consumers of psychotherapy services often lack awareness of the role values play in the psychotherapeutic endeavor. At times, therapists may unintentionally influence clients to change some of their values and behaviors in certain directions. Jadaszewski suggests that a key aspect of informed consent is clarifying with clients some potential ways that values can influence psychotherapy. Informing clients about the role of values in therapy can guard against undue influence by the therapist. For example, a key element in some addiction treatment programs is that clients accept that there is a power higher than themselves. Although clients are encouraged to define for themselves what this higher power is, some addiction counselors may be tempted to impose their own personal beliefs of what the higher power is, which raises ethical issues. Counselors are cautioned about this kind of value imposition in their professional work in this ACA (2014) standard:

Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. Counselors respect the diversity of clients, trainees, and research participants, and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature. (A.4.b.)

School counselors receive a similar caution in the ASCA (2016) code:

[School counselors] respect students’ and families’ values, beliefs, sexual orientation, gender identification/expressions and cultural background and exercise great care to avoid imposing personal beliefs or values rooted in one’s religion, culture or ethnicity. (A.1.f.)

A school counselor violated these ethical standards and imposed her personal beliefs for a preference of sexual abstinence at her school. A South Shore Public School District counselor, Grossman claimed she was following her fundamental Christian beliefs when she removed the pamphlets on instruction in the use of condoms and replaced them with literature advocating abstinence. When her contract was not renewed, she brought suit against the school district, contending that the district was hostile to her religious beliefs (Grossman v. South Shore Public School District, 2007). The Seventh Circuit Court of Appeals took the position that religious beliefs do not trump the policies and requirements of the employing school district. Grossman acted unethically in disregarding the curriculum of the school and advocating her own personal beliefs about abstinence. The court concluded that the nonrenewal of her contract was based on her actions rather than on her personal beliefs (Phan et al., 2013).

In group work, values imposition may come from both the leader and the members in the group. The group leader should not short-circuit members’ exploration of issues by providing answers. Some members may inappropriately respond by giving advice to another member. Value clashes often occur between members, and leaders have a responsibility to intervene so that no member can impose his or her values on others in the group. The group leader’s central function is to help members find answers that are congruent with their own values, and these answers will not be the same for all group members.

David Kaplan, chief professional officer at the American Counseling Association, states that the lack of competence across sexual orientations cannot be used as an excuse to refuse to counsel an LGBT client (personal communication, August 6, 2016). All counselors are expected to have basic competencies across race, ethnicity, gender, sexual orientation, and all other characteristics listed in the nondiscrimination statement of the ACA’s (2014) Code of Ethics. Farnsworth and Callahan (2013) state that values are intrinsic to the process of psychotherapy, and value conflicts will occasionally pose challenges for conducting therapy, regardless of how accepting and compassionate the trainee may be.

Merely disagreeing with a client’s value system is not ethical grounds for a referral; it is possible to work through value conflicts successfully. Consider a referral only when you clearly lack the necessary skills to deal with the issues presented by the client. Do not try to convince yourself that you are working in a client’s best interest by referring a person because of your discomfort with their beliefs and actions. Farnsworth and Callahan (2013) believe referrals are appropriate when they reflect self-awareness on the part of the trainee that the client’s goal is beyond the scope of the trainee’s competence. Farnsworth and Callahan (2013) suggest that trainees who experience discomfort with certain clients should honestly consider the degree to which prejudice may be biasing their evaluation of a situation. “Because value conflicts are an inescapable element of psychotherapy, the best protection that can be afforded to clients is for all trainee clinicians to develop greater personal and professional awareness of their own values and recognize the impact that those values have on the services they provide” (p. 205). To competently deal with value conflicts, trainees must maintain awareness of potential conflict areas with clients and their own internal reactions to clients throughout the duration of the therapy process. The counseling process is not about your personal values; it is about the values and needs of your clients. Your task is to help clients explore and clarify their beliefs and apply their values to solving their problems. If clients conclude that their lives are not fulfilled, they can use the counseling relationship to reexamine and modify their values or their actions, and they can explore the range of options open to them.

Hancock (2014) provides a core principle in managing value conflicts: “When there is a conflict between a student’s ‘sincerely held’ religious beliefs and the needs of that client, without question the client’s needs must come first” (p. 6). Referring a client because his or her religious beliefs conflict with your values can and does lead to feelings of abandonment and violates the ethical principle of“do no harm” (David Kaplan, personal communication, August 6, 2016). Before considering a referral, explore your part of the difficulty through consultation or supervision. What barriers within you would make it difficult for you to work with a client who has a different value system? When you recognize instances of such value conflicts, ask yourself these questions: “Who’s comfort is paramount in the client–counselor relationship?” “Why is it necessary that there be congruence between my value system and my client’s value system?” “Have I considered the potential for harm to my client in making a referral?”

It can be burdensome for clients to be saddled with your disclosure of not being able to get beyond value differences. Clients may interpret this as a personal rejection and suffer harm as a result. Counseling is about working with clients within the framework of their value system. If you experience difficulties over conflicting personal values, the ethical course of action is to seek supervision and learn ways to effectively manage these differences. Linde (2016) points out that the 2014 ACA Code of Ethics makes it clear that counseling is about the client, not the counselor.

Value conflicts may become apparent only after a client has been working with you for some time. Consider this scenario. You believe you would have difficulty counseling a woman who is considering an abortion. You have been counseling a woman for several months on other concerns, and one day she discloses that she is pregnant. She wants to explore all of her options because she is uncertain about what to do. Would you tell your client that you needed to refer her because of your values pertaining to abortion? Could such a referral be considered client abandonment? Would it be ethical for you to offer advice from your value position if she asks for your advice? What are the ethical and legal aspects of imposing your values on this client? If you cannot maintain objectivity regarding a certain value, this is your dilemma to struggle with and is not the client’s problem. Your ethical responsibility is to seek supervision or consultation. If you were to refer this client, you still have the obligation to understand how this conflict of values may be influencing the direction of therapy and why you considered a referral to be necessary (Farnsworth & Callahan, 2013).

Many people think the mandate to avoid discriminatory referrals is a new directive. However, this mandate is consistent with Carl Rogers’s concept of unconditional positive regard, which has influenced the counseling profession for more than 50 years. Person-centered theory rests on the foundation of acceptance, respect for a client’s autonomy, and avoidance of judgment. These core principles are infused in the ACA’s Code of Ethics (David Kaplan, personal communication, August 6, 2016).

It is understandable that students often wrestle with the question of when to refer a client. Professional associations do not present a uniform theme, and different professions have different positions on the justification for referral due to a clinician–client value conflict. If ethics scholars and professional associations have differing perspectives, counselor education faculty and students also may be unclear about the circumstances determining the ethics of referrals.

Insufficient training is sometimes used as an excuse or a cover for the real reason for making a referral—the counselor’s difficulty with the client’s values. Beginning counselors often have not had enough time or experience to feel competent across a wide range of client problems. When faced with a topic you know little about, good first steps are to educate yourself, seek supervision, and obtain further training. It may seem that you are only one step ahead of your client in terms of knowing how to help this person, but the impulse to refer can hurt the client. It also will significantly inhibit your growth as an effective counselor.

Shiles (2009) notes that far too little has been written about situations in which referring a client is inappropriate, unethical, and may constitute an act of discrimination. Shiles asserts that inappropriate referrals have been made for clients with differing religious beliefs, sexual orientations, or cultural backgrounds. Counselors often rationalize these referrals as a way to provide the client with the best services; however, such practices may ultimately be discriminatory. Shiles makes the following observations:

• Referrals have become common practice among mental health service providers at the expense of exploring other possibilities. Mental health providers may not be aware of the potential ethical violation in their referral decision because this topic is not highlighted in the professional literature.
• The overuse of client referral among mental health providers often involves discriminatory practices that are rationalized as ways to avoid harming the client and practicing beyond one’s level of competence. Discriminatory referrals have gone unnoticed and unchallenged far too often.
• The psychological community needs to critically examine why mental health practitioners may refer clients over value conflicts and why these practitioners assume that such practices are appropriate, reasonable, and acceptable.

The Code of Ethics of the American Association for Marriage and Family Therapy (2015) has this nondiscrimination standard: “Marriage and family therapists provide professional assistance to persons without discrimination on the basis of race, age, ethnicity, socioeconomic status, disability, gender, health status, religion, national origin, sexual orientation, gender identity or relationship status” (1.1). The AAMFT code also addresses referrals: “Marriage and family therapists respectfully assist persons in obtaining appropriate therapeutic services if the therapist is unable or unwilling to provide professional help” (1.10). We have difficulty with the concept of a therapist being unable or unwilling to work with a client. This vague wording can be used to discriminate and seems to open the door to referral based primarily on a therapist’s values or personal beliefs and preferences. What does unable mean? What are the implications of being unwilling? These two AAMFT standards seem to contradict each other, and clarification is sorely needed.

McGeorge, Carlson, and Farrell (2016) studied family therapists’ beliefs and practices related to the referral of lesbian, gay, and bisexual clients and found that the majority of participants believed it is ethical to refer LGB clients based on counselors’ (a) values and religious beliefs, (b) negative beliefs about LGB people and relationships, and (c) lack of competence in working with LGB individuals. This result surprised McGeorge and her colleagues because the preponderance of the literature concludes that referral based on sexual orientation is a discriminatory practice that harms LGB individuals. They take the position that “training programs need to communicate that students are expected to develop clinical competence to work with LGB clients, which teaches students that they cannot ethically make the choice to avoid working with this or any other population” (p. 15). We tell our students who want to make a referral based on a value conflict to ask themselves these questions:

• What skills am I lacking in counseling a client struggling with a critical life decision?
• Is this my issue and feelings of discomfort or are these my client’s feelings?
• Can I obtain the knowledge necessary to acquire competence through continuing education, consultation, or supervision?
• How quickly can I gain the knowledge necessary to be of service to my client?
• What is stopping me from gaining that knowledge, supervision, or consultation?
• How can I determine what would ethically justify a referral?

A related key question is, “When does an individual become a client?” Kaplan’s (2014) answer is that “the counselor’s ethical obligations to an individual start at first contact or assignment, not at the first session” (p. 146). For example, a counselor in private practice who does not have any openings cannot dismiss a person who calls inquiring about services. The counselor has an ethical obligation to provide alternative options, such as other practitioners in the area. This ethical obligation is present even though the counselor will never provide any counseling services to the individual.

We have emphasized that it is not ethical to refer clients based solely on a difference of values and beliefs between the counselor and the client. Through supervision, counselors in training can learn how to manage their values and how to avoid using their professional role to influence clients in a given direction or to make decisions for clients about how to live. In addition, counselors in training can explore their values and beliefs and increase their self-awareness and identify potential future or current value discrepancies in personal therapy. By being proactive, counselors in training can guard against unintentionally imposing their values on clients. It is the professional responsibility of the counselor to be invested in the process of a client’s decision making rather than directing the person toward outcomes that the counselor deems “right.” When counselors enter a professional relationship, they take on the values of the profession as expressed in the code of ethics and are expected to bracket off personal values as they enter the world of the client (Sells & Hagedorn, 2016).

Consider the following list of potential clients and indicate whether you believe you could work with them or would be challenged in doing so because of your countertransference or your own values. When would you need to consider supervision to stay neutral or to work effectively with the client? You may think it unlikely that you will encounter some of these situations, but you need to be prepared to deal with them if and when they do arise. Use this code in the following examples:

A = I could work with this person effectively.

B = I would be personally challenged in working with this person.

C = I would need to seek supervision to explore how my values or countertransference could affect my work with the person.

1. A woman who is considering an abortion and wants help in making her decision
2. A teenager who is having unsafe sex and sees no problem with this behavior
3. A person who shows little conscience development, who is strictly interested in his or her own advancement, and who uses others to achieve personal aims
4. A gay or lesbian couple wanting to work on conflicts in their relationship
5. A person who wants to leave a partner and children to pursue a sexual affair
6. A person with strongly held religious beliefs that differ from your own
7. A woman who says that if she could turn her life over to a higher power she would find peace
8. A couple who comes for couples counseling while maintaining an affair
9. An interracial couple coming for premarital counseling
10. A high school student who thinks she may be bisexual and wants to explore her feelings around coming out
11. A same-sex couple wanting to adopt a child
12. An investment counselor who misleads clients to get a commission and who is not held accountable
13. An interracial couple wanting to adopt a child and being faced with their respective parents’ opposition to the adoption
14. A client from another culture who has values very different from yours (such as arranging the marriage of their children)
15. A transgender person seeking support for coping with societal pressures and discrimination
16. An undocumented worker seeking assistance in coping with severe discrimination by an employer
17. A couple that has an “open marriage” and regularly engages in swinging
18. A person with very strong political opinions that differ vastly from your own
19. Parents who want your help in changing a child’s behavior because it does not conform with their religious or cultural beliefs
20. A mandated client who has no intention of changing and who is convinced he does not have a problem

Look back over the list and pay particular attention to the items you marked 'B' or 'C'. What are some of the difficulties that come up for you in these situations? If you were seeking supervision, what questions would you ask? Do any of these situations have legal implications? As you reflect on your responses, think about your ethical responsibilities as a counselor. What underlying beliefs do you have that may make it difficult to help certain clients? What might you need to shift in your thinking to effectively work with clients that trigger you?