Here's something that might surprise you. The ethical codes we follow today didn't come from a committee sitting around a table trying to get things right. They came from a catastrophe. In the 1940s, Nazi physicians conducted horrific experiments on concentration camp prisoners prisoners without consent, without justification, and without any semblance of human decency. The Nuremberg trials that followed didn't just prosecute war crimes, they produced the Nuremberg Code in 1947, the first international framework established that voluntarily informed consent is an absolute requirement in any research or clinical intervention involving human beings. But the violations didn't stop there. Right here in the United States, the Tuskegee syphilis study ran from 1932 to 1972, 40 years during which time hundreds of black men in Alabama were deliberately denied treatment for syphilis so researchers could observe the disease's natural progression. They were never told that they had syphilis, they were never given penicillin, even after it became the standard treatment. The study only ended because a whistleblower leaked it to the press. Tuskegee directly led to the Belmont report in 1979, establishing that the principles of respect for persons, beneficence, and justice that still anchor research ethics today. The mental health profession took notice. The ACA and NASW didn't develop their ethical codes in a vacuum. They developed them in a world where the consequences of unethical practice had already been written in human suffering. That's the world we're walking into today. Ethics isn't paperwork, it isn't a section of on the exam you memorize and forget. It's the framework, the standards between your claims and harm, including harm that clinicians can cause without even intending to. Let's get into it. Welcome back to the Leicester Lifeline Podcast, the podcast that helps you build the clinical knowledge and confidence you need to pass your exams and show up for the people that need you in your clinical practice. I'm your host, Matt Lawson, and today we are covering one of the most heavily tested and most practically important topics in all of mental health training, ethics and laws. We're going to hit the major ethical codes, the core moral principles that anchor them, confidentiality and its limits, informed consent, boundaries in dual relationships, ethical decision-making models, and the key legal concepts every pre-licensed therapist needs to know. And yes, five multiple choice questions, of course, just like always. Before we get into it, just a couple of quick things. The Circle Group, the online community that I created for Licer Lifeline, is up and going. I am offering a 14-day free trial. You can go into it, check it out, see if it's something that might help you for your studies and decide, you know, if you want to stay. That 14-day trial is free. You can cancel anytime just to check it out. Also, want to make sure that you all are taking a look at the newsletter. It's really growing. It's really neat to see how quickly this is growing. It's a great study tool. You know, it's something that's nice to have. It gets delivered weekly along with the podcast, kind of reinforces some of the topics that we talked about in the podcast and just gives you some practical knowledge and understanding on how to retain it for the exams. At this point, I would tell you to go check out the show notes, which I will have the links in the show notes, but also I'm happy to say that the Licenger Lifeline website is up and live. Um, so you can go to Leicester Lifeline, all one word, license your lifeline.com, and um you can check out the links there for the different things like the circle group and the newsletter. Lots happening here over the last week. It's pretty exciting to see all this growing, and I can't thank everyone enough that has supported this podcast over time. Um I'm really hoping that this just keeps growing the way it is. Having said that, please make sure that you pass this along to anyone that you know that may benefit. This profession, probably more than any profession, should be the least competitive field in the world. Um, we are all in this together as clinicians, and we need to support each other. Um and if this is something that can help more people get into the profession, please don't hesitate to pass it on. Also, one more quick note um if you want to contact me, um, check out um licensurelifeline at gmail.com for my direct email, um, or you can go through the Instagram. Now you can also kind of go through the website as well. Um, but if you use the feature through BuzzSprout, which is who hosts this podcast, um, I won't be able to respond to the to any messages that you send through the fan mail feature. Um, um it's it's pretty much just read-only. I don't even know who sends it, so I'll just get like a message, and that's kind of it. So if you do want to get in contact, you can use those things that those methods that I just mentioned to do that. Okay, and on with the show. All right, let's see what's going on in the world of mental health this week. And I want to say up front, all three of the stories um today connect directly to what we're covering in this episode, so ethics and law. Um, that's not by design, that's just where the field is right now. Um, so first up, tech and mental health. AI therapy tools, chatbot counselors, and emotional wellness apps are now used by millions of people seeking quick and affordable support. And this week's experts are raising serious flags. Um, mental health conversations contain highly personal information, trauma, relationship struggles, medication, and suicidal thoughts. Um, privacy advocates are arguing that emotional and psychological data deserves stronger protection than ordinary app activity. And that's this is this needs to be taken care of. Um, you know, it this is another scenario in the tech world where tech is just outpacing everything um very quickly, and we're we're playing catch up right now. And uh this is what we need to get on top of the security. World Health Organization has weighed in um warning of risk of well-being, especially with younger people. And this matters for for pre-licensed clinicians. Um, you know, ACA and NA NASW codes both have things to say about technology, confidentiality and informed consent. As AI tools become more embedded in care, knowing your ethical obligation around tech technology isn't an option anymore. We need to do our due diligence in really understanding uh the tech, how it's used, and the privacy that it um affords the people that we work with. Also, we are celebrating mental health awareness month. Um, and new data from KFF shows that among insured adults who describe their mental health as fair to poor, 43% reported at least one time in the past year when they needed mental health services or medication, but did not receive them. At the time, at the same time, over over 61 million adults in the U.S. experienced a mental illness in 2024 with death due to suicide, gun violence, drug overdose, and remaining overdose, all these things are remaining pretty high. Those numbers are in context that you're working in, right? Clients who are going to sit across from you are coming from that reality. And every ethical decision you make around confidentiality, around duty to warn, around informed consent is made in service of those individuals, which is exactly why today's topic matters so much. I can't emphasize enough that this isn't something that we necessarily need to worry about as much as we need to be very aware and in tune. Um, you know, it's ethics and you know, the the law are these things that you're gonna butt up against. Like just the nature of our work, you're going to butt up against all of these issues from time to time. And it's just important that you stay informed, um, stay on top of them, stay, stay just keep like an ear to the ground. Um, because we just we do. We need to keep awareness of them, not so much always worrying about them. Before we get into the main topic today, I want to take a minute to talk about something that becomes incredibly important once you move from studying ethics to actually practicing in the real world. Because one of the biggest clinical stressors for clinicians often isn't therapy itself, it's the administrative side of work. Documentation, scheduling, secure communication, keeping everything organized and compliant. That's where simple practice comes in. Simple practice is an all-in-one platform built specifically for therapists and health professionals. It helps manage scheduling, notes, billing, telehealth, and client communication in a way that keeps your practice organized and professional. Right now, they're offering a seven-day free trial along with 70% off for a one full year of simple practice as part of the mental health professional day promotion. If you're listening after May 19th, you're also um continuing their core, they're also continuing their core offer of a seven-day free trial plus 50% off your for your first four months. Um, so if you're preparing to become a counselor or already starting to think about seeing clients, it's definitely worth checking out. I'm gonna have a link in the show notes. Take a look, it supports the show. Now let's get back into it. What would you do if a client told you they were going to hurt someone? Not hypothetically, not I've been having some angry thoughts, but a specific person, a specific plan, and then they look at you and say, But you can't tell anyone. That's confidential, right? What do you do? If you felt any hesitation answering that, this episode is for you. And honestly, if you felt confident, stay with stay with me. Because ethics in law is one of those areas where the more you know, the more you realize the answer is rarely as simple as it first appears. Today is gonna be part one of a two-part series on ethics and law. We're gonna cover the ethical codes that um govern your practice, the five moral principles that anchor everything, and the one area that trips up more pre-licensed therapists than almost anything else: confidentiality and limits. Part two will be coming next week. Um, that's gonna be informed consent, boundaries, dual relationships, and what to do when ethics and law actually conflict. So here's something worth saying out loud before we dive into the content. Ethics isn't paperwork, it's not a section of on the exam you memorize and forget. It's the framework that stands between your clients and harm, including harm that may be well-meaning but can still cause harm without even intending to. That framing, it really matters because the way you approach ethics as a living framework versus a compliance checklist will show up in how you answer questions and how you practice. Now, the codes, if you're a counselor, your primary ethical framework is the ACA Code of Ethics, published by the American Counseling Association, last updated around like 2014. Um, there's actually a revised version coming later this year, but for now the 2014 codes is what is being tested on. I'm really interested to see if they put more stuff in there about technology, but we'll see. For my social workers out there, your primary framework is going to be the NASW Code of Ethics. This was last updated in 2021 because apparently social workers are a lot more on top of it than counselors. Um, so for the exam, you need to know both. Here's what matters most. Both codes of ethics cover the same core territory: confidentiality, informed consent, boundaries, competence, supervision, and technology. They share the same DNA, but they diverge in one important area. The ACA code is centered more on the counseling relationship. It's focused on you and your client autonomy, the therapeutic alliance, and the individual that's actually in the room with you. The NASW code goes broader, it has six core values. One of them is social justice. The NASW code explicitly calls social workers to challenge the systemic injustices, not just serve individual clients, but advocate at the community of and societal level. If you are getting into this profession without some sense of just social wanting society to be better, um, you know, this may not be the best profession for you. Um, because we are. We are people that you know advocate for people. Um, we want to see the best for the individuals both in front of us and in our communities. And this is actually a part of what it means to be a responsible clinician. So on the exam, when a question involves systemic advocacy or social justice, that tends to be NASW territory. When it's focused on individual therapeutic relationship, that tends to be more ACA, right? One more thing. Both codes distinguish between aspirational ethics and mandatory ethics. Aspirational ethics are the ideals, best practices, standards we strive toward. Mandatory ethics are the floor, right? The minimum you are required to meet. Violating aspirational ethics means you feel s like short of a best practice, right? You you didn't you just kind of fell short of best practice. Violating mandatory ethics can mean disciplinary action, loss of licensure, legal consequences. You gotta know the difference. All right, let's get into the five moral principles. Everything in both codes, every rule, every standard, every guideline flows from these five core moral principles. So if you understand these, the rules start to make sense instead of feeling like they're just it's just like an arbitrary list. First up, you have autonomy. That's the client's right to make their own decisions about their own life, even decisions you disagree with. And this comes up a lot. Um, we all go into this practice, we all become clinicians with kind of pieces of our identity, pieces of who we are that just make us a being on this planet. And you're gonna butt up against people that have different sense of being than you are. Um autonomy is why informed consent exists. It's why we don't impose our goals, the goals that we have for the work that we do with somebody on them. It's why we don't manipulate, even with good intention. The client is a self-determining human being, not a passive recipient of your expertise. Next up, you have beneficence. Do good actively, not just avoiding harm. Actually, work to promote your client's well-being. This is why we stay current with evidence. Um, you know, it's it's it's why we refer people out when we need to. Um, beneficence is this forward-leaning dimension of ethical practice, non-malfeasance, which is really fun to say. Do no harm. Um, how many times have you heard that in a movie or seen it on a show, right? As a clinician, you do no harm. And most clinicians have heard this once or twice outside of grad school. But it's it's more nuanced than it sounds. Harm isn't always obvious. Can harm come from practicing outside your cobbins? Yes. From failing to refer? Yes. From boundary erosion you didn't catch early enough. Yes. Nonmalfeisance requires ongoing vigilance, not just the absence of obvious wrongdoing. Okay, let's talk about fidelity. Being faithful. Um who would have thought that being a therapist means you gotta be be faithful? But this makes sense, right? Keeping your promises, honoring your agreements that you made your clients at the start-up treatment. Fidelity is what makes the therapeutic um relationship trustworthy. And I am not kidding when I tell you I have seen many a therapist's reputations ruined by not being faithful to their clients. And you know, this is stuff like you know, talking in public to a non-clinician about um a client. You know, you're you're at lunch with a friend that you know you you you knew from college, and you're talking about this patient that you're working with, blah, blah, blah. It is amazing how stuff like that can get back to patients. Um, I've definitely heard situations where patients overheard their therapist talking about them. So it is like you break fidelity, you break these promises that you keep, you really break your reputation. All right. Um, some frameworks add a sixth um principle here, veracity. This is just being truthful, representing your credentials accurately, documenting honestly. It shows up on some exams, so know it. So, you know, this is don't say you're a sex therapist if you're not licensed as a sex therapist, if you're not credentialed as a sex therapist. If you're not a doctor, doctorate level clinician, don't call yourself a doctor. Um, it's that easy, but it it happens. Little memory anchor for all of these. Um, A, B, N, J, F. Always be notably just, faithful, and if you want to add the six, you can add a V at the end of it for verified. Now, here's what makes this clinically useful and not just a list to memorize. These principles don't always point in the same direction. The hardest ethical situations and the most common exam questions involve conflict between them. A client who wants to make a decision that could harm them. The that's autonomy versus non-malfeasance. A client who discloses something that puts someone else at risk. That's confidential confidentiality, which flows from autonomy versus justice and duty to protect. Knowing the principles gives you a framework for thinking through those conflicts, which brings us directly to the most important topic in today's episode: confidentiality and its limits. Let's go back to where we started. A client tells you they're gonna hurt someone. What do you do? Before we answer that, let's establish what confidentiality actually is and why it matters so much. Confidentiality is the ethical obligation to protect client information from disclosure without their consent. It's the foundation of everything. Clients tell us things they would never tell another human being sometimes. Um, you know, maybe they've shared it with a significant other here or there, but you know, most of the time, a lot of the time, I shouldn't say most, a lot of the time, people are coming to us to talk about things that they just don't talk to other people about. Um, the moment that trust is broken without good reason, the therapeutic relationship is damaged, sometimes irreparably. But what everyone needs to know before they see their first client, confidentiality is not absolute. There are four situations where it must be broken. Not may be broken, must be broken. First, credible threat to an identifiable third party. I'm sure you all have heard about Terasoft. 1976, California Supreme Court ruled in Terasoft versus the regents of the University of California that a therapist has the duty to pr protect an identifiable third party when a client makes a credible threat against them. So this happened on a UC Berkeley campus. Um a person um was going to the center, uh the student health center to get therapy. They said that they were going to hurt their girlfriend at the time or an ex-girlfriend. And the therapist notified campus police. The individuals briefly detained the client and that that was then released. Nobody warned Terasoft, even though the person was arrested and detained for a little bit. Nobody still warned the ex-girlfriend. Two months later, he killed her. Family sued. Um, the court ruled that the duty protect extended beyond the client to the identifiable third party. So she should have been warned about what this individual's intentions were. So that question I asked at the beginning um, client tells you they're gonna hurt someone, what do you do? Does it matter that they say they won't actually do it? No, the clinical assessment of credibility is what drives the obligation, not the client's reassurance. That's the part people get wrong on the exam and in practice. Um, to protect doesn't automatically mean call the potential victim. It means take whatever clinically appropriate action is necessary. Warning the victim, notifying law enforcement, uh in initiating hospitalization, warning is one option. And you know, this all comes with context. Like you really like knowing your client, knowing what they're capable of. Of knowing if they have a plan. Like all these things need to be taken into consideration. And you can like talk to your supervisor about these things. Even if you know early on you're kind of suspecting it, it's important to just talk to people about these things. Talk to your other clinicians about these things. Second, the other thing that you have to report on, mandatory reporting. Every state requires mental health professionals to report reasonable suspicion of child abuse or neglect. Most states extend this to old elder abuse as well. Um, and this can be a tricky one. Like I have seen individuals that were abused when they were children and are disclosing by the time when they're adults. And I've heard like therapists get kind of get confused as to if they have a duty to inform anybody or talk about it if this doesn't happen. And you know, so and I'm talking like people that were abused like when they were in their when they were like 16 and now they're 18. Should the therapist be informing for informing somebody? And this is a again like a big question to talk to supervisors about, a big question to consider your state laws about. Um, but it it is, it's it's one of those things that people kind of get confused on. Third, imminent danger to the clients themselves. So when a client presents with imminent risk of suicide or serious self-harm, meaning danger is imminent and serious, not just possible. Confidentiality can be breached to protect project protect them. This may mean contacting family, notifying emergency services, or initiating an involuntary hold depending on state or clinical assessment. This one in particular is really important to get emergency contacts. It makes it really important to get emergency contacts for people, especially if you're doing remote therapy. Um, I have had friends who were doing remote therapy, and an individual stated that they're gonna hurt themselves. They had to plan everything. Knowing emergency contacts, knowing the local authorities, knowing the local hospitals in that situation, if you're doing remote therapy becomes extremely important. The last one here is a valid court order. If a court orders disclosure, you are generally required to comply. But here's something important to know before you disclose anything, in a legal proceeding, you can assert privileged communication on your client's behalf, which brings up a distinction that shows up in every licensing exam. Confidentiality verse and privileged communication are not the same thing. Confidentiality is ethical, it's your professional obligation to protect your client's information. Privileged communication is legal, it's the client's right to prevent you from testifying in court. One lives in the therapy room, one lives in the courtroom. Both belong to the client, not to you. Write that down. Like that is an important one. God forbid you are ever. I've never, you know, in the 20 years of me being a therapist, I have never been in court. And I I've had friends, I've had to go to court, but luckily I have never had to, and I hope it never happens to you. It is not a fun situation. Ethics is really about knowing that these rules exist and why they exist and having the clarity to act on them when it counts. In part two of this little series here, we're going to cover informed consent boundaries and dual relationship, ethical decision-making models, and what to do when the law or ethical code actually conflicts with each other. That'll be for next week. Um definitely had to split these up because it is so much information. But I hope you got a lot out of that first part. Okay, let's get into some multiple choice questions. A pre-licensed counselor is working with a client who discloses he is having thoughts of harming his neighbor. He describes a specific plan, but tells the therapist I would never actually go through with it. You can't tell anyone, right? The therapist assesses the threat as credible. According to the Sarah Terasov ruling, the most appropriate next step is to a maintain confidentiality because a client stand um stated he has no intention of acting, B. Consult with a supervisor and take steps to protect the identifiable third party, C immediately terminate the therapeutic relationship, or D. Increase session frequency to and monitor the situation more closely. Alright, answer is gonna be B. The Terasov ruling establishes the duty to protect, and the clinical assessment of credibility is what triggers the that obligation, not the client's reassurance. Option A is wrong because stated intent doesn't override clinical assessment. Option C is wrong because termination isn't the appropriate clinical response. Do not do that. Do not terminate someone just because you don't like what they're saying. Question number two. The primary difference between the ACA Code of Ethics and the NASW Code of Ethics is best described as A. The ACA Code uh applies to all mental health professionals while the NASW code applies only to social workers. B the ACA Code emphasizes the individual counseling relationship while the NASW code extends ethical responsibility to social justice at a system level. C. The NASW code was developed more recently and supersedes the ACA code in all ethical situations, or D. The ACA code addresses confidentiality while the NASW code does not. Answer is gonna be B. Both codes cover core territory here. Confidentiality, informed consent, boundaries, competence. The meaningful distinction is the scope. The ACA code is centered on the individual council relationship. The NASW code explicitly extends ethical responsibility to systemic advocacy and social justice. When you see a questioning, a question involving um societal or community level advocacy, that's going to be NSA NASW territory. Question number three A therapist is working with a 10-year-old client whose mother reports that her ex-husband has been leaving unexplained bruises on the child during visitations. The mother asked the therapist not to report because she is afraid it will complicate the custody case. The therapist's legal obligation is to a respect the mother's wishes and gather more information before deciding whether to report, B. Consult with a supervisor and make joint decision about whether to report. C. File a mandatory report based on reasonable suspicion of child abuse, or D. Refer the case to a specialist in child abuse before taking action. Answer here is C. Mandatory reporting law requires reporting reasonable suspicion of child abuse, not certainty, not proof, and not parents' permission. The mother's concern about the custody case does not override your legal obligation. You know, in and you can. Question number four Which of the following best describes the difference between confidentiality and privileged communication? Is it A, confidentiality is a legal concept, privileged communication is an ethical concept. B confidentiality is the therapist's ethical obligation to protect the client's information. Privileged communication is the client's legal right to prevent the disclosure in legal proceedings. C. Privileged communication applies in the therapy room. Confidential applies only in legal settings. D. Both confidential confidentiality and privileged communication belong to the therapist. Answer is going to be B. This distinction is on every licensed exam. Confidentiality is ethical, your professional obligation, privileged communication is legal. The client's right in court both belong to the client, not the therapist. Alright, last question. A therapist is treating a client for anxiety. During sessions, the client briefly mentions feeling hopeless, having passive thoughts of suicide, but denies any plan, intent, or means, and it has a strong protective factor, including family support, and future goals. The therapist conducts a thought um lethality assessment based on the presentation. The most appropriate next step is to a breach confidentiality immediately and notify a client's family. B. Initiate involuntary psychiatric hold given the presence of a suicidal ideation. C document the assessment thoroughly, continue treatment, increase monitoring, or d refer the client to a higher level of care immediately. Answer to this one is gonna be C. This question tests whether you understand thresholds for breaching confidentiality around around danger itself. Um and that threshold is, you know, if it's imminent, that's when you want to report. Um passive passive suicidal ideation, which you're going to hear a lot um in therapy, without a plan, without intent, or a means with strong protective factors. Again, you want to assess the individuals, um, the like the whole the whole individual, everything that this individual go has going on, not just what they're saying. So the clinically appropriate response is thorough documentation, continued treatment, and increased monitoring. Option A and B would be appropriate if the risk were imminent. It's not here. All right, folks, that is gonna be it for this episode. We covered a lot. Um, you know, that's why I'm doing a second part to this because it's a lot of info. Um, I hope you're still awake because this is not the most exciting topic. Um, but you need to know it. You need to know the codes. ACA anchors, the individual counseling relationship, NASW extends ethical responsibility to social workers and social justice, but both get tested on and both matter. Um part two of this, we went over the five moral principles. Um, it's not just a list, they're a framework for thinking through compla uh complexity, autonomy, beneficence, non-malfeasance, justice, fidelity, and veracity, if your exam includes that. Um you need to know when the principles conflict, and they will, and where clinical and ethical judgment lives. In the third section of this, confidentiality is foundational, but it's not absolute. Know exactly where it ends. Terasoffs, mandatory reporting, imminent danger to self, valid court order. Not roughly, precisely, and lock in the distinction between confidentiality and privileged communication. It will be on the exam, more than likely. So next week in part two, we're gonna go get like more into informed consent and why it's so much more than a form you just hand somebody in a waiting room. We're gonna look at boundaries and dual relationships, including one question that cuts through all the complexity, um, ethical decision-making models, because when things get hard, you need a process, not just a rule. And what to do when your ethical code and law actually conflicts with each other. Um, this one's that it's good, it's fascinating, but it's it's a lot and it's long and can sometimes be boring. So um, before I let you go, I want to uh let everybody know that the you know cheat sheets for I'm creating been creating cheat sheets for these episodes, which are in the uh circle group. Um it's part of what you get as part of that membership. And like I said earlier, um that will be available on the new LeicesterLifeline.com website. You can go to a link there. You can get 14 days free to take check the site out. Um, you know, this is uh something I'm just getting started. So if you get in there and you're one of two or one of three people, don't be intimidated. Um, that's how these things get started. Um, you know, I'm I'm very grateful to the foundational people that are taking a look at this. Um, and I do have uh rewards for those individuals that are kind of founding um this little endeavor here. Um, but I will see you in part two, and until next time, keep learning.