Currenf and Emerging Ethical Issuesin Counseling: A Delphi Sfudy ofExperf Opinions

Barbara Herlihy and Roxane L. Dufrene

A Delphi study was conducted to ascertain the opinions of panei expertsregarding the most important current and emerging ethical issues facingthe counseiing profession. Expert opinions on ethical issues in counselorpreparation also were sought. Eighteen panelists responded to 3 roundsof data collection interspersed with feedback. Themes that emerged asimportant ethicai issues were ensuring that counselors practice ethicallyand abide by the American Counseiing Association (2005) ACA Code ofEthics, deaiing with social justice and diversity issues, strengthening theprofessionai identity of counseiors, and ensuring competence in providingservices within a ciimate of change.

The environment in which counseling is practiced is complex and everchanging, and new ethical issues are constantly emerging. This makes itdifficult for even the most ethically conscientious practitioners to keep

current. Gounselors look to the American Gounseling Association (2005)ACA Code of Ethics (hereinafter referred to as the Code), which represents theconsensus of the profession regarding ethical behaviors, as a primary sourceof guidance when they are confronted with ethical dilemmas. However, theCode may be of limited value when counselors seek guidance regarding newand emerging issues. Published codes cannot keep up with the pace of change;the Code typically is revised only once every 7 to 10 years (Herlihy & Corey,2006) and may not address cutting-edge issues around which no consensushas been achieved (Mabe & RoUin, 1986). As a result, counselors need to relyon other resources in order to maintain best standards of ethical practice.

Published research in ethics can be "particularly helpful for professionalstrying to cope responsibly with new and emerging areas of practice" andcan "provide an opportunity to consult with the most knowledgeable andexperienced scholars in the profession" (Welfel, 2006, p. 13). The purposeof this study was to obtain consensus of a Delphi panel of experts on whatthey believe to be the most important current and emerging ethical issuesfacing the counseling profession. The timing for such a study seemed to befortuitous, because the current iteration of the Code has been in place for4 years now and further revisions are unlikely to occur before 2012 at theearliest. We hoped that results of this study might point to areas of needed

Barbara Herlihy and Roxane L. Dufrene, Department of Educational Leadership, Counseling, andFoundations, University of New Orleans. Correspondence concerning this article should be addressedto Barbara Herlihy, Department of Educational Leadership, Counseling, and Foundations, Universityof New Orleans, 348 Education Building, 2000 Lakeshore Drive, New Orleans, LA 70148 (e-mail:bherlihy@uno.edu).

© 2011 by the American Counseling Association. All rights reserved.10 Counseiing and Vaiues • October 2011 • Voiume 56

research, which might in turn provide knowledge that would assist counsel-ing practitioners and inform future code revisions.

Three research questions guided this study:

Question 1 : What do experts believe are the most important ethical issuescurrently facing the counseling profession?

Question 2: What do experts believe are the most important emerging ethi-cal issues that the counseling profession will need to address duringthe next 5 years?

Question 3: Do experts identify social justice concerns as important currentand emerging ethical issues?

The last question was included in the study because counseling for socialjustice has risen to a place of prominence in the profession and is evidentthroughout the current Code. The ACA Ethics Code Revision Taskforce rec-ommended changes to the previous code, ACA's (1995) Code of Ethics andStandards of Practice, with a special focus on multiculturalism, diversity, andsocial justice (Kocet, 2006).

Method

The Delphi technique, which has long been supported in the literature as aconsensus-building method (Young & Jamieson, 2001), relies on the informedintuitive judgment of a panel of experts. Using mulfiple rounds of data coUecfionand analysis, the experts collect opinions on problems or issues that are difficultto quantify (Hekner, 1983). Through a series of quesfionnaires interspersed withcontrolled feedback on opinions derived from earlier rounds of responses, a con-sensus is generated (Davis, 1997). The number of rounds of data coUecfion canvary, although a three-round Delphi is typical (Skulmoski, Hartman, & Krahn,2007). The number of parficipants is determined by the number of individualswho have the required experfise and are willing to parficipate; the number canrange from as few as four to more than 170 (Skulmoski et al., 2007).

The Delphi technique uses written responses rather than bringing indi-viduals together for discussions and therefore is useful for engaging partici-pants who carmot come together physically. This format reduces potentialbias because participants are separate and unknown to each other. No twoDelphi studies are alike, and the method can be modified to respond to theneeds of the individual researcher (Davis, 1997). Because we were seeking theopinions of experts regarding current and future ethical issues in counseling,the Delphi technique seemed ideally suited for our purposes.

Participants

In a Dephi study, the decision-making population, or Delphi panel, mustconsist of individuals who are recognized as having high levels of relevant

Counseling and Values • October 2011 «Volume 56 11

expertise in the area being considered (Davis, 1997). To identify potentialexpert participants, we compiled a list of individuals who met at least oneof the following criteria: (a) served on the 2005 ACA Ethics Code RevisionTaskforce, (b) served as chair of the ACA Ethics Committee within the past5 years, (c) authored or coauthored major texts in counselor ethics, and (d)had established a record of published research in counselor ethics across arange of ethical issues. We believed that individuals with these specific typesof experiences would have given in-depth consideration to a wide spectrumof ethical issues. We identified 22 individuals, most of whom met more thanone of the criteria, who might serve as Delphi panelists.

Procedure

After obtaining institutional review board approval, we sent an invitationto participate in the study to the 22 potential participants by e-mail. Twentyindividuals responded to the invitation, all who agreed to participate in threerounds of data collection.

In Delphi studies, the initial questions typically are broad and open-endedso as to "widely cast the research net" (Skulmoski et al., 2007, p. 10). ForRound 1, participants were contacted by e-mail and asked to identify whatthey believed to be the most important ethical issues facing the counselingprofession today, and to identify the emerging issues they believed the profes-sion will need to address over the next 5 years. These broad questions wereused to capture as many issues as possible. Participants were instructed thatthey could include short, explanatory narratives for issues they identified, orthey could simply name issues they believed were self-explanatory. Informedconsent was obtained from each participant, and brief instructions wereprovided. Participants returned their responses by e-mail correspondence.

Round 1 generated a wealth of data. Although some panelists simplylisted issues they deemed important, other respondents wrote lengthy nar-ratives. To organize the data in preparation for Round 2, we separated theresponses into current issues and future issues categories. We then reducedthe data by creating themes within each category, merging responses undera single theme when multiple participants described the same issue in dif-fering words. For example, four responses under the first category, currentissues ("how multiple relationships can be managed rather than avoided,""managing boundaries in the counseling relationship," "avoiding personalrelationships that are harmful to clients," and "understanding potentiallybeneficial relationships"), composed the theme of managing boundaries/multiple relationships. Within the second category, future issues, threeresponses ("duty to warn issues with adolescents," "individuals who areat risk for suicide or violence," and "students engaging in suicidal or para-suicidal behaviors") composed the theme dealing with clients who pose adanger to self or others. Some themes included as many as nine individualresponses, whereas other themes reflected a single response. We noted that

12 Counseiing and Values " October 2011 "Voiume 56

a number of the responses named ethical issues that were specific to coun-selor preparation and training. This may have occurred because most of thepanelists were counselor educators. Therefore, we created the third category,counselor preparation issues.

We then created a survey instrument that listed the themes within the threecategories, with participant responses in their own words presented undereach theme. This detailed feedback was given so that participants wouldhave the full benefit of each other's thinking and so that participants wouldhave the opportunity to correct any misinterpretations of their meanings. Weformatted Round 1 responses into SurveyMonkey for ease of responding.Participants were asked to rate each of the themes based on a 5-point Likertscale ranging from strongly agree (5) to strongly disagree (1), indicating theirextent of agreement that the item was an important current ethical issue, anemerging ethical issue, or a counselor preparation issue.

To prepare a survey instrument for Round 3 after the Round 2 responseswere received, we calculated the means for each item (based on the 5-pointLikert scale) and arranged them in order from highest to lowest mean scorein each of the three categories. Because there were a large number of itemsin the first two categories of current issues and future issues (28 and 24,respectively) after Round 2, we reduced the number of themes. Within thecurrent issues category, 14 items were retained, with mean scores rangingfrom 4.00 to 4.56 (see Table 1). Fourteen items were also retained in the futureissues category, with means ranging from 3.88 to 4.53 (see Table 2). Withincounselor preparation issues, the number of items was smaller (seven); thefive items with a mean score of 4.00 or higher were retained (see Table 3).This reduction process created a more efficient survey instrument withoutlosing those themes considered most important by the Delphi panelists.

In Round 3, participants were contacted again by e-mail. A Microsoft Worddocument attachment was sent that contained the 14 themes under currentissues, 14 themes under future issues, and five counselor preparation issues.Participants were asked to identify the four most important themes in eachof the three categories, and to rank order them in the order of their impor-tance, with 1 = most important and 4 = fourth most important. Participants wereinstructed to return the Microsoft Word attachment by e-mail.

Results

Eighteen expert panelists responded to all three rounds of data collection. Aswas noted earlier, responses from Round 1 were organized into 59 themes:28 themes for the current issues category, 24 themes for the future issuescategory, and seven themes for the counselor preparation issues category.For Round 2, participants were asked to rate the extent of their agreement,using a 5-point Likert scale, that each theme was an important issue withineach of the three categories. Descriptive statistics, including mean scores,were calculated for all 59 themes. For the final round, the number of items

Counseiing and Values « October 2011 «Voiume 56 13

TABLE 1

Current Issues: Results for Rounds 1,2, and 3Round 1 Round 2 Round 3

Category 1 : Current Issues Themes n

4

13

3

24

4

4

42

71

3

IV)

2

1

1

3

1

2111

1

11

11

M

4.44

4.174.33

4.33

4.564.39

4.50

4.00

4.114.11

4.064.06

4.22

4.22

3.94

3.89

3.78

3.72

3.72

3.673.593.563.50

3.50

3.393.33

3.283.00

SD

0.62

0.790.69

0.77

0.620.92

0.71

0.97

0.470.76

0.731.00

0.88

1.00

1.11

0.90

1.11

0.83

1.18

1.031.020.860.79

0.86

0.981.14

0.961.14

n

11

77

9

65

6

5

43

43

1

1

Sum

38

2119

18

1414

13

11

98

65

1

2

Rank

1

23

4

1. Ensuring that counselors practiceethicaliy/abide by the code

2. Strengttiening the professionai identityof counseiors

3. Determining boundaries of competence4. Practicing with muiticuiturai

competence5. Wortdng with clients who pose a danger to

self or others6. Managing confidentiality7. Managing boundaries/multiple

relationships8. Addressing issues of social justice and

advocacy9. Dealing with diagnosis and third party

payments10. Ensuring access to care11. Dealing with advances in technology and

cybercounseling12. Committing to counselor self care13. Managing confidentiality with minor

clients14. Dealing with issues related to informed

consent15. Dealing with conflicts between law and

ethics16. Dealing with the changing nature of the

family17. Helping counselors understand that

ethics is meant to guide their ownbehavior, rather than judging thebehavior of other counselors

18. Managing relationships with other mentalhealth professionals and paraprofessionals

19. Counseling clients on end of life decisionmaking

20. Addressing religious/spiritual issues withclients and each other

21. Child custody issues22. Managing conflicts with business goals23. Conflicts of interest24. Issues raised when services are

delivered in nonoffice, off-site settings25. Generational differences in how clients

want to access and participate incounseling

26. Decline of membership in ACA27. Counseling researchers may be in

conflict about the cultural validity of theirsampling, assessment, and design

28. Use of sliding fee scalesNote. /V= 18. Round 1: n = the number of participants who endorsed the theme in Round 1.Round 2: the first five themes were selected for Category 3. Round 3: n = number of participants whoendorsed the theme at any ranking. Boldface indicates themes with the four highest rankings. Sum= sum of each rankings, where 4 = most important to 1 = fourth most important. Rank = ranking oftheme based on the largest sum score; ACA = American Counseling Association.

14 Counseling and Values » October 2011 »Volume 56

TABLEFuture Issues: Results foi

Category 2: Future Issues Themes1. Dealing with sociai justice and

diversity issues2. Being accountabie for measuring

effectiveness of counseling3. Serving emerging popuiations and

deaiing with issues created bymedicai advances

4. iUlanaging diagnosis and changingconcepts of mental health

5. Dealing with new and emergingtechnoiogies

6. Ensuring continuing professional growth7. Deaiing with licensure issues8. Working with clients who pose a danger

to self or others9. Maintaining confidentiaiity

10. Deaiing with issues reiated to the globai-ization of counseling

11. Responding to needs created by theeconomic crisis

12. Promoting counselor seif care13. Dealing with complexities of supervision14. Managing boundaries/dual relationships15. Planning for code revisions16. Educating consumers17. Dealing with changing family systems18. Maintaining ethicai research practices19. Dealing with chiid custody issues20. Coping with business demands21. Differentiating between coaching and

counseiing22. Dealing with counseior involvement in

legal system23. Promoting social consciousness24. Determining ethics of brief therapy

n

9

1

6

2

712

33

4

5114111212

1

211

2r Rounds 1,2,

Round'M

4.29

4.12

4.06

3.88

4.003.883.94

4.534.18

4.06

3.944.124.184.353.763.763.763.713.653.59

3.53

3.413.293.06

1SO

1.05

0.96

0.83

0.60

0.710.780.66

0.621.02

0.97

1.030.930.730.790.970.970.900.771.000.87

1.13

0.871.110.93

and 3Round 2 Round 3n

10

7

8

9

745

43

5

4222

Sum Rank

28 1

20 2 (tie)

20 2 (tie)

18 4

161514

1210

8

8643

Note. A/= 18. Round 1: n = the number of participants who endorsed the theme in Round 1.Round 2: the first five themes were selected for Category 3. Round 3:n = number of participants whoendorsed the theme at any ranking. Boldface indicates themes with the four highest rankings. Sum= sum of each rankings, where 4 = most important to 1 = fourtti most important. Rank = ranking oftheme based on the largest sum score.

was reduced to include only those that had the highest mean scores afterRound 2. In Round 3, the final round of data collection, participants rankedthe top four themes in each of the three reduced categories.

For the final round, the four most important themes for each categorywere calculated. To facilitate readability and understanding of the results,we reverse-scored the rankings. For example, an item ranked by participantsas 1, most important, was reverse-scored to a 4. To derive the sum score foreach item, each ranking was multiplied by the number of respondents whogave the item that rank, and the scores were then totaled. For example, forTheme 5 in the current issues category ("working with clients who pose a

Counseling and Values • October 2011 »Voiume 56 15

TABLECounselor Preparation Issues

Category 3: Counselor Preparationissues Themes

1.2.3.4.

5.

6.

7.

Teaching ethicai decision makingGatekeeping for the professionDefining our professionai identityiViodeiing appropriate reiationships incounseior education programsFostering the personal development ofstudentsTraining for counselor educators in socialjustice and advocacyThe burgeoning of online trainingprograms

3;: Results for Rounds

n262

1

2

1

1

Round 1M

4.564.724.39

4.44

4.00

3.78

2.78

SD0.620.460.78

0.71

0.84

1.11

1.06

1,2, and 3

Round 2n

181613

14

11

Sum573837

28

20

Round 3Rank

123

4

Note. A/ = 18. Round 1: n = the number of participants who endorsed the theme in Round 1.Round 2: the first five themes were selected for Category 3. Round 3: n = number of participants whoendorsed the theme at any ranking. Boldface indicates themes with the four highest rankings. Sum= sum of each rankings, where 4 = most important to 1 = fourth most important. Rank = ranking oftheme based on the largest sum score.

danger to self or others"), the total was calculated as follows: 1st ranked= zero responses ( 0 x 4 = 0), 2nd ranked = three responses ( 3 x 3 = 9), 3rdranked = two responses ( 2 x 2 = 4), and 4th ranked = one response ( 1 x 1 =1) for a total score of 14 for the six responses (see Table 1).

Current Issues

Ensuring that counselors practice ethically and abide by the code was thecurrent ethical issue deemed most important by the experts. More than half(n = 11,61%,) of the participants ranked this item; eight of the 11 experts whoselected this theme ranked it "most important," which contributed to its highsum score of 38 (see Table 1). Sum scores for the remaining three of the topfour current issues ranged from 21 to 18, indicating that the panelists viewedthese issues as being similar to each other in importance. Strengthening theprofessional identity of counselors was ranked 2nd; this theme was rankedby seven of the 18 participants (39%) and had a sum score of 21. Determiningboundaries of competence was ranked 3rd; seven participants (39%) rankedthis item, and its sum score was 19. Finally, practicing with multiculturalcompetence was ranked 4th most important; 50% (n = 9) of the participantsselected this item, which had a sum score of 18.

Three other themes had mean scores among the top four after thesecond round and continued to receive relatively strong endorsementsin the final round. These three themes were working with clients whopose a danger to self or others, managing confidentiality, and managingboundaries/multiple relationships, with sum scores of 14, 14, and 13,respectively (see Table 1).

16 Counseling and Values • October 2011 »Volume 56

Future Issues

Dealing with social justice and diversity issues emerged in the final roundas the most important future issue, with 10 (56%) of the participants rank-ing this theme as one of the four most important for a sum score of 28 (seeTable 2). As was found in the current issues category, the sum scores for thesecond, third, and fourth most important themes were closely clustered (20,20, and 18, respectively), indicating that the experts viewed these issues asbeing similar in relative importance. Being accountable for measuring theeffectiveness of counseling, and serving emerging populations and dealingwith issues created by medical advances were tied for second ranking withseven participants (39%) and eight participants (44%) ranking these twothemes as important, respectively. The fourth most important theme, rankedby 50% (n = 9) of the participants, was managing diagnosis and changingconcepts of mental health. Other future issues that also retained relativelystrong endorsements through the third round included dealing with newand emerging technologies, ensuring continuing professional growth, dealingwith Iicensure issues, and working with clients who pose a danger to self orothers, with sum scores of 16,15,14, and 12, respectively.

Counselor Preparation Issues

After the final round, there was consensus that teaching ethical decisionmaking is the most important issue in counselor preparation; all 18 expertsassigned it a ranking resulting in a sum score of 57. The theme rankedsecond most important, by 16 (89%) of the participants, was gatekeepingfor the profession, with a sum score of 38 (see Table 3). Other themes thatwere strongly endorsed were defining counselors' professional identity (n= 13, 72%) and modeling appropriate relationships in counselor educationprograms {n - 14, 78%), with sum scores of 37 and 28, respectively.

Discussion

Several themes were rated by the panelists as important ethical issues inmore than one of the three categories. These recurring themes were ensuringethical practice, addressing social justice and diversity, strengthening theprofessional identity of counselors, and ensuring competence in providingcotmseling services. An overarching theme that seemed to encompass most ofthe issues identified by the experts across all three categories was a concernfor maintaining best practices within a climate of change.

Ensuring Ethical Practice

According to the panelists, "ensuring that counselors practice ethicallyand abide by the code" is the most important ethical issue currently

Counseiing and Vaiues " October 2011 "Voiume 56 17

faced by the counseling profession. In the initial round, this issue wasidentified by four panelists who expressed concerns that our profes-sion is not doing a good job of helping counselors understand ethicalbehavior and demonstrate it in practice and that most violations are notaddressed by licensing boards, professional associations, or colleagues.This latter issue has been discussed in the literature. Most violationsgo unreported (Welfel, 2006), and counselors generally are reluctantto confront or report the unethical behaviors of their peers (Bernard& Jara, 1986; Lowman, 2006). These findings are worrisome not onlybecause of the continuing harm that may be caused to clients but alsobecause public trust is based on a belief that counselors hold their fel-low professionals to acceptable standards of ethical behavior (Herlihy& Corey, 2006; Remley & Herlihy, 2010).

The panelists did not identify specific ethical behaviors they believedcounselors may fail to understand and demonstrate in practice; how-ever, researchers have investigated the types of ethical violations thathave been reported most frequently to state counselor licensure boards(Neukrug, Healy, & Herlihy, 1992; Neukrug, Millikin, & Waiden, 2001).Neukrug et al. (2001) found that the most frequent complaints made tostate licensing boards were (in descending order of frequency) inappro-priate dual relationships, incompetence, practicing without a license ormisrepresenting one's qualifications, sexual relationships with clients,and breach of confidentiality. The Delphi panelists identified issuesrelated to these behaviors, including managing boundaries/multiplerelationships, determining boundaries of competence, and maintainingconfidentiality, as important ethical concerns both in current practiceand in the future.

Given the high priority assigned to ensuring ethical practice, it is notsurprising that the panelists selected "teaching ethical decision making"as the most important issue in counselor preparation. The importanceof professional judgment when confronted with ethical dilemmas hasbeen underscored (Cottone & Tarvydas, 2007), and numerous ethicaldecision-making models have been described (see Cottone & Claus, 2000).However, it appears that little research has been conducted to determinehow professional judgment is taught or which models (if any) practitio-ners actually are using or whether they find these models to be helpful.Despite the energy expended in designing ethics courses, the effectsof instruction on ethical development of students and counselors havenot been documented. A large amount of research has been generatedregarding counseling students' and professionals' perceptions of ethicaldilemmas, but even the most recent studies have relied on self-reportquestionnaires or surveys (Bodenhorn, 2006; Helbok, Marinelli, & Walls,2006; Zakrzewski, 2006). Hill (2004) suggested that counselor educatorsfirst assess their "baseline of information" (p. 183) regarding curriculaand current ethics teaching methods.

18 Counseiing and Vaiues «October 2011 «Voiume 56

Addressing Social Justice

When our experts looked to the future, they ranked "dealing with socialjustice and diversity" as the most important emerging ethical issue withwhich counselors will need to deal with over the next 5 years. This futureissue was given a high priority by the experts consistently throughout thethree rounds of data collection: It was named by more panelists than anyother future issue in the initial round, remained among the top three issuesin Round 2, and emerged as the top ranked issue in the final round. Partici-pants expressed a need for counselors to participate more fully in advocacyand social justice efforts, both globally and within our own demographicallychanging society. They were concerned about issues such as discriminationagainst gay, lesbian, bisexual, transgender, and queer clients and the potentialfor more value clashes with clients as societal diversity increases.

Social justice was also present as a current issue, although it did not receiveas high a ranking in that category. In the current issues category, "practicingwith multicultural competence" (ranked 4) and "addressing issues of socialjustice and advocacy" (ranked 8) were presented as separate themes. If thetwo themes had been merged and presented as a single option, a higherranking might have resulted for social justice/multicultural counseling asa current issue. Although social justice was not ranked in the final round asa counselor training issue, it was one of the seven themes that were presentin Rounds 1 and 2. Recent literature has begun to identify issues that informthe development of ethical understanding from a social justice perspectiveand that need to be included in counselor training curricula (Pack-Brown,Thomas, & Seymour, 2008).

Strengthening Professional Identity

Concerns related to defining and strengthening the professional identityof counselors emerged as both an important current issue (ranked 2) andas an issue in counselor preparation (ranked 3). In Round 1, professionalidentity issues were named by only one panelist as a current issue, andby one panelist as an issue in counselor preparation. One expert wroteabout the need for counselors to "strengthen our professional identityso that we can confidently take our place at the table with other mentalhealth professions." A second panelist emphasized the importance oftraining counselors who provide "positive, developmentally sensitive,wellness-oriented services and interventions" and of defining our uniqueidentity rather than competing for the rights to do psychological testingor prescribe medications. The high rankings assigned to this issue in thefinal round demonstrate the consensus-building process that can occur ina Delphi study, when rounds of controlled feedback inform panelists ofeach other's perspectives and provide them with opportunities to changetheir views (Skulmoski et al., 2007).

Counseling and Values » October 2011 »Volume 56 19

Ensuring Competence in Counseling Practice

Competence in counseling is difficult to define, because it is a complex con-cept with many possible levels along a continuum (Remley & Herlihy, 2010).Evaluating competence of counselor trainees, or "gatekeeping for the profes-sion," was ranked 2nd among the ethical issues in counselor preparation. Inthe initial round, panelists highlighted some of the difficulties inherent inthe gatekeeper role, such as evaluating trainee competence/incompetence,lack of appropriate oversight in counselor education programs that leadsto incompetent graduates, and dealing with students who lack the personaland interpersonal competencies to become effective counselors. Multiplemodels for gatekeeping and dismissing students from counselor educationprograms are available (Dufrene & Henderson, 2009). These models conformto the requirements of the Code but have not yet provided details on exactlyhow remediation should occur.

Counselor educators and supervisors are responsible for evaluating compe-tence of trainees, but professional counselors are responsible for determiningtheir own boundaries of competence (Remley & Herlihy, 2010). "Determiningboundaries of competence" was ranked the third most important currentissue in the final roimd. Counseling practitioners struggle with balancingtheir dual responsibilities to practice only within the boundaries of theircompetence (ACA, 2005, Standard C.2.a.) and at the same time to stretchthose boundaries of competence. Counselors are obligated to develop skillsin new specialty areas including skills pertinent to working with a diverseclient population, but they must ensure the competence of their work asthey develop and practice these new skills (ACA, 2005, Standards C.2.a. &C.2.b.). The panelists noted the challenges for counselors of accurately as-sessing their level of competence and of being asked in their work settingsto perform tasks they do not feel competent to perform.

Maintaining Best Practices in a Climate of Change

The reality that counseling is a relatively new and evolving mental healthprofession is reflected in our experts' judgments regarding the importanceof establishing our professional identity and of increasing our ability toensure that counselors practice ethically and abide by the Code. The emer-gence of advocating for social justice as a priority in the profession addsnew dimensions to ethical issues that have long been a focus of concern andresearch. For example, practicing with multicultural competence becomesa more challenging mandate as the diversity of our society increases, andtraditional injunctions against shifting boundaries and engaging in multiplerelationships need to be revisited when working with diverse populations(Herlihy & Corey, 2006).

The changing climate in which counseling is practiced raises some newethical questions that were identified by our experts. According to the pan-

20 Counseling and Vaiues " October 2011 "Volume 56

elists, important issues the profession will need to address over the next 5years are serving emerging populations and dealing with issues created bymedical advances (tied for ranking 2), being accountable for demonstrat-ing the effectiveness of counselors (also tied for ranking 2), and managingdiagnosis and changing concepts of mental health (ranked 4).

Biomédical advances in areas such as genetic testing, life-sustaining tech-nologies, and HIV and AIDS care raise new ethical issues for counselingpractitioners (Cottone & Tarvydas, 2007; Remley & Herlihy, 2010). The Del-phi panelists noted that as the U.S. population continues to age, counselorswill be called on to assist clients with end-of-life decision making and otherlongevity-related issues. They also predicted that there will be an increasedneed for services to emerging populations, such as immigrants; veteransand their families; people affected by war, the economic crisis, and addic-tions; and other types of trauma, crisis, and catastrophe. These phenomenaaffect mental well-being and family stability, and they present challengesto maintaining cultural competence that counselors will need to address incoming years (Arredondo, Tovar-Blank, & Parham, 2008).

As reported by Schmacher (as cited in Rollins, 2007), the issue of account-ability today and in the future is at the forefront of professional dialogue.As a result of increased state and federal legislation and regulation of healthcare and managed care, more accountability is being required. Issues identi-fied by Schumacher refiected the types of knowledge that are needed to helpcounseling professionals adapt to accountability requirements. Increasingly,it will be important for counselors to evaluate how counseling outcomes(particularly client outcomes) are affected by the implementation of coun-seling interventions. As one expert panelist stated in this study, counselorsneed to know what interventions are effective and how they work, and howthis knowledge affects practice.

Participating in diagnosis continues to be an arena fraught with ethicalquandaries for counselors, whose orientation to Wellness and social justicecan create conflicts with the prevailing values of managed mental healthcare (Danzinger & Welfel, 2001; Herlihy, Watson, & Patureau-Hatchett,2008; Kress, Eriksen, Rayle, & Ford, 2005; Zalaquett, Fuerth, Stein, Ivey, &Ivey, 2008). The Delphi panelists noted the difficulties of reconciling theWellness orientation of counselors with Diagnostic and Statistical Manual ofMental Disorders diagnosis and of dealing truthfully with third party payers.They also expressed concern about the consequences of diagnosis on clientdevelopment and treatment.

Implications and Recommendationsfor Further Research

Some limitations to this study should be noted. First, expert panelists whodid not participate in this study might have identified other ethical issuesand might have ranked them differently. We attempted to minimize the

Counseling and Values • October 2011 »Volume 56 21

effects of this potential limitation by choosing appropriate and multiplecriteria for eligibility to participate. Additionally, the trustworthiness of ourfindings is strengthened by the fact that all 18 expert panelists participatedin all three rounds of data collection. Second, a greater consensus of theexperts might have been achieved if additional rounds of data collectionhad been conducted. It was evident that panelists did change their viewsafter reviewing the input of their colleagues. However, as Helmer (1983)has noted, complete convergence of opinions carmot be expected because ofthe uncertainties of predicting the future and because results are based onthe intuitive judgments of experts rather than verifiable facts. We were alsoaware that response rates decrease when the number of rounds increases(Skulmoski et al., 2007).

Kaplan et al. (2009) discussed specific new mandates that were added tothe Code to assist counselors with managing ethical dilemmas that arise indifficult areas of practice. Future researchers might investigate whether thesenew provisions in the Code are indeed providing useful guidance to coun-selors as they encounter ethical quandaries in their work. For example, doesthe Code's increased attention to cultural sensitivity provide useful adviceto counselors in dealing with social justice and diversity, which the Delphipanelists identified as the most important ethical issue that counselors willconfront over the next 5 years? Has the requirement that treatment modalitiesmust have a scientific basis helped counselors to be more accountable formeasuring the effectiveness of coimseling (ranked 2 among future issues)?Are the new standards on end-of-life care helping counselors better serveemerging populations and deal with issues created by medical advances(ranked 3)? Do the additional standards on diagnosis clarify counselors' re-sponsibilities related to managing diagnosis and changing concepts of mentalhealth (ranked 4)? Does the expanded section on technology applicationsassist counselors as they deal with new and emerging technologies (ranked5)? The term dual relationships was elimiriated from the Code's language, andthe standards now allow counselors to interact with clients outside of coun-seling sessions under certain conditions. Does this change in language clarifya confusing issue so that counselors are better able to manage boundaries/dual relationships (ranked 7)? Finally, according to the Code, confidentialitymay be broken in cases when there is serious or foreseeable harm to a clientor others. Is this standard proving useful to counselors as they work withclients who pose a danger to self or others (ranked 8)?

Results of this study suggest several additional questions that might beaddressed by future researchers: How well do consumers understand theunique professional identity of counselors? How well do practicing coun-selors understand the appropriate procedures (as recommended in the Code)for dealing with unethical behaviors of a colleague? What are the factorsthat discourage them from taking action? To what extent are counselingpractitioners engaging in advocacy for their clients and for the profession?What are the ethical issues inherent in international/global counseling? As

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the complex climate in which counseling is practiced continues to change,are new and unforeseen types of ethical violations occurring? The Neukruget al. (2001) study might be updated to investigate what types of complaintsstate counselor licensure boards are receiving in the 21st century.

The results of this study suggest several implicafions for counselor educators.Counselor educators need to continue to explore how ethical decision making isbeing taught, what models are being promoted, and how effective these modelsare in helping prospecfive coimselors reason through ethical dilemmas. Giventhe importance assigned by the Delphi panelists to addressing issues of socialjustice and to strengthening our professional idenfity, we need to ensure thatcounselor educafion graduates know how to advocate for their clients and forthe profession and that counselor educators are teaching advocacy skuls acrossthe curriculum. Finally, we suggest that coimselor educators can provide lead-ership by partnering with pracfifioners to produce more rigorously designedoutcome studies that demonstrate the effectiveness of counseling.

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