Ethical Dilemmas in Therapy: A Decision-Making Framework
By Kristen McClure, MSW, LCSW | TherapistWorksheet.com
Most therapists encounter ethical dilemmas not as dramatic violations but as gradual, uncomfortable drift — small decisions that accumulate into problems, or situations where there is no clean right answer and every option involves some cost. A framework for ethical decision-making serves you better than a list of rules.
The Sources of Ethical Obligation
As a mental health professional, your ethical obligations come from multiple sources that sometimes conflict:
- Your professional code of ethics (NASW, APA, ACA, AAMFT — depending on your license)
- Your licensing board’s regulations (state law, which may differ from your code)
- Federal law (HIPAA, ADA, mandated reporting statutes)
- Your employer’s policies (when applicable)
- Your own ethical values and clinical judgment
When these conflict, the hierarchy matters. State law typically overrides professional code. Licensing board regulations define minimum standards. Your code may require more.
A Framework for Ethical Decision-Making
When facing an ethical dilemma, work through these steps:
1. Identify the ethical issues
Name what values or obligations are in tension. Is this a confidentiality vs. duty to protect conflict? A client welfare vs. institutional policy conflict? Naming the tension precisely is the first step toward resolving it.
2. Gather relevant information
What do the relevant codes say? What does state law require? What are the clinical facts? Who is affected and how?
3. Identify the options
What are the realistic courses of action? What are the potential outcomes of each? Not just for the client — for others who may be affected, for the therapeutic relationship, for your professional standing.
4. Consult
Ethical dilemmas are among the situations that most warrant consultation — with a supervisor, a trusted colleague, your professional association’s ethics helpline, or legal counsel when indicated. Consultation does not eliminate your responsibility for the decision. It informs it.
5. Make the decision and document your reasoning
Document not just what you decided but why — the factors you weighed, the consultation you sought, the reasoning that led to your conclusion. This is protective and demonstrates ethical decision-making process.
6. Evaluate the outcome
After acting, reflect. What happened? Would you make the same decision again? What would you do differently?
Common Ethical Dilemmas in Practice
Confidentiality vs. duty to protect
When a client discloses intent to harm an identifiable third party, most states require action (Tarasoff-derived duty to warn or protect). The threshold, required actions, and specifics vary by state. Know your state’s law. Do not apply a general principle without knowing your specific jurisdiction’s requirements.
Multiple relationships
Working with someone you know socially, treating family members of a current client, becoming involved with a former client — these situations create complexity that affects clinical objectivity and judgment. Some multiple relationships are always prohibited (sexual contact with current clients). Others require careful management and consultation. When in doubt: consult, document, and consider referral.
Client welfare vs. institutional policy
When your employer’s policy conflicts with what you believe is best for a client, you face a genuine ethical tension. Address institutional concerns through appropriate channels first. If the policy requires you to act in ways you believe violate your ethical obligations, consult your licensing board about your options.
Competence boundaries
Working beyond your training — taking on a diagnosis you do not know how to treat, using a technique without adequate training — is an ethical issue, not just a clinical one. The ethical obligation is to know what you do not know and to refer appropriately.
Self-disclosure
What you share about yourself with clients, when, and why — governed by the principle that self-disclosure serves the client’s treatment, not the therapist’s needs. Each disclosure is a clinical decision with ethical dimensions.
Frequently Asked Questions
What should I do if I think I made an ethical error?
Address it honestly. Consult with a supervisor or trusted peer. Determine whether consultation with your licensing board or legal counsel is indicated. Document accurately — do not retroactively alter records. Most licensing boards distinguish between good-faith errors and intentional violations. The cover-up is often worse than the error.
When should I contact my state licensing board for guidance?
Before you make a major decision in an uncertain ethical situation, when you are considering an unusual action, or when you are uncertain about your legal obligations. Most licensing boards offer ethics consultation — an underused resource.
Is it ethical to terminate with a difficult client?
Yes, under certain conditions — when you have provided adequate notice, made appropriate referrals, and are not abandoning a client in crisis. Difficulty alone is not sufficient grounds; clients who are hard to work with often need you most. Inability to provide adequate care, ongoing safety issues that cannot be managed, or significant clinical harm from the relationship may be grounds. Consult before terminating in difficult situations.
Do ethical codes differ by license type?
Yes. NASW (social workers), APA (psychologists), ACA (counselors), and AAMFT (marriage and family therapists) each have their own codes, with significant overlap and some differences. Know your own code. If you hold multiple credentials, you are held to all of them.
Kristen McClure, MSW, LCSW is a licensed therapist who creates practical clinical tools to help therapists navigate the hardest moments in their work.