Ethical issues arise from time to time, and when they do, it is often best to seek additional guidance. Members of the NHMHCA board are always available to assist in what may be a very stressful time for any member, depending on the situation. All you need to do is email a member of the board and explain the situation as best you can. We never know where this might lead us; we may have more questions and have a need to reach out to you, so please
 include complete contact information.

Ethics Thoughts 

 Traci Belanger, LCMHC, NCC, Ethics Chair for NHMHCA


One topic I believe often takes up real estate in the back of our “ethical brains” is our duty to warn others if our client presents as a danger to self or community. Few of us want to openly think or talk about this issue – it’s disturbing and anxiety provoking – yet it is a subject which surfaces during ethics and quality control workshops again and again.

I’ve noticed this specific topic has popped up on several ethics listserves of late, so I thought I would give some basic information, but more than anything this is a topic we need to have an answer quickly when needed. The average Clinical Mental Health Clinician may find him or herself in such need of this information at any time. Clinicians who work with more chronic and severely challenged populations might have this thought in mind more often than the private practitioner who sees less severely challenged clients on a short-term basis, but no matter your placement, you at some point may need to decide whether the situation in front of you rises to the level of Duty to Warn.

The below information is a combination of information from the State of NH’s Board of Mental Health Practice ( ) , CPH’s “Avoiding Liability Bulletin” and AMHCA’s code of ethics ( ) .

Our clients’ confidentiality is a precious commodity. We are sometimes working with clients whose trust has been broken time and time again. Having the courage to share disturbing information may emerge during the first session, or sometimes the eleventh. What we as clinicians do with that information is of utmost concern to them. Yet, if we hear that our client is harboring serious thoughts of harming themselves, we find this a less stressful and confusing situation than hearing them clearly comment on intent toward harming others.  There is not enough space here to talk about all of the subtleties surrounding this topic – and again, please be aware that as your board, NHMHCA is not giving specific information for answers to any of these ethical conundrums, nor do we tell any member to act in a certain way, just because of our suggestion. We strongly suggest each clinician take the time to figure out what s/he feels s/he would need to do PRIOR to finding yourself in such a situation.  But here are some things to think about:

Board of Mental Health Practice:

330-A:35 Civil Liability; Duty to Warn

1.      “Any person licensed  under (the state) has a duty to warn of, or take reasonable precautions to provide protection from, a client’s violent behavior when the client has communicated to such licensee a serious threat of physical violence against a clearly identified or reasonably identifiable victim or victims or a serious threat of substantial damage to real property.”

2.      “The duty may be discharged by, and no monetary liability or cause of action shall arise against, any person licensed under this chapter if the licensee makes reasonable efforts to communicate the threat to the victim or victims, notifies the police department closest to the client’s or potential victim’s residence, or obtains civil commitment of the client to the state mental health system.”

3.      No monetary liability and no cause of action may arise concerning client privacy or confidentiality against any person licensed under this chapter for information disclosed to third parties in an effort to discharge a duty under paragraph II.


1.       “Each state treats the subject matter of dangerous patients according to its own statutes and case law…” 

Be sure that you know what the precise duty is in your state, when the duty is triggered, whether or not there is an immunity from liability statute in your state, and if so, what actions must be taken in order to be entitled to the immunity available (see NH’s above)”.

2.       In the state of California, “no cause of action shall exist, unless the patient communicates to the therapist a serious threat of physical violence. Such a provision limits the burden upon therapists to ‘predict’ violence.” (This is a good discussion to have with your insurance carrier prior to having an incident).

AMHCA:  Code of Ethics (2015) Section 2, Confidentiality part C & E:

1.       “The release of information without consent of the client may only take place under the most extreme circumstances: the protection of life (suicidality or homocidality), child abuse, and/or abuse of incompetent persons and elder abuse. Above all, mental health counselors are required to comply with state and federal statues concerning mandated reporting.”

2.        “The anonymity of clients served in public and other agencies is preserved, if at all possible, by withholding names and personal identifying data. If external conditions require reporting such information, the client shall be so informed.”

Once again, this information is listed to give each clinician food for thought around this extremely delicate and potentially detrimental situation. Please use the links above to inform yourself about such situations and discuss these issues with your employer, your supervision team, and your insurance agents. I again also want to quickly plug for members to not only attend the NHMHCA workshops, but also to join our open meetings as we really do want to know what everyone is doing out there. Until next time, let your ethics be your umbrella, so be careful there are no holes!


“Pssssst, your URL is Showing: the Ethics of Media Management”

By Traci Belanger, LCMHC, NCC


            Hello everyone, my name is Traci Belanger and I’m your newly elected Ethics Chair. I’ve had many positions with the board since joining NHMHCA 20 years ago, including Member-at-Large, Professional Development Chairperson and Secretary to the board, which I just recently left to become your Ethics Chair.

            I’m hoping to use this space in The Collaborator wisely by presenting articles to make you think. While there are many changes going on within our profession, and outside of our profession, which are rapidly creating muddied and murky ethical streams to cross, my hope is to give you a place to check in and read about some of the changes. I in no way shape or form have all of the answers on how to solve your own responses to such changes. However, I will hope to shed light on them hoping you will – with all apologies to Aretha Franklin - think.  This column is not a fix-it site, and many times I am learning just as much as all of you. But if I find some topics I believe are of importance to make you stop and think a moment, I will place those on display.

            For my first foray, I’d like to bring up media of all types. Let’s face it, we can’t get away from media. The Internet, “smart” phones, television, even for those who still listen to the radio in our vehicles, media is ubiquitous and invades nearly our every waking moment. Media creates new ways for clients to signal for our attention; inversely, we use media to advertise for new clients. But media can also be overwhelming, and - if left unchecked – can land us in ethical hot water.

            How do your clients contact you? Do you use e-mail? Cell phone messages? Linked-in? Facebook? Is your EMR (electronic medical record, just in case you honestly don’t know) encrypted? If you use an EMR, you probably have encryption; most of us do. Encrypting every computer (including laptops, Surfaces and notebooks) you use in your practice to keep your clients’ private information private is an absolute ethical must, and I dare say very few of us do not subscribe to at least one, if not three, ways of keeping those files safe.

            But what about that “smart phone”? Did you know that by most ethical standards – including AMCHA – any device you use to talk to clients should be encrypted? It should. Yet I know of many clinicians who receive text messages from their clients or use the same phone to talk to clients and to do personal business. “Certainly a short phone call to check in or to reschedule someone is not unethical” I hear you say, “and I only have one phone.” Or suppose one day you find out a friend of a friend somehow became your friend on Facebook and is now your client. Do you secretly unfriend them? Do you leave it alone and hope your feed doesn’t come up on their feed? Do you spend a session explaining why it is not acceptable for them to post a rant about their life on your feed expecting you to answer?

            One VERY easy solution to some of these quandaries is to add a social media paragraph to your Consent to Treat document. How you decide to conduct your media relations is completely up to you, but your clients in our media bloated society should have a clear picture of what you will and will not do. Making an appointment by text ok with you? Fine, just make the client aware of the phone involved and make them aware if the phone line is not encrypted. You feel comfortable making appointments by e-mail, but not carrying on conversations by e-mail, make that clear so that if the number of words you use to answer to a client’s paragraph long question can be counted on less than one hand, they do not feel chastised in some way. Laying out your boundaries up front will save you much frustration on both sides later on.

            Speaking of frustration, while it often appears as though the rest of the world can say anything it wants on Facebook, how much you present could be a simple matter of making sure your privacy controls are in place. Not sure how to do that? Ask the nearest 16 year old. Or, better yet, go to Facebook and look to the top of the page to the right. See where the picture of a lock is? Click on that. You can even have Facebook help you to go through a privacy check up on your account. Of course you want to share with your family and loved ones – that’s one of the reasons Facebook was created. But without privacy controls in place, it’s easy for information we’d prefer to keep private to become public, including what petitions you may have signed and what groups send you their newsfeed.

            These are two simple and very easy ways to tighten up your media security. There are many more and I will be saving those for future discussion. However, if you would like to share any of your favorite security measures, feel free to contact the newsletter and I will receive your comments and questions. If you feel there are ethical issues I need to spotlight, please feel free to send me that information as well. I also want to quickly plug for members to not only attend the NHMHCA workshops, but also to join our open meetings as we really do want to know what everyone is doing out there. Until next time, let your ethics be your umbrella, so be careful there are no holes!

 Posted 10-2016