Please no plagiarism and make sure you are able to access all resources on your own before you bid. Main references come from Murray, C., Pope, A., & Willis, B. (2017) and/or American Psychological Association (2014). You need to have scholarly support for any claim of fact or recommendation regarding treatment. APA format also requires headings. Use the prompt each week to guide your heading titles and organize the content of your initial post under the appropriate headings. Remember to use scholarly research from peer-reviewed articles that is current. Please follow the instructions to get full credit for the discussion. I need this completed by 02/26/19 at 7pm. 

Discussion – Week 1

Ethical Implications of Historical Trends

Societal attitudes toward human sexuality change over time, sometimes gradually and sometimes more rapidly. For example, consider how controversial some of the work of Alfred Kinsey was in the 1940s and 1950s, even though many of the topics he addressed would be considered tame by today’s standards (indeed, some viewed his work as controversial simply because he was talking about taboo subjects). As another example, homosexuality was included as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until 1973. Today, many people would consider such an inclusion to be discriminatory, biased, and oppressive.

In this week’s Discussion, you consider how historical trends intersect with current understandings of competent, ethical practice in sexuality counseling. To prepare for this assignment, choose one historical perspective regarding sex and sexuality that has changed over time. Think about how this perspective change impacts the role of sexuality counselors, especially in regard to ethical considerations.

With these thoughts in mind:

Post by Day 4 an example of a change in historical perspective regarding sex and sexuality that impacts the role of sexuality counselors. Explain how this impact might have ethical implications for the practice of sexuality counseling today. Be specific and provide references to the American Association of Sexuality Educators, Counselors, and Therapists (AASECT) and/or American Counseling Association (ACA) codes of ethics, especially in reference to issues surrounding boundaries and sexual contact with current or former clients.

Be sure to support your postings and responses with specific references to the Learning Resources.

Required Resources

Course Text: Murray,      C., Pope, A., & Willis, B. (2017). Sexuality counseling:      Theory, research, and practice. Thousand Oaks, CA: Sage

Chapter 1, “Addressing Sexuality in Professional       Counseling”

Article: American      Association of Sexuality Educators, Counselors, and Therapists. (2008). Code      of ethics. Retrieved from http://www.aasect.org/code-ethics

Article: American      Counseling Association. (ACA). (2014). ACA Code of Ethics. Retrieved      from http://www.counseling.org/docs/ethics/2014-aca-code-of-ethics ?sfvrsn=4

Article: Berry,      M. D., & Lezos, A. N. (2017). Inclusive sex therapy practices: A      qualitative study of the techniques sex therapists use when working with      diverse sexual populations. Sexual and Relationship Therapy, 32(1),      2–21. Retrieved from the Walden Library databases.

Article: Southern,      S., & Cade, R. (2011). Sexuality counseling: A professional      specialization comes of age. The Family Journal, 19(3),      246–262. Retrieved from the Walden Library using the SAGE database.

Inclusive sex therapy practices: a qualitative study of the
techniques sex therapists use when working with diverse
sexual populations

Michael D. Berrya,b and Anastasia Natasha Lezosc

aSex and Couple Therapy Service, McGill University Health Centre, Montreal, Canada; bLaboratory for the
Biopsychosocial Study of Human Sexuality, Department of Psychology, McGill University, Montreal, Canada;
cDepartment of Counselling Psychology, McGill University, Montreal, Canada

ARTICLE HISTORY
Received 18 August 2015
Accepted 22 April 2016

ABSTRACT
Attention to the clinical needs of diverse client populations, including
lesbian, gay, bisexual, trans* and queer (LGBTQ) clients, openly non-
monogamous clients, and bondage and discipline, sadism and
masochism (BDSM) lifestyle clients, has grown in recent years. This
study reports interview-based qualitative research findings, from a
sample of sex therapy specialists and subject-matter experts (n D 34),
on key clinical principles and practices used in the treatment of such
diverse client groups. Three clinical principles are identified: therapist
self-reflection, client-affirmation, and normalizing. Core clinical
techniques to support these overarching principles are then
described and discussed. The utility of such techniques, and relevant
treatment considerations in inclusive sex therapy practice with
diverse clients, are evaluated in relation to interview data.

KEYWORDS
Sex therapy; LGBTQ; inclusive
psychotherapy; diversity;
minority clients

Introduction

It has been argued that a substantial proportion of research and clinical literature on sex
and marital therapy assumes a heterosexual and dyadic default position. While much clin-
ical literature proposes that techniques effective in heterosexual relationships may be
applied to lesbian, gay, bisexual, trans* and queer (LGBTQ) populations, an overview of
relevant literature suggests that critical attention should be given to the generalizability of
heterosexual healthcare models, and the unique needs of diverse populations (Macdonald,
1998; Mayer et al., 2012; Spitalnick & McNair, 2005). As Barker and Langdridge argue,
research on sex therapy with sexually diverse and non-normative populations � including
LGBTQ and openly non-monogamous clients � is at a nascent stage in its development
(Barker, 2011; Barker & Langdridge, 2010a). Additionally, published research suggests
that psychotherapy generalists may often be undertrained in sexual psychotherapy and
uncomfortable addressing sexual issues with their clients (Haboubi & Lincoln, 2003).
With respect to LGB populations specifically, Evans and Barker hold,

CONTACT Michael D. Berry michael.berry2@mcgill.ca

© 2016 College of Sexual and Relationship Therapists

SEXUAL AND RELATIONSHIP THERAPY, 2017
VOL. 32, NO. 1, 2�21
http://dx.doi.org/10.1080/14681994.2016.1193133

mailto:michael.berry2@mcgill.ca

http://dx.doi.org/10.1080/14681994.2016.1193133

http://www.tandfonline.com

http://www.tandfonline.com

research over the past decade has consistently confirmed that the majority of therapists are ill-
equipped to work with lesbian, gay and bisexual (LGB) clients, having had little training on the
topic of sexuality, and often expressing a lack of knowledge about such clients (2010, p. 375).

Consequently, attention to the points of convergence and divergence between hetero-
sexual and non-heterosexual client groups are an important area for continued research.
In this area, clinicians and researchers alike have begun to evaluate the degree to which
best practices in sex therapy with normative (i.e. heterosexual, dyadically-partnered) client
groups can be generalized to more diverse client groups.

The unique needs of diverse and non-normative client groups, and the distinctive skills
and competencies psychosexual therapists require in their work with such populations,
are an important area for current and future study. As a means of researching such diverse
populations, it is held that semi-structured-interviews can be used to positive effect, and
can be useful in accounting for the facts that: “[1] people construct their reality and [2]
there are multiple, equally valid, socially constructed versions of ‘the truth’” (Hill et al.,
2005, p. 199). As Smith and Osborn write, in a semi-structured interview, “the respondent
shares more closely in the direction an interview takes, and the respondent can introduce
an issue the investigator had not thought of. In this relationship, the respondents can be
perceived as the experiential expert [sic.] on the subject and should therefore be allowed
maximum opportunity to tell their own story” (2003, p. 57). Within this research project,
we have used a semi-structured interview methodology, in order to identify the common-
alities of experience (Hill, 2012) amongst clinical practitioners working with diverse sex-
ual populations, and to explore the implications that these commonalities have for
clinical best-practices.

This qualitative research project evaluates the special competencies, and clinical practi-
ces sex therapists use in their work with non-normative client groups. The influence of
broad social norms of sex and gender, as applicable to the client and therapist alike, is dis-
cussed. The predominance of heterosexually oriented research and clinical literature, and
the impact of this model, as identified by research participants, is then addressed. Finally,
we describe a set of key clinical principles, which we have designated as the foundations
of an “inclusive sex therapy” model that attempts to acknowledge sexual and gender
diversity in client populations. The foundations of this inclusive model include values
commonly observed in the contemporary psychotherapy field, such as nonjudgmentality
and self-reflective practice. Consequently, data from this study are described, which indi-
cate the prospective usefulness of specific counseling practices � including normalizing,
horizontalizing, and client-affirmation (Langdridge, 2007) � in work with diverse client
groups. The data gathered in this study suggest that widely-accepted, “common-sense”
strategies, if employed in an intentionally reflective and self-conscious manner, may sup-
port the implementation of inclusive practices in sex therapy.

Methodology

A series of open-ended verbal research interviews was conducted with sex therapy special-
ists, and subject matter experts, from March 2012 to October 2013.

Participants (n D 34) were recruited using a snowball-sampling method, and were
recruited based on their specialized clinical expertise (either research- or clinically-based)

SEXUAL AND RELATIONSHIP THERAPY 3

in sex and couple therapy. While the designations, professional licensure, and � in some
instances � the primary treatment orientation/model differs between participants, the
majority of interviewees are licensed practitioners in the sex and couple therapy speciali-
zation. Table 1 provides an overview of the clinical licensure, degree level, and declared
theoretical/clinical orientation of the interviewees who participated in this research. The
majority of respondents are educated to the PhD level, and were licensed as psychothera-
pists, or psychologists, at the time of interview.

The majority of interviews (n D 22) were conducted in an audio-only format (telephone,
or Skype-audio-only), while the rest were conducted in person (n D 10) or by Skype-with-
video (n D 2). 10 general questions were included, encompassing the domains of:

� the interviewee’s theoretical orientation,
� background and licensure, as well as prior clinical training and experience,
� client populations worked with,
� clinical techniques used when covering sexual material/content from a psychother-
apy vantage point,

Table 1. Interview participants’ licensure, degree level and theoretical orientation.
Interviewee Professional licensure Degree level Theoretical orientation

1 Licensed psychologist PhD Existential/humanistic; sex therapy
2 Licensed psychologist PhD Cognitive behavioral; integrative;

sex therapy
3 Sex coach PhD Sex coaching
4 Licensed psychologist PhD Cognitive behavioral; mindfulness;

sex therapy
5 Licensed psychologist PhD N/R
6 Registered psychotherapist PhD N/R
7 Registered psychotherapist N/R Integrative
8 Registered psychotherapist Masters Sex therapy; family therapy
9 Licensed marriage and family therapist Masters Sexual health model
10 Licensed psychologist PhD Psychodynamic
11 Licensed marriage and family therapist PhD Sex therapy
12 Licensed marriage and family therapist Masters Cognitive therapy
13 Registered psychotherapist Postgrad. diploma Psychosexual therapy
14 Licensed clinical social worker Masters Integrative and LGBTQQIAA-affirming
15 Registered psychotherapist Masters Psychodynamic psychotherapy
16 Psychiatrist Medical doctor Psychiatric
17 Licensed psychologist PhD Sex therapy
18 Licensed clinical social worker PhD Cognitive behavioural; eclectic; relational
19 Registered psychotherapist Masters Integrative; sex therapy
20 Registered psychotherapist Masters N/R
21 Registered psychotherapist Bachelor of nursing Cognitive behavioral; sex therapy
22 Psychiatrist Medical doctor Humanistic; medical; sex therapy
23 Licensed psychologist PhD Integrative; sex therapy
24 Registered psychotherapist Masters Psychosexual therapy
25 Registered psychotherapist N/R Sex therapy
26 Registered psychotherapist Bachelor of nursing Sex therapy
27 Licensed psychologist PhD Psychosexual therapy
28 Registered psychotherapist N/R Integrative; psychosexual therapy
29 Registered psychotherapist PhD Sex therapy; sexual health model; family

systems
30 Licensed psychologist PhD Gestalt; sex therapy
31 Licensed psychologist PhD Sex therapy; sexology
32 N/A (researcher only) PhD Human sexuality research
33 Registered psychotherapist Masters Analytical psychology; sex therapy
34 Licensed psychologist PhD Psychodynamic psychotherapy

Note: N/R D not reported, N/A D not applicable.

4 M. D. BERRY AND A. N. LEZOS

� alliances and integrative treatments (especially referral practices),
� experiences working with diverse and non-normative client groups, and
� core values and clinical methodologies recommended in working with non-norma-
tive client groups.

Interviews ranged in duration from 30 minutes to 90 minutes.

Researchers’ backgrounds and demographic details

Three researchers and one research supervisor participated in this research project. The
primary researcher developed the interview procedure, in consultation with the research
supervisor and with colleagues in a research seminar (see “Interview Methodology”
section, below, for more information).

The primary researcher is a white, cisgendered male in his early 30s, who identifies as
“hetero-flexible.” At the time of data collection, he was a PhD candidate in research psy-
chology at University College London. His research specialization is in sex and relation-
ship therapies, and treatment of sex- and gender-related issues; he identifies his primary
theoretical orientation as psychodynamic and existential. His core beliefs on the psycho-
therapeutic treatment of diverse client populations center on inclusivity, and diversity-
affirming practice.

Research Associate 1 is a Chinese, cisgendered female in her late 20s, who identifies as
heterosexual. At the time of data collection/analysis, she was a PhD candidate in experi-
mental psychology, specializing in mentalization- and attachment-theory. She was
recruited to assist with coding, and identified no prior expertise or preconceptions on the
specific topics evaluated in this research.

Research Associate 2 is a bi-racial, cisgendered male in his mid-20s, who identifies as
queer. At the time of data collection/analysis, he was a Masters student in counseling psy-
chology, specializing in clinical psychotherapy with HIV-positive men. He was recruited
to provide oversight for the coding procedure, and to act as an external auditor. He identi-
fies his main beliefs on the topic as centering on LGBTQ-affirmative practice.

The Research Supervisor for this project is a white, male, cisgendered professor in psy-
chology. He is in his 60s, and did not declare his sexual orientation. His primary theoreti-
cal background is in psychodynamic and attachment research. He identified no major
preconceptions on the specific topics evaluated in this research.

Interview methodology

A semi-structured verbal interview guide was used. This guide was developed by the first
author of this paper, and subject to a three-phase review process, involving: (1) peer
review, (2) supervisory review, and (3) subject expert review. The peer review process
involved the presentation of the research model, and the proposed interview guide to two
separate graduate student seminars in research psychology. Feedback was solicited from
seminar participants, and the interview guide was revised accordingly. The interview
guide was then subject to supervisory review by the research supervisor, and further
amended in accordance with his feedback � at this stage, the interview guide was short-
ened into a limited number of questions, and a more “open-ended” format was adopted.

SEXUAL AND RELATIONSHIP THERAPY 5

Finally, the review was subject to subject expert review. In this phase, three senior (i.e.
more than 10 years of licensed clinical practice) psychotherapists reviewed the interview
template, providing feedback for further revisions (these clinicians were not asked to
describe their sex/gender orientation, or their primary theoretical model).

The final interview guide served as a general template for each interview, after being
modified slightly on a case-by-case basis, based on the specific expertise of each inter-
viewee. Consequently, a semi-structured interview technique was used in which themes of
interest that arose in the dynamic interaction of the interview were explored. After each
interview, a supervisory meeting was held with the research supervisor, who verified that
the interview was topical and focused.

Data analysis method

Two data analysis methods were used conjunctively in analyzing the qualitative interview
data: grounded theory and thematic analysis. In analyzing the interview data, we adhered
to the grounded theory model developed by Glaser and Strauss (1967), and further elabo-
rated by Charmaz (2003, 2006). This method entails working “back and forth” between:
(1) the data obtained through interviews and (2) the underlying research theories and
interview praxis. This grounded-theory-based analysis entailed an ongoing process of crit-
ical and analytic reflection carried out throughout the course of the research project. This
grounded theory methodology, can be “described more appropriately…as ‘retroduction’
than as induction: a ‘double fitting’ or alternating shaping of both observation and expla-
nation, rather than an ex post facto discovery of explanatory ideas” (Katz, 2001,
pp. 333�334). This form of grounded theorizing allows for a dynamic relationship
between the collection and analysis of data (Bryant & Charmaz, 2007).

Thematic analysis was used to analyze the interview data, and identify themes/patterns
expressed by interviewees. As Boyatzis writes, “a theme is a pattern found in the informa-
tion that at minimum describes and organizes the possible observations and at maximum
interprets aspects of the phenomenon” (Boyatzis, 1998, p. 4). It is also asserted that the
themes produced through thematic analysis can be either inductive (deriving directly
from analysis of the data), or deductive (deriving from a prior theory or research)(Braun
& Clarke, 2006). Rather than an either-or methodology, however, Boyatzis has asserted
that this model can be considered on a continuum between theory-driven and data-driven
approaches. An inductive, data-driven coding model was used in this research project,
with the primary coder deriving the themes and codes from a close reading of the data,
and through inter-rater consultation.

Quality and trustworthiness in qualitative research: steps taken to ensure
reliability and validity of the data

A number of steps were taken to ensure the reliability and validity of the data. As Morrow
writes, the trustworthiness of qualitative data has several, trans-paradigmatic operational
criteria (2005). These criteria include:

� social validity,
� grounding in reflexive practice and measures to control for bias (including bracketing),

6 M. D. BERRY AND A. N. LEZOS

� adequacy of data, and
� adequacy of interpretation.

First, in order to ensure reflexive practice, and control against bias, the lead researcher
is engaged in a series of critical, phenomenologically based bracketing exercises, following
the bracketing model developed by Fischer (2009). These exercises were designed to help
him: (1) identify his biases and preconceptions and (2) “shelve” these biases through criti-
cal self-reflection � especially critical journal-writing, and regular consultation with the
research supervisor for this project.

To ensure reliability, after initial themes and codes were developed, the coding system
was revised, and reliability was confirmed through an assessment of inter-rater reliability.
In thematic analysis, inter-rater reliability is considered to be: the consistency of judgment
between multiple different raters. Research Associate 1 was recruited to assess inter-rater
reliability through double coding; both reviewers analyzed the same 20-page section of
interview transcripts, to identify possible codes. In this method,

each person makes judgments without interacting or seeing the judgments of the other
observer. Following the observation period or completion of the judgments, the two observ-
ers compare their results…the two observers [then] discuss each observation until agreement
is reached (Boyatzis, 1998, p. 151).

Through this method, a set of thematic codes was agreed between reviewers. A second,
20-page section of text was then assigned to each reviewer to code, using the pre-agreed
set of codes. Inter-rater reliability was calculated for agreement on the presence of each
code, between each reviewer. Cohen’s Kappa for inter-rater reliability was .72, which is
regarded as good (Ballinger, Yardley, & Payne, 2004). Finally, the primary researcher
developed a complete list of codes/themes, based on the content of all interviews.

Research Associate 2 was recruited to serve as an external auditor. He was recruited to
review the interview coding scheme/chart, and provided with summary/example state-
ments of the themes outlined in the coding scheme. This auditor provided qualitative
feedback on the accuracy and completeness of the complete coding chart. The auditor’s
feedback was provided both in-person, in a meeting with the primary researcher, and
Research Associate 1, and in writing. Overall, the auditor deemed the complete chart to
be consistent with the previously developed inter-rater chart, and accurate in reflecting
the themes/sub-themes in the interviews.

The explanatory notes written for each interview were used as a reflective practice tech-
nique to assess: the efficacy of the research method, the implications of interview content,
and in particular, the contributions made by both the interviewee and the interviewer. The-
matic analysis was used to analyze the interview data, and identify themes/patterns, related
to clinical practice with LGBTQ and other “diverse population” clients, as expressed by
interviewees. An inductive, data-driven coding model has been used in this research, with
the primary coder deriving the themes and codes from a close reading of the data.

Steps taken to ensure client confidentiality

Interviews were not administered � and are not reported � anonymously. Informed con-
sent for interviews specified that the interview participant would be cited, by name, as an

SEXUAL AND RELATIONSHIP THERAPY 7

academic source in any published findings. As this research project examined the practi-
ces of mental health professionals, case studies and clinical examples were common in the
interviews. A number of steps were taken to safeguard the anonymity and confidentiality
of interviewees’ patients/clients. Interview participants were asked to report on case mate-
rial anonymously, within the bounds of confidentiality. No content that could serve to
identity-specific clients was requested, and any such content was carefully screened and
removed from interview transcriptions.

Results: sexuality and normativity

Clients’ expectations about sex are identified as a crucial, defining element of the thera-
peutic process. Data from this study suggest clients’ expectations are shaped by sociocul-
tural influences. A number of interviewees suggest that such expectations may often take
the form of particular (especially, performance-based) expectations about sexual behavior,
which rely on a taken-for-granted view of the sexual response cycle. Additionally, the data
suggest that clients may often hold a narrowly delimited view of healthy sexuality and
appropriate sexual behavior. This “narrow view of what sex should involve” Barker
stresses,

leads to them trying to only do a certain kind of narrow range of things. And of course, if
those things don’t really do it for them, or if they become so tuned into the other person that
they can’t really tune into themselves at all—or what they might desire—because they have
to keep it in such a narrow range (research interview, March 30, 2012).

Furthermore, according to the data suggest that this narrow view of sexuality is largely
defined by the culturally pervasive assumption that healthy individuals tend to: (A) desire
to be sexually active (sub-theme 4-D) and (B) conform to a particular, well-defined set of
sexual behaviors (sub-theme 4-B). A number of interviewees appear to agree with a wider
body of published research, which holds that this circumscribed, culturally specific per-
spective tends to restrict normative standards of sexuality to a particular set of behaviors,
and a largely predetermined set of personal meanings, marked by:

� Heteronormativity � which privileges heterosexual relationships, implicitly or explic-
itly devaluing non-heterosexuality, (sub-theme 1-B; sub-theme 4-C).

� Mononormativity � which sets monogamous unions as the de facto standard for
sexual relationships,

� Presumption of male-active/female-passive sexuality.
� Presumption that the desire/drive to have sex is a necessary criterion of normal/
healthy (sub-theme 4-D) sexuality (which opposes asexuality, and pathologizes/stig-
matizes low levels of desire or sexual initiative)(Barker, research interview, March 30,
2012; Barker, 2005; Barker & Langdridge, 2010a, 2010b; Berry & Barker, 2014;
Braun-Harvey, research interview, November 15, 2012; Winn, research interview,
January 16, 2013).

This finding is linked to the thematic area of affirming client identities outside the nor-
mative range. The data from this study suggest that the pressure to conform to these cul-
turally sanctioned standards of sexual behavior is often an influential factor in the sex

8 M. D. BERRY AND A. N. LEZOS

therapy process, and that these normative pressures may influence both clients and thera-
pists (including sex therapy specialists) (theme 3). To combat these normative pressures,
intentional affirmation of diverse client identities may be used, with a view to counter-act-
ing internalized prejudices/homophobia (theme 2).

In the clinical arena, a goal that many interviewees view as foundational is: fostering a
critical and reflective examination of what the client really wants to attain through sex
therapy. In many instances, this task involves a close evaluation, or re-evaluation, of the
client’s initial goals, to determine how they fit with the client’s personal, and relational pri-
orities. A relevant associated theme in the data is: emphasis on the possible need to affirm
non-normative identities. Interviewees stress that internalized homophobia and other
forms of internalized prejudice may influence clients’ initial goals, and are an important
consideration in the therapy process (sub-theme 2-A). Consequently, a number of inter-
viewees recommend the use of permission-giving as a client-affirmative clinical technique
(theme 2, especially sub-theme 2-C). Additionally, the therapist’s use of a critical and self-
reflective stance was identified as a sub-theme within the practice of affirmative sex ther-
apy with diverse clients (theme 3). In order to meaningfully affirm diverse clients, the
data support outside findings that it is necessary for the therapist to identify (to the great-
est degree possible) their own biases/prejudices, which may often extend to the “minority”
clients with whom they work.

The data suggest that a sense of internal conflict in relation to one’s own sexuality, or
one’s deeper sexual desires/preferences, may not be uncommon for sexual “minority” cli-
ents, and may be the consequence of socially conditioned messages about normal sexual
behavior. This experience of sexual prohibitions may often contribute to the comorbid/
contributing experience of depression and anxiety that many clients face. Another rele-
vant sub-theme is apparent in some interviewees’ emphasis on the importance of personal
authenticity (sub-theme 2-F). The data appear to reflect an implicit assumption that valid/
viable clinical goals � often linked to the values of self-actualization, and personal fulfill-
ment � depend on helping the client identify and negotiate core identity aspects (theme 2
and theme 3).

Results: sex therapy and non-normative clients

A number of interviewees make reference to the degree to which the clinical principles
they use with heterosexual, dyadic clients can be generalized to diverse and “minority”
clients. A number also share their thoughts on the possible limitations of such (i.e. het-
erosexually-oriented) approaches in non-normative client groups, highlighting the differ-
ences that may obtain when working with such clients.

A point of concern for many interviewees is the ostensively widespread limitation on
sexual material/topics in general healthcare and psychotherapy training, identified by a
number of specialist interviewees and in the wider literature (Athanadiasis et al., 2006;
Barker, research interview, March 30, 2012; Braun-Harvey, research interview, November
15, 2012; Britton, research interview, March 7, 2012; Tsimitsiou et al., 2006) (sub-theme
1-C). The data collected in this study suggest that such training limitations and personal
discomfort may also extend to specialist groups � such as couple and relationship thera-
pists � for whom client sexuality may be a more immediate clinical issue. Ravella suggests
that it may be relatively common for a couple or relationship counselor to avoid a focused

SEXUAL AND RELATIONSHIP THERAPY 9

discussion of sexual issues in general (research interview, January 11, 2013). Even for sex
therapists working with LGBTQ clients, Britton suggests, it may be the case that “few
have the background, the training, the sensitization, the language, the understanding, and
the ok-ness with being able to ask the right questions” (Britton, research interview, March
7, 2012) (sub-theme 1-A). This factor is a main impetus for the high emphasis on
advanced specialization training and professional development, evident in the research
findings from this study. Data suggests that part of the diagnostic challenge when working
with LGBTQ clients may also be systemic: it is held that the DSM diagnostic categories
are, in and of themselves, heterosexually biased, being based on a heterosexual response-
cycle model of penetrative sexuality (Tiefer, 1991).

Results: key principles in inclusive sex therapy

An emergent challenge in this study was: to determine how sex therapists can work effec-
tively with a diverse range of clients, and to identify the clinical practices sex therapists
use in dealing with non-normative clients. Analysis of survey data illustrates a number of
key principles and practices that may facilitate critical and reflective diagnosis and treat-
ment in the psychosexual therapy context. As stated above, the core inclusive principles
identified in this research are consistent with widely-held humanistic values in the con-
temporary psychotherapy field. Thus, in working with diverse clients, four main clinician
principles are highly emphasized by interviewees:

(1) a nonjudgmental stance towards diverse clients,
(2) an understanding of diversity � in particular, understanding the wide variety of

possible identities that a client may have, and the specific challenges that are likely
to be associated with these identities, (sub-theme 4-A)

(3) an appreciation of fluidity � recognition that the client’s identity, behaviors and
therapy goals are apt to change over time, and

(4) a reflective, self-critical approach to practice � a commitment to reflective practice,
self-monitoring/introspection, and recognition of broad values and possible preju-
dices, as well as situation-specific responses to particular clients (sub-theme 2-B).

The data suggest that the clinician’s conceptualization of diversity is rooted in an indi-
vidually specific understanding of the identity categories that a client may occupy within
the parameters of social discourse. It is emphasized that the clinician’s perspective (like
the client’s) is influenced by the clinician’s subjective social and cultural background,
which may contribute to the development of personal prejudices.

Table 2 presents an overview of the themes and sub-themes identified in the data from
this study. In the following section, we will describe in greater detail the key principles
identified in the data.

Results: key practices in inclusive sex therapy

In the data presented above, high level of importance is placed on therapists developing
and maintaining a clear understanding of their own views of, and position on, non-nor-
mative sexualities. While there is a widespread language of “openness,” and agreement on

10 M. D. BERRY AND A. N. LEZOS

Table 2. Inclusive sex therapy practices: themes and sub-themes identified in research interviews (n D 34),
including representative statements.

Themes/sub-themes Representative statements

(1) Interviewee identifies knowledge/
understanding of diversity as an
important skill

there’s one sort of line whereby we regard LGBT, asexual, bondage and
discipline, sadism and masochism (BDSM), non-monogamous, all of
sort of what is seen as minority sexuality or gender. But it’s not
actually minority in all cases, some of it’s majority. But, anyway, the
marginalized ones, we can train people specifically in each of those
things…So people have an awareness—they can get a lot more
knowledge of specific identities and specific practices.

(1-A) Therapy field seen as ill-equipped to
deal with diverse (i.e. LGBT) clients

[A lot of psychologists are] going to take their heteronormative bias,
and they’re going to say: “oh, ok, all gay men just want to stick it in
the anus, because there’s no vagina”.

I’ll bet you there are a lot of psychologists who don’t even know that
there’s such a thing as anal-receptive and anal-active. “What would
THAT mean?” they’d say.

(1-B) Interviewee emphasizes that a
heteronormative model of sexual
behavior may be common in mainstream
sex therapy and/or sexual medicine

a lot of what is pathologized by the mental health community, specifically
in the DSM and its diagnostic categories, and in the languaging and the
posturing and the judging of many mental health practitioners, who
actually work with some of the same people I work with, fail them in
their lack of sensitivity, and even training, around sexuality.

[Clinician recommends] systemic approaches, and some of the systemic
ways of questioning—Socratic questioning and circular and interventive
interviewing techniques—they’re fabulously non-directive, but also very
probing in a very respectful way. And I think the systemic notions of
neutrality and curiosity, those key principles, are really good principles
for looking at the sort of diversity of human sexual behavior.

one book I read … was like: “all of the examples in the book are going
to be heterosexual people, because that’s statistically the norm, so,
people in same-sex relationships will have to think about how it
applies to them”. I was just like ahhhhhh?

(1-C) Need for more/better training (for
sex therapists) in sexual diversity

I also think if you were to poll…certified sex therapists… what you’d
find is that very, very, very few of them are gay-identified, and…few
as well, have the background, the training, the sensitization, the
language, the understanding, and the ok-ness with being able to ask
the right questions.

(2) Interviewee emphasizes possible need to
affirm identities outside the norm

we have to be aware of the world we live in, so that’s where something
like Darren Langdridge’s gay-affirmative therapy is [useful]. You might
have to work a bit at affirming, say, identities that are outside the
norm, the normative, because the person has so much experience of
having those disaffirmed, that you know, maybe you put your
therapeutic weight around saying: “actually yes, kink is ok, non-
monogamy is ok. Yes it’s alright to be gay.”

(2-A) Influence of internalized
homophobia on client emphasized as
important to treatment

a lot of…the work that I’m seeing and doing has been related to
trauma histories, and internalized homophobia.

We spent quite a lot of time talking about [this client’s] sense of, really,
disapproval, and his own very deep prejudice about homosexuals. So
he was one of these gay people that—[while] he was quite keen on
gay rights, and ostensibly was very active in protesting equality of
sexual orientation…—actually he had terrible prejudices about it,
and felt that gays were lesser.

(2-B) Interviewee emphasizes reflective
stance (therapist’s use of)

when people say ‘open and supportive’ I often say to myself: ‘what the
fuck does that mean? What are you talking about? So, when I supervise
folks and they say “I want to be open and supportive” one of the things
that comes up for me is you know, that position of being open and
supportive is a potential iatrogenic injury to your client,

if they don’t understand what you mean, or you can’t define what that
means.

(2-C) Permission-giving as a clinical
technique

a lot of what we all do is permission-giving and normalizing.
every session, re-permission them, we begin with permission. And
there’s an implicit permission given just in having them being ok
about asking for help around sex.

the fact that I’m going to demonstrate the language is itself permissive
because it allows them to respond in a like manner. Sometimes I will
frame a question which, as it were, subsumes another question along
the way. Like I might say about masturbation: I don’t say ‘do you
masturbate,’ I say ‘when you masturbate, do you find that…’

(continued)

SEXUAL AND RELATIONSHIP THERAPY 11

Table 2. (Continued )

Themes/sub-themes Representative statements

(2-D) Use of a non- pathologizing or
sexual health model

I try not to pathologize any more than I have to. You know, sometimes a
person will call me up and say: “my wife is experiencing sexual
aversion,” and I try to discourage them from labeling it.

I don’t like the word ‘dysfunction,’ you know? It’s all part of the DSM. I
usually talk about sexual ‘problems’, or sexual ‘difficulties’, or sexual
‘issues’.

(2-E) Use of a dimensional (rather than
categorical) model of sexual health/
problems

I see it as on the continuum of worry-problem-and-disorder, as see it as,
on the continuum, a sexual problem, not a sexual disorder or
dysfunction, or a psychiatric diagnosis.

(2-F) Emphasis on personal authenticity [My work focuses on] helping people become who they truly are. In
other words, claiming the authenticity of their sexual being.

(2-G) Clinician lets the client lead the
therapy process

I’m often quite led by the client…there’s quite a trust the client has a
pretty good idea what the important things to bring are.

I would offer the opportunity to see whether they wanted [to discuss
the therapy relationship] or not. I think it’s really important to give
control, if you like, of the direction, to the client at all times.

(3) Use of normalizing the client’s concern or
identity (as a clinical technique)

Whatever they’re dealing with, basically what you say is: “you know
what? What you’re feeling right now is perfectly normal.

Across orientations, across modalities, normalizing is a terrifically
important part of what a psychotherapist does. So, measuring
outcomes, and measuring progress powerfully interfaces with
normalization—that the expectations the people have about their
lives change—and something that initially would have seemed to
them utterly unsatisfactory as an outcome becomes, actually, a very
good outcome.

He’s telling me “I’m a monster, I shouldn’t have been born”. And I’m
telling him: “actually, that’s not [true].

Well, I don’t see transgender in that way, I don’t think there’s anything
wrong with being transgender, and transgender people exist in all
times and all cultures, and they’re perfectly ok people”.

(4) Interviewee uses social constructionism to
conceptualize client cases

increasing the possibilities for somebody is really part of therapy. And
loosening what is sedimented. And enabling them to see things a bit
differently…In a way, therapy has a lot in common with, say, queer
theory, or sort of certain branches of social constructionism, which are
about kind of loosening up and trying to see multiple alternatives
rather than just one fixed route.

(4-A) Interviewee emphasizes fluidity/
variability (and attention to fluidity) of
client’s identity and sexuality

The reality is that sex by its nature tends to be variable, flexible, and
have different roles and different meanings for people.

[One] way to go is the more queer kind of approach…not necessarily
expecting them to be the same from session to session, and seeing
sexuality as something much more fluid and changing and much
more integrated with the rest of their life. And not really thinking:
how do I work with a lesbian client? How do I work with a
transgender client?

(4-B) Narrow definition of “sex” seen as
prevalent in society (and as internalized
by client)

To me, the problem with the word ‘sex’…is that it’s been so limited in
its definition that I don’t even LIKE the word anymore. But when you
talk about somebody seeking something, what the pleasure model,
what I would like to see happen is that they actually seek connection.
And that’s a whole different ball game. That’s not sticking-it-in and
getting off, you know.

(4-C) Heteronormative model of sex seen
as prevalent in society (affecting clients)

the entire world is still heterosexist and heteronormative, including
[psychology] professionals.

(4-D) “Sexual imperative” (assumption
that everyone wants sex) seen as
prevalent in society

a lot of the information out there makes people feel abnormal if they
don’t want to have sex, you know, five times a week.

12 M. D. BERRY AND A. N. LEZOS

the importance of psychotherapist “nonjudgmentality” within the data, Winn emphasizes
that such terms are not self-evidently meaningful. Specifically when working with sexual
“minority” clients, a critically self-aware understanding of � and ability to articulate �
what is intended by “open and supportive” counseling is identified as an essential attri-
bute. The “position of being open and supportive,” Winn emphasizes “is a potentially iat-
rogenic injury to your client, if they don’t understand what you mean, or you can’t define
what that means” (research interview, January 16, 2013) (theme 1).

Hence, while nonjudgmentality is largely viewed as a core principle and value of psy-
chotherapeutic work (Rogers, 1957), the data gathered in this study indicate that nonjudg-
mentality must be functionally linked to the other principles described, and supported by
a range of clinical practices and techniques, which will be elaborated in the following
sections.

In conjunction with a nonjudgmental orientation, the data suggest that a high level of lit-
eracy and knowledge about sexual diversity is a key therapist attribute when dealing with
clients in general, and non-normative clients in particular. We may identify the need for
familiarity with: diversity, the core issues that specific client groups commonly face, and the
specific language clients may use (Sub-theme 1-C). The importance of familiar understand-
ing is illustrated by the fact that sexual “minority” is a problematic term, since, as stated
above, it presupposes that LGBTQ individuals, and other sexualities outside the hegemonic
norm, are statistically uncommon, obscuring the reality of sexual variance. As Barker
emphasizes, while there is a culturally situated, widespread perception of LGBT, asexual,
bondage and discipline, sadism and masochism (BDSM), non-monogamous, and queer
individuals as being “minority” sexuality, they are “not actually minority in all cases”; con-
sequently, rather than comprising an actual or statistical minority, these groups constitute a
distinct conceptual category � constituting “what is seen as minority sexuality or gender”
(Barker, research interview, March 30, 2012).

In addition to understanding such internal biases in the discourses about sexuality, it is
important for the therapist to have a strong understanding of the subjective experiences
clients may likely face. In working with gay male clients, for instance, Britton illustrates
the importance of specialized knowledge, stating,

if I don’t even know the words, how can a guy who’s gay feel comfortable asking me “am I
ok? Am I normal? How do I get past this? This is something I’m longing for.”? I have to have
that nuanced background myself (Britton, research interview, March 7, 2012).

Specialist familiarity pertains to the intersections of a number of social factors, includ-
ing: sexuality, race, class, gender and other variables. In this respect, attentiveness to the
unique challenges particular clients may face, based on early life experiences is of eminent
importance. As a number of interviewees point out, different social milieus, including
sub-cultural groups and social classes, may respond very differently to sexual factors and
diverse sexual identities, with clients facing varying levels of stigma and shaming, based
on their social background. Appreciation of fluidity involves breaking down and challeng-
ing dominant identity categories, addressing the client in a highly individuated way in
order to understand them on their own terms, and potentially working to overcome or
counteract some of the restraints of dominant discourse.

The data from this study provide evidence that social constructionist theory can be an
invaluable diagnostic and psychotherapeutic framework, which may help the therapist to

SEXUAL AND RELATIONSHIP THERAPY 13

understand the client’s unique background and personal experiences (Theme 4). By focus-
ing on the significant social and cultural variables that impact on a client’s sexuality and
relationship, it may be possible to identify elements that inhibit or strengthen the client’s
sexuality, and contextualize the role that sociocultural factors play both in the patient’s
life and in the therapy process. Interviewees suggest that it is vital that the therapist works
to maintain a sense of the dominant discourses that affect their clients, “knowing the sort
of world that [their] clients are likely operating within” (Barker, research interview, March
30, 2012). This technique requires acknowledgement that sexual difficulties often occur
within interpersonal social relationships, and are situated within a sociocultural context.
A crucial factor when evaluating the sexual concerns of a non-normative client, therefore,
may be in interpreting the client’s sociocultural milieu, evaluating how the client’s sexual
difficulties may be rooted in their social setting, and how this may affect them � with or
without their awareness.

Interview data indicate that the application of social constructionist theory (theme 4),
and the therapist’s attempts to interpret and normalize the client’s sexuality and sexual
problems (sub-theme 2-C), may generally involve a detailed sexual history taking. This
often includes examination of the client’s family of origin, community experience, and
early and ongoing messages surrounding sexuality. For LGBTQ clients, for example, it
may be especially important to evaluate the early messages the client encountered in their
family of origin, regarding sexual orientation, including the possible influence of hetero-
normative models of sexuality. A vital benefit of using social constructionist theory is to
help the client situate their sexual difficulties within the context of their own life. In this
regard, working with social constructionist theory may compel the therapist to begin with
the sexual problem presented by the client, and expand outwards, reflecting wider rela-
tionship issues, or a more expansive range of psychosocial concerns.

More broadly, evaluating the social and relational context of sexuality and sexual diffi-
culties vis-�a-vis social constructionism entails rendering explicit that which is implicit in a
person’s life, by exploring the way that social messages and values may have been internal-
ized by the client, both with and without the client’s awareness.

Discussion: practices in inclusive sex therapy � normalizing, horizontalizing,
and affirming

At the level of clinical practice, a number of techniques, grounded in the principles identi-
fied in the data, are relevant. First, thematic analysis of interview data revealed normalizing
as another key practice, both in diagnosing/assessing clients, and throughout the treatment
process (sub-theme 2-D). The technique of normalizing involves several dimensions. The
therapist aims to help the client to conceive of sexual problems as understandable and nat-
ural responses to psychological and relational factors. Further, the therapists seek to help
the client develop a flexible perspective on sexual behavior, which reduces the level of
stigma that may be associated with social standards of sexual behavior and normality.
Therefore, as a clinical intervention, normalizing entails a number of facets, including:

� explicitly questioning normative standards of sexual behavior, under the assumption
that imposing normative frameworks on client’s sexual behavior may produce iatro-
genic injury (Winn, research interview, January 16, 2013),

14 M. D. BERRY AND A. N. LEZOS

� normalizing the client’s sexual identity, and possible fluidity of this identity (Barker,
research interview, March 30, 2012),

� emphasizing that the client’s sexual difficulties and problems are normal responses to
their current life circumstances, when compared to what others would likely experi-
ence in such circumstances (sub-theme 2-C; Dunn, research interview, January 29,
2013; Fonagy, research interview, April 4, 2012),

� fostering a clinical environment in which the discussion of sexual issues and sexual
problems is experienced as natural/appropriate (Hertlein, Weeks & Sendak, 2009;
Milrod, research interview, October 11, 2012; Savage, research interview, November
4, 2012) ,

� situating clinical work within a context of critical research that self-consciously aims
to challenge dominant standards of sexual normality, which are often seen as restric-
tive and damaging to the client’s clinical aims (Barker, research interview, March 30,
2012; Kleinplatz, 1996; Mahrer, 2012; Ravella, research interview, January 11, 2013;
Tiefer, 1996). Please consult Table 3 for an overview of the key principles and techni-
ques of critical sex therapy.

Levine’s “first principle of clinical sexuality” clearly indicates the importance of social
and cultural discourses, which define categories of normality and abnormality that
strongly influence the client’s sexuality, and impact powerfully on sexual functioning
(Levine, 2007). Consequently, as Fonagy emphasizes, “across orientations, across modali-
ties, normalizing is a terrifically important part of what a psychotherapist does” (research
interview, April 4, 2012). Normalization, for many interviewees, appears to serve a de-
stigmatizing function, helping to problematize the expectations surrounding sexual
behavior that contribute to the client’s sexual problem, or their subjective cognitive and
affective experience of a perceived sexual dysfunction (sub-theme 2-E).

It is possible to identify two sexually specific aspects of normalization as a diagnostic
and therapeutic technique: normalization of the client’s sexual identity and behaviors and
normalization of the client’s sexual difficulties. Normalizing the client’s identity and
desires/behaviors, serves an important “permission-giving” function, intended to help
reduce the guilt or shame that may be implicated in the client’s sexuality. Normalizing the
difficulties that have brought the client to therapy, Barker points out, is largely a matter
“of saying: look, everyone who comes here struggles with this kind of stuff. It’s not, really,
it’s not just you. It’s kind of everybody” (Barker, research interview, March 30, 2012). The
data suggest that normalization is frequently supported by the use of psychoeducational

Table 3. Summary of inclusive sex therapy principles and techniques identified in survey of sex therapy
specialists/experts.
Principles
� Maintaining a stance of nonjudgmental acceptance
� Ensuring familiarity with sexual diversity
� Use of social constructionist analysis
Techniques
� Normalizing (i.e. the client’s sexuality and/or sexual problem)
� Horizontalizing (conceptualizing the client’s sexuality within the wider horizon of their identity)
� Affirming-as-necessary (especially, affirming the client’s identity and subjective experiences)
� Emphasis on reflective practice
� Maintaining a non-pathologizing stance
� Refuse to take on a client (in cases of obstructive, self-identified clinician bias/prejudice)

SEXUAL AND RELATIONSHIP THERAPY 15

techniques. Of particular importance is the critical stance towards categories of normality
that the clinician models in the therapeutic encounter. As a number of interviewees indi-
cate, normalizing should not result in the reification of categories of normality (i.e. by sit-
uating the client within the norm and by implication positioning other behaviors as
abnormal). Rather, normalization entails critically examining, or deconstructing, the cli-
ent’s sense of abnormality, and problematizing/challenging the taken-for-granted notions
of normality that affect the client’s sexual problems.

Another technique that may be useful for therapists working within an inclusive sex
therapy orientation is: horizontalizing (Berry & Barker, 2014). Horizontalizing entails
situating the client’s specific concern (i.e. a sexual problem/dysfunction) within the
wider “horizon” of their lived experience, rather than focusing strictly on the clinical
issue. Additionally, the clinician seeks to understand and work with specific salient
aspects of the client identity (for instance, sexual “minority” status, or a non-normative
sexual identity) within the wider psychosocial horizon. Thus, in horizontalizing the
therapist refrains from treating the client’s sexual problems or sexual identity as
the sole issue of importance in the therapy. Rather, a horizontalizing approach to the
therapeutic encounter involves interpreting the client, and their clinical concerns, as
complex, multidimensional and non-static. As Barker suggests, within this model,
“you’re not seeing a person in front of you and thinking ‘they’re a lesbian’, ‘they’re a
heterosexual’, ‘they’re asexual’, ‘they’re kinky’. It’s much more like…seeing that person
as diverse, as ever-changing, as plural” (research interview, 2012, March 30, 2012). Sex,
sexuality, and sexual problems, though very important, are considered to be only parts
of the clinical picture. Horizontalizing may be of particular value for clients who them-
selves have come to see a single � and often stigmatized � aspect of their sexuality as
being singularly important or focal.

The data from this study suggest that this type of singular fixation may in fact serve to
impede clinical work, particularly where clients experience shame or internalized preju-
dice associated with some aspect of their sexuality. As such, the clinical technique of
affirming-as-necessary is recommended as an inclusive sex therapy practice. In this
respect, the “gay affirmative therapy” model � which aims to provide a “positive frame-
work” for clinical practice that serves to affirm LGBTQ identities � offers a framework
for working with non-normative clients, and diverse sexualities (Davies, 1996). Published
research has shown that affirmative therapy can help counteract experiences of stigmati-
zation or disaffirmation that the client has experienced, and potentially counteract dam-
age to the client’s self-esteem, which the data from this study indicate may be a concern
for some non-normative clients (Bigner & Wetchler, 2012; de Vries, de Vries, research
interview, February 5, 2013; Rutter, 2012). Consequently, affirmative therapy may serve
an immediately therapeutic effect, in addition to fostering the conditions for more effec-
tive psychotherapy, by enabling the client to engage directly with issues that may have
otherwise been (consciously or unconsciously) avoided.

As Langdridge states, the affirmative model requires the therapist to acknowledge and
work with the dual impact that the psychotherapist and the wider sociocultural world
have on the client’s sexual identity (Langdridge, 2007). Consequently, this therapeutic
technique requires a high level of self-reflective awareness and critical engagement with
the socially constructed aspects of the client’s identity, the clinician’s identity, and the
context of the clinical encounter.

16 M. D. BERRY AND A. N. LEZOS

Discussion: use of reflective practice, maintaining a non-pathologizing
stance, refusing to take on clients when obstructive therapist bias is present

The therapist’s ongoing reflective practice and critical self-evaluation are identified both in
the data from this study and the wider published research as foundations for a well-articu-
lated, open, nonjudgmental, and supportive stance (Mann, Gordon, & MacLeod, 2009;
Stedmon & Dallos, 2009). While the therapist’s reflective practice may be a particularly
important practical issue in working with diverse and non-normative clients, the core
principles and techniques of self-reflection are of high importance with all clients and
clinical issues. A number of tools may be usefully implemented in the therapist’s own
practice, to foster critical self-reflection. Such tools may include journaling, mindfulness
practice, or the therapist’s own psychotherapy/counseling (Berry & Barker, 2014). In addi-
tion, interview data suggest that many therapists view clinical supervision and profes-
sional dialogue with colleagues as very important reflective tools, which are often used to
gain perspective on clinical practice, to gain insight into their own cognitive and affective
responses to the therapy encounter, and to analyze transference and counter-transference
processes.

A diagnostic and treatment framework that appears to be especially common
amongst research participants is emphasis on a non-pathologizing model, or use of a
sexual health model. Often used conjunctively, alongside normalizing, and within a
stance of nonjudgmental acceptance, the sexual health (non-pathologizing) model
emphasizes that many sexual concerns fall within the range of normal/healthy sexual
functioning, and informs the critical orientation to standard diagnostic systems. Within
this framework, there is a self-conscious attempt to avoid the language of pathology,
and “the defining baseline [for a clinically treatable sexual issue] is whether it’s a prob-
lem for them or not” (de Vries, research interview, February 5, 2013). Braun-Harvey,
who works exclusively with men, and specializes in the outpatient treatment of men
with concerns of out-of-control sexual behavior, describes his use of the sexual health
model, stating:

I work from a sexual health perspective…I don’t do out-of-control sexual behaviour as a sex-
ual disease, or disorder. I don’t use the terminology of addiction or, you know, another kind
of disorder or disease perspective. I see it as on the continuum of worry-problem-and-disor-
der, as…a sexual problem, not a sexual disorder or dysfunction, or a psychiatric diagnosis.
(research interview, November 15, 2012)

For many psychosexual therapists working within an anti-pathologizing, or sexual-
health, framework, the diagnostic language used in conventional psychodiagnostics is
inherently problematic. Many interviewees who use this model emphasize the distinction
between “problem” and “dysfunction,” stressing that the language employed in DSM is
intrinsically pathologizing, as it casts variant sexuality and sexual behavior as dysfunc-
tional/pathological. Table 2 provides a summary of critical sex therapy techniques drawn
from the interview data, and relevant outside research, which are seen to be of particular
utility in working with sexually diverse clients and client populations.

Finally, where nonjudgmentality and reflective practice continue to be obstructed
by a therapist’s biases, a final avenue is suggested. Alman, a psychosexual therapist
working within a principally cognitive behavioral framework, a technique that
underlines the importance of self-reflective practice, and illustrates the pragmatic

SEXUAL AND RELATIONSHIP THERAPY 17

challenges of nonjudgmentality that the clinician may encounter. Genuine acceptance,
she states, is

a necessity if you’re a sex therapist. You can’t even have that: you’d want to do what?—kind
of response inside, let alone express it…So I feel if a [therapist] knows that they can’t deal
with certain issues, then they shouldn’t. It’s a moral responsibility not to take clients who
play in BDSM, for instance, if [the therapist] find[s] that personally repugnant. (Alman,
research interview, January 9, 2013)

Thus, the conceptualization of moral/ethical responsibility she describes implies the
following technique: refusing to accept a client, or terminating the therapy process in
instances where a self-perceived bias/prejudice threatens to compromise the treatment.
This technique appears to be strongly linked with self-reflective practice, as it presupposes
recognition of one’s own biases and clinical limitations. There is a clear ethical mandate
that psychotherapists refrain from administering psychotherapy services that are apt to be
ineffectual, or damaging to the client, entrenched in the ethical protocols of the psycho-
therapy profession (Leach & Harbin, 1997; Welfel, 2012). However, further research in
this area is needed, in order to assess the overall use and efficacy of self-reflective practice
amongst clinicians, and specifically to determine psychotherapists’ competencies in iden-
tifying their own subjective biases, especially in working with sexual problems.

Limitations and future directions

Client diversity, and the strategies involved in working with varied client groups, is an impor-
tant area for current research and clinical literature. The data gathered in this study, and
described above, suggest the value of a number of core principles and key techniques that
may be used critically in working with diverse client populations in sex therapy practice.
While this data provide the foundation for a clinically applicable set of principles and guide-
lines for working with diverse populations, which we have described in this paper, there are
a number of limitations to this study that may be addressed through further research.

In terms of the research methodology, while the semi-structured interview format
allowed for a more detailed and comprehensive examination of each participant’s areas of
interest and expertise, this format limits the replicability of a qualitative study of this
nature. Again, it is important to note that, measures (aforementioned) were taken to
ensure trustworthy and credible data; however, in a qualitative study of this kind, these
criteria for trustworthiness cannot be equated with exact replicability (Morrow, 2005).
Additionally, with respect to the interview methodology differences in the format of inter-
views (i.e. in-person versus Skype-with-video versus audio-only) create a difference in the
qualitative experience of the interview, and appeared to correlate with a difference in
length, with in-person interviews being longer, and more detailed. For future research, in-
person interviews may be favorable.

Based on this research project, a number of areas for future research can be identi-
fied. First, psychotherapy process and outcome research� both qualitative and quanti-
tative � would be useful to assess the clinical advantages of these techniques in terms
of therapy efficacy. In this respect, the further development of an inclusive sex therapy
model, as an evidence-based therapy, is a productive objective for future research, in
our assessment.

18 M. D. BERRY AND A. N. LEZOS

Conclusion

Based on the findings represented in this study, we have recommended prospective value
of core principles including: maintenance of a nonjudgmental stance, developing and
maintaining familiarity with sexual diversity, and the use of a social constructionist frame-
work in conceptualizing work with diverse clients. Relatedly, we have described six clinical
techniques, which are grounded in these principles. These include:

(1) normalizing,
(2) horizontalizing,
(3) affirming-as-necessary,
(4) reflective practice, and
(5) maintenance of a non-pathologizing stance.

Data from this study have also suggested that in instances where the therapist holds an
obstructive bias towards a client, the onus falls on the therapist to (6) refuse to take on, or
continue therapy with, this client.

The data and clinical recommendations presented here, in our assessment, are a needed
addition to the field in light of the limited research on therapists’ work with diverse client
populations. Clinical principle and practice literature, as presented here, is intended to
help improve the confidence, knowledge, and insight of practitioners who work with
increasingly diverse client populations.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Michael D. Berry, PhD, is a research associate in the laboratory for the Biopsychosocial Study of
Sexuality at McGill University. He also serves as the manager of clinic operations for the Sex and
Couple Therapy Service at the McGill University Health Centre. His primary interests include: the
application of empirical research to advance clinical practice, and the use of fair and empowering
clinical practices with diverse communities.

Anastasia Natasha Lezos, MA, is a graduate of the counselling psychology postgraduate program at
McGill University in Montreal, Canada. She has a strong research interest in human sexuality, and
a clinical interest in counselling and psychotherapy within a social justice framework.

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SEXUAL AND RELATIONSHIP THERAPY 21

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individual use.

• Abstract

Introduction
Methodology
Researchers´ backgrounds and demographic details
Interview methodology
Data analysis method
Quality and trustworthiness in qualitative research: steps taken to ensure reliability and validity of the data
Steps taken to ensure client confidentiality
Results: sexuality and normativity
Results: sex therapy and non-normative clients
Results: key principles in inclusive sex therapy
Results: key practices in inclusive sex therapy

• Discussion: practices in inclusive sex therapy – normalizing, horizontalizing, and affirming
• Discussion: use of reflective practice, maintaining a non-pathologizing stance, refusing to take on clients when obstructive therapist bias is present

Limitations and future directions
Conclusion
Disclosure statement
Notes on contributors
References

AmericanAssociation of Sexuality Educators, Counselors and Therapists

Code of Ethics & Conduct for AASECT Certified Members

Article I: Preamble

Recognizing its responsibilities to society and given its own national and international

objectives, the American Association of Sexuality Educators, Counselors and Therapists

(AASECT) has adopted the following Code of Ethics & Conduct (Code). The Code

applies to all Certified AASECT members and encompasses any activity that directly or

indirectly relates to professional identity or training. The Code does not replace or modify

the requirements for or purposes of certification as a sex educator, counselor, therapist or

Supervisor.

As a professional association, AASECT has a duty to advocate and enforce both high

quality services from and proper conduct/professionalism by its members in order to

ensure both. Through setting forth standards of ethical conduct for practice-related

conditions, qualities, skills and services, the Code is intended to assist AASECT Certified

members with judgments made in the course of their professional services.

Certified members of AASECT, in the conduct of all aspects of their life that relates to

their professional work and identity, are expected to honor the Code, and AASECT

certification is predicated upon adherence thereto.

Article II: Conditions of Certification

AASECT Certification may be terminated for sufficient cause as outlined in the Bylaws

and the formal Application for Certification.

Those applying for AASECT Certification must submit the following as part of the

application process:

1. Notification in writing to the AASECT Office of:

a. denial of an application for or disciplinary action taken against any

professional license or certification by a state or federal entity, or by a private

certification

entity;

b. conviction, guilty plea, or no contest plea of a felony;

c. conviction, guilty plea, or no contest plea of a misdemeanor directly related to

public health or the provision of safe and competent sexual health counseling

or therapy;

2. a. Current AASECT Certified members are required to notify the AASECT
Board of Directors (Board) in writing within thirty (30) days should an action

listed in paragraphs (a) – (c) of the above Section 1 occur.

b. In the event any professional licensing board or certification entity initiates
charges against a current AASECT Certified member, that member shall

provide the Board with written notification of the charges, along with any

related documentation. Such notification must be made within thirty (30)

days of the Certified member’s knowledge of the charges and any request

from AASECT for information or documentation related to such charges must

be satisfied within thirty (30) days of such request.

c. Decisions on all applications for AASECT certification or recertification may
be suspended until the adjudicatory outcome of charges has been determined.

Denial of applications shall be by two-thirds vote of the entire Board in

accordance with the policies and procedures established by the Bylaws and

the Formal Application for Certification.

Article III: Grounds for Corrective Action:

Actions that may constitute grounds for discipline involving a Certified member include,

but are not limited to:

1. violation of AASECT Practice Guidelines, Code of Ethics & Conduct and/or

other policies developed and implemented from time to time by the Board

(collectively, AASECT Standards);

2. violation of guidelines and ethical standards established by the sexual health

community;

3. denial of an application for or disciplinary action taken against any professional

license or certification by a state or federal entity, or by a private certification

entity;

4. conviction, guilty plea, or no contest plea of a felony;

5. conviction, guilty plea, or no contest plea of a misdemeanor directly related to

public health or the provision of safe and competent sexual health education,

counseling or therapy;

6. failure to promote the safety and welfare of the public, whether through negligent

acts or omission, or through misrepresentation;

7. misuse or reproduction of AASECT certification materials, logos, abbreviations,

or emblems that are the exclusive property of AASECT without the express

written permission of AASECT;

8. failure to relinquish and/or refrain from using AASECT Certificates, the

AASECT logo and/or emblems, the AASECT name, and/or AASECT

abbreviations, when so directed by AASECT;

9. misrepresentation or falsification of material information in connection with an

application, credentials, assessment documentation, continuing education reports,

or other materials or information submitted to AASECT;

10. engaging in inappropriate conduct in connection with the certification or

certification renewal processes, including, but not limited to:

1. noncompliance with assessment procedures or instructions;

2. violation of confidentiality agreements signed in accordance with the

candidate application and/or assessment administration; or

3. publishing, reproducing, or distributing assessment materials or information.

11. termination from an employment position involving the use of AASECT

certification and where the conduct leading to such termination involved:

1. child or elder abuse;

2. sexual abuse;

3. substance abuse; or

4. job-related crimes.

12. filing a complaint with AASECT deemed to be false, frivolous or intended to

harm a member, certified member or applicant and not intended to protect the

public;

13. discipline by or expulsion from a grievance board of a university, college,

governmental agency, or professional organization to which the Certified member

belongs;

14. failure to comply with a duly entered order of the Board;

15. failure to cooperate with an investigation conducted by the Board;

16.failure to report known or suspected violations of AASECT Standards within

thirty (30) days of such knowledge or suspicion;

17.unprofessional conduct as determined by the Board.

The information available to, as well as the deliberations of the Board, shall be deemed

confidential. The outcomes, negative determinations and sanctions may be published on
the AASECT website. Any action taken regarding continued or terminated membership,
with concomitant conditions made by the Board is final and cannot be appealed. The

Certified member will be notified in a timely fashion by the Board in writing of any

decision regarding membership or certification status.

Article IV: Administrative Sanctions

Sanctions imposed by AASECT may include, but are not limited to:

1. Temporary or permanent loss of eligibility for certification or membership.

2. Suspension of Certificate or membership.

3. Probation of Certificate or membership.

4. Revocation of Certificate or membership.

5. Assessment of monetary sanctions to recover costs associated with the

investigation and administrative prosecution by AASECT.

Article V: Additional AASECT Authority and Disclosure

In the interest of protecting the public and the integrity of the profession, AASECT shall

have the authority to:

1. Disclose an individual’s certification and/or membership status on its

website.

2. Disclose a member and/or certified member’s AASECT disciplinary history on its

website.

3. Provide AASECT disciplinary history and/or complaints filed regarding a

Certified member to the agency(s) responsible for state licensure, employers,

and/or other professional certification or credentialing organizations.

Please see Disciplinary Procedures for concerns related to enquiries or complaints.

Article VI: Code Of Conduct

Principle One: Competence and Integrity

Competence

AASECT Certified members shall be committed to maintaining high standards of

scholarship and practice and shall be accountable as an individual to the AASECT

Standards. Additionally, Certified members shall perform any professional service in

accord with the prevailing standards of performance in professional activities when

measured against generally prevailing peer performance.

The Certified member shall have training in sexuality education, counseling, therapy,

and/or supervision that is in accord with AASECT Standards and the laws relevant to the

jurisdiction in

which the Certified member practices.

The Certified member shall recognize the necessity and benefit of professional growth by

participating in continuing education as determined by the Practice Guidelines and by the

Certification standards.

Informed Consent

The Certified member shall recognize his/her limits of competence and shall

communicate them at the earliest possible time and at any time thereafter to the

consumer. When the Certified member’s level of competence does not afford optimal

benefits to the consumer, the Certified member shall, in a timely and efficient manner,

recommend referral to better-qualified sources.

The Certified member shall not knowingly permit any consumer to misunderstand the

Certified member’s competency and shall clarify credentials, training, affiliations,

experiences and skills in an honest and accurate manner.

Aiding/Abetting Unqualified Practice

The Certified member shall not enter into association for professional practice with or

assist, aid, or promote in any manner the practice of an unqualified or incompetent person

which shall include any person whom the Certified member knows or has reason to

believe, does not adhere to the Code or is in violation of any law. This shall include, but

is not limited to, making a referral to an unqualified or incompetent person.

The Certified member shall not provide any remuneration, regardless of form, to any

source for receiving the referral of a consumer for professional services unless the source

of the referral maintains continued involvement in the care of the consumer. Conversely,

the Certified member shall not receive any remuneration regardless of form from any

source for providing the referral of a consumer for professional services unless the

Certified member maintains continued involvement in the care of the consumer. Any

such financial arrangement must be disclosed to and approved and acknowledged in

writing by the

consumer.

The Certified member who becomes emotionally, physically or otherwise impaired or

disabled to a degree that it impacts on the best interest of the consumer shall, in a timely

and efficient manner, make a referral of the consumer to a qualified and appropriate

professional source so as to avoid any undue abandonment of the consumer.

Principle Two: Moral, Ethical, and Legal Standards

The Certified member shall accept that the quality of his/her professional services (are) is

dependent upon both personal morality and professional ethics and on the ability to

maintain legal standards.

The Certified member shall be aware of and monitor the fact that his/her personal needs

may influence judgments and actions in the therapeutic relationship and shall, regardless

of experience or training, have a qualified review source such as a supervisor available to

assist in safeguarding against unwise or inappropriate judgments and acts.

The Certified member shall not enter into any dual relationship regardless of nature that

jeopardizes the well-being of the consumer.

The Certified member shall avoid any action that might violate or diminish the legal and

civil rights of the consumer.

The Certified member shall not engage in or condone practices by any source that are

inhumane or that result in illegal or unjustifiable action relevant to race, handicap, age,

gender, sexual orientation, religion or national origin.

The Certified member shall make only factual, honest, and clearly stated (not misleading)

public announcements, statements or communications such as (but not limited to) for

advertising or promotional purposes.

The Certified member shall not set forth identification with AASECT such as (but not

limited to) membership or certification status in an announcement statement, or

communication, whatever the form, that also includes a college or university degree,

unless that degree is based on academic merit and is from an appropriately accredited

higher education institution.

The Certified member shall act in accord with AASECT ethics, standards and guidelines

related to education, counseling, therapy, supervision and research.

The Certified member shall act in accord with the standards and guidelines for the

protection of consumers promulgated by other professional associations with which the

Certified member is affiliated and the laws of the jurisdiction(s) in which the Certified

member provides professional services.

The Certified member shall report any ethical, regulatory, or legal complaint or judgment

relevant to their practice filed against the member with this report being submitted in

writing within thirty (30) days of knowledge to the Chair of the AASECT Disciplinary

Committee.

Principle Three: Welfare of the Consumer

Given that consumers are in unique and vulnerable positions with respect to the sensitive

nature of services related to sexuality education, counseling, therapy, research and

supervision, Certified members shall constantly be mindful of the responsibility for

protection of the consumer’s welfare, rights and best interests and for the rigorous

maintenance of the trust implicit in the consumer relationship.

1. The member shall, from the onset of professional contact with a consumer or a

potential consumer, clarify:

a. Professional training, experiences and competencies;

i. AASECT’s mission includes responsibility for providing education and

certification for sexual health professionals. One of AASECT’s objectives

is consumer protection and to ensure that the public is not misled by

inaccurate claims of those AASECT members.

ii. If a Certified member lists certification among his/her

credentials, that member must specify the area of certification (i.e., as a

sexuality educator, sexuality counselor, sex therapist or supervisor) in any

manner, media or forum. For example, a certified sexuality counselor may

not advertise him or herself as a certified sexuality educator. Only

AASECT Certified Supervisors may advertise themselves as offering

AASECT supervision.

iii. AASECT members who are candidates for degrees,

certification or supervisor may not state their candidacy as part of their

identification in any manner, media or forum. For example, a candidate for

a degree program such as a doctorate or for AASECT sex therapy

certification may not advertise that status. Consumers can be misled by

titles such as “Ph.D Candidate” or “Sex Therapy Certification Candidate”.

b. The nature of the professional services available to the consumer (with an

explanation of mutual roles and duties);

c. The limits of intervention effectiveness;

d. Personal values or professional preferences that reflect biases rather than
being responsive to the needs and well-being of the consumer;

e. Any exceptions to confidentiality and privileged com­munications (e.g. duty

to warn, mandatory reporting, etc.); and

f. Any financial issues, especially the payment obligations of the consumer.

2. The Certified member shall treat all information received about a consumer as

confidential including, but not limited to, the mere existence of an educational

counseling or therapeutic relationship with the consumer. Where required by law,

the Certified member will develop a policy consistent with reporting requirements

under HIPPA/ PIPPA and follow all legal requirements protecting consumer

privacy.

3. The Certified member shall advocate the consumer’s privileged communication as

granted by the laws of the jurisdiction applicable to the consumer and/or the

Certified member. In the event that there is uncertainty about the effectiveness or

validity of the consumer’s consent to release information that is potentially

confidential and/or privileged, the Certified member shall obtain appropriate legal

determination.

4. The Certified member shall divulge information received from a consumer or

prospective consumer to the extent required only in the following circumstances:

a. When the consumer provides written and informed consent, which indicates:

i. The type and nature of information to be released;
ii. Knowledge of the purpose for which the information will be used;
iii. Designation of the source that will receive the information;
iv. That the consent is given voluntarily and with competency; and

v. The consumer’s name and the date on which the consent is given.

b. When there is clear and imminent danger of bodily harm or to the life or safety

of the consumer or another person; such disclosure shall be made in accord

with the laws of the

jurisdiction in which the member practices.

c. When applicable law declares that such information may be released.

5. The Certified member may only use identifiable information about the consumer

for purposes of education, training, research or publication, but may not do so

without the consumer’s written informed consent.

6. The Certified member may reveal information about a consumer’s treatment and

treatment plan only to the extent that such is revealed in consultation with another

professional, such as a supervisor or coworker, for treatment purposes. Such

information may not include any confidential or identifying information about the

consumer, unless the consumer provides written consent.

7. The Certified member shall keep meaningful records relevant to the professional

services provided to and contacts (of any nature) with the consumer and shall

have a secure system for the preservation of records with the minimal contents

and duration of retention being in accord with the laws that are applicable to the

jurisdiction in which the Certified member practices, but no less than the

following:

a. A full record shall be retained intact for no less than 7 years after completion

of the last date of professional services or contact or more as required by

applicable provincial, state or federal/national law. In the case of minor clients,

a full record shall be retained intact for no less than 7 years after the client

reaches the age of majority and after completion of the last date of professional

services or contact or more as required by applicable provincial, state or federal

law;

8. The Certified member shall have a formal (written) arrangement for the

preservation of consumer records upon his/her ceasing of practice, death or

incapacity. This arrangement must be in accord with the laws of the jurisdiction in

which the Certified member practices.

9. The Certified member shall, when providing professional services in a group

context or to a couple or family, make a reasonable effort to promote safeguarding

of confidentiality on the part of each consumer in the group, couple or family.

10. The Certified member shall orient the minor consumer to the limits of

confidentiality pertaining to a parent’s right to know as defined by the laws of the

jurisdiction in which the member practices.

11. The Certified member shall, regardless of the reasons for which the consumer

sought professional services and regardless of the theory or technique being used

by the Certified member, predicate every sex counseling or therapy intervention

with an assessment and a meaningful discussion with the consumer(s) as to

planning for counseling or therapy. Such plan shall be consistently documented in

writing, justified academically, evaluated for effectiveness, monitored for

strengths and weaknesses and periodically modified accordingly.

12. The Certified member shall not engage in any dual relationship, regardless of

nature or circumstances, with a consumer or with persons who have a primary

relationship with a consumer served by the Certified member if such dual

relationship could potentially be detrimental to or jeopardize the well-being of a

consumer. A dual relationship occurs when a Certified member is in a

professional role with a person and (1) is simultaneously in another role with the

same person, and/or (2) is simultaneously in a relationship with a person closely

associated with or related to the person with whom the Certified member has the

professional relationship, and/or (3) promises to enter into another relationship in

the future with the person or a person closely associated with or related to the

consumer.

13. The Certified member practicing education, counseling or therapy shall not

engage, attempt to engage or offer to engage a potential, current, or former

consumer in sexual behavior whether the consumer consents to such behavior or

not. Sexual behavior includes, but is not limited to, kissing; sexual intercourse

and/or the touching by either the Certified member or the consumer of the other’s

breasts or genitals; sexual solicitation, physical advances, or verbal or nonverbal

conduct that is sexual in nature, that occurs in connection with the Certified

member’s activities or roles as an educator, counselor or therapist, and that either

(1) is unwelcome, is offensive, or creates a hostile workplace or educational

environment, and the Certified member knows or is told this or (2) is sufficiently

severe or intense to be abusive to a reasonable person in the context.

14. The Certified member shall terminate professional services to the consumer when

it is reasonably evident or should be evident that the consumer is not obtaining

benefits sufficient to justify continued services by such Certified member. Upon

termination, the Certified member shall make referral to another professional

source and/or offer reasonable follow-up to further the best interests of the

consumer.

Principle Four: Welfare of Students, Trainees and Others

The Certified member shall respect the rights and dignity of students, trainees and others

(such as employees), maintain high standards of scholarship and preserve academic

freedom and responsibility.

1. The Certified member shall, from the onset of professional contact with students,

trainees and others over whom the Certified member has administrative,

educational or supervisory authority clarify: the Certified member’s professional

qualifications and competencies; the objectives, responsibilities and duties of all

concerned and any financial issues, especially any payment obligations.

2. The Certified member shall maintain in confidence personal information

regarding a student, trainee, or others obtained in his/her professional role; the

provision of confidentiality does not, however, preclude fulfilling a professional

responsibility or duty to consumers, educational or training institutions or

programs, professional associations or governmental/regulatory or legal sources.

3. The Certified member shall maintain high standards of scholarship and present

information that is accurate and timely in all administrative, educational and

supervisory activities.

4. The Certified member shall keep meaningful and systematic records of all

administrative, educational and supervisory activities.

5. The Certified member shall not coerce or require a student, trainee or other to

serve as a subject for a research project.

6. The Certified member shall not provide diagnosis, therapeutic counseling or

therapy or any other clinical service to students or trainees or those over whom

the Certified member has administrative, educational or supervisory authority.

7. The Certified member shall not harass in any manner a student, trainee or other

person over whom the Certified member has administrative, educational or

supervisory authority. Certified members do not engage in sexual relationships

with students or supervisees who are in their department, agency, or training

center, or over whom Certified members have, or are likely to have, evaluative

authority.

8. The Certified member shall not, during the administrative, educational or

supervisory period enter into any dual relationship, regardless of nature, that

jeopardizes the well-being of the student, trainee or other.

9. The Certified member shall not, during the administrative, educational or

supervisory period, engage, attempt to engage or offer to engage the student,

trainee or other in sexual behavior.

10. The Certified member shall be cognizant that a dual relationship subsequent to the

administrative, educational or supervisory period may potentially jeopardize the

well being of the student, trainee or other.

Principle Five: Welfare of Research Subjects

Certified members shall conduct their investigations with respect for the dignity, rights

and welfare of the subjects. Research must be ethical and legal at its inception and

throughout the course of the investigation, with Certified members being mindful of not

justifying investigative techniques that are solely considered by the intended or achieved

outcome.

1. The Certified member shall be involved only with sex research that is carried out

by persons qualified to perform such investigations or under the direct supervision

of persons so qualified.

2. The Certified member shall be involved only with sex research that designates

and identifies (in writing) to the potential subjects the names and professional

qualifications of the person(s) or persons with ethical scientific and legal

responsibility for the conduct of the investigation.

3. The Certified member shall be involved only with sex research that provides

adequate protection(s) to human subjects at risk. Any research project must:

a. Include the voluntary and informed consent of each subject; and

b. Be in accord with applicable legal authority of the jurisdiction within which

such research is being conducted.

4. The Certified member shall only be involved with sex research that protects the

confidentiality of research data including the identity of participants or others

revealed during the investigation.

5. The Certified member shall only be involved with sex research that requires all

investigators to be honest and accurate in their dealings with research subjects and

all persons receiving information about the research.

6. The Certified member shall only be involved with sex research that offers to

provide an explanation of the purpose of the investigation and of the individual

and collective results to each person who serves as a research subject.

7. The Certified member shall only be involved with sex research that has been

prefaced by the submission of a research pro­posal for peer review with special

reference to ethical and legal safeguards for the potential research subjects. This

peer review may occur in different forms, such as an institutional review board for

evaluation for ethical pro­priety, and must be in accord with all relevant laws.

8. The Certified member shall not engage in any type of sexual relationship or

sexual behavior with research subjects as defined above in Principle Three (3),

paragraph thirteen (13).

©2014. American Association of Sexuality Educators Counselors & Therapists

(AASECT). All rights reserved.

Couples

Sexuality Counseling: A Professional
Specialization Comes of Age

Stephen Southern1 and Rochelle Cade2

Abstract
For individuals and couples experiencing such distress, sexuality counseling, an emerging specialization in professional counseling,
may provide relief, understanding, healing, and intimacy. This review attempts to describe the paradigm shifts and key figures in the
field, sexuality counseling as a professional specialization, the process of sexuality counseling including assessment, diagnosis and
treatment planning, and various roadblocks to intimacy. It concludes with advocacy of the new specialization as a synthesis of
trends in sexual health.

Keywords
sexuality counseling, sex therapy, sexual dysfunction, brief sex therapy, medical model, New View of women’s sexuality

‘‘When sexual function goes along smoothly, it is usually taken

for granted and given little thought. But if sexual function is a

problem in one way or another, it can be a source of anxiety,

anguish, and frustration that often leads to general unhappiness

and distress in personal relationships’’ (Masters, Johnson, &

Kolodny, 1986, p. 462). For individuals and couples experien-

cing such distress, sexuality counseling may provide relief,

understanding, healing, and greater intimacy.

Sexual issues were addressed in the origin of psychotherapy

with the development of psychoanalysis. Over the years, the study

and treatment of sexual dysfunction and dissatisfaction contribu-

ted to the emergence of a new field, sex therapy. Classic models

for sexual responding were developed through ethnographic and

laboratory research. Advances in medical technology and new

medications led to the medicalization of sex therapy as an exten-

sion of a patriarchal, masculine model of sex. Feminists rejected

the focus on medical treatment of genital responses and advocated

focus on relational and cultural factors. The contemporary sexual

health movement promises to advance integrative approaches to

helping couples with sexual satisfaction and optimal sexual func-

tioning. The convergence of sociocultural factors suggests that

the time is right for a sexuality counseling specialization within

professional counseling. The following overview attempts to

describe the paradigm shifts and key figures in the field, sexuality

counseling as a professional specialization, the process of sexual-

ity counseling including assessment, diagnosis and treatment

planning, and various roadblocks to intimacy.

Emerging Sexualities: Whither
Sexual Health

Anecdotal data and expert opinion estimated that 50% of
couples and 50% of individuals experience sexual problems

during their lifespan (Masters & Johnson, 1970). Recent

research has confirmed that sexual disorders are common, even

normative in the United States. Data from a large-scale sample

of U.S. adults, aged 18–59, reported prevalence rates for sexual

dysfunction in the past 12 months: 43% for women and 31% for
men (Laumann, Paik, & Rosen, 1999). Heiman (2002b)

summarized the results of several studies concluding that

10–52% of males and 25–63% of women in the general popu-
lation experience sexual problems. Studies of particular popu-

lations have revealed even higher prevalence rates than those

reported for the general population.

Large-scale epidemiological studies (Bancroft, Loftus, &

Long, 2003; Laumann, Gagnon, Michael, & Michaels, 1994;

Laumann et al., 1999, 2005; Mercer et al., 2003) have con-

firmed that sexual dysfunction in one or more components of

sexual response is commonly encountered in the clinic and the

community. Heiman (2007, p. 89) summarized the prevalence

and epidemiological studies estimating that 63% of women
reported some arousal or orgasm problems. Some women

described marked distress with their difficulties in functioning,

while others reported satisfaction with their relationships and

sex lives even though there were some sexual problems.

Rosenbaum (2007) reported that as many as 15% of premeno-
pausal women present sexual pain disorders including

1 Department of Psychology and Counseling, Mississippi College, Clinton, MS,

USA
2
Department of Counselor Education, University of Houston-Victoria,

Victoria, TX, USA

Corresponding Author:

Stephen Southern, Department of Psychology and Counseling, Box 4013,

Mississippi College, Clinton, MS 39058, USA

Email: Southern@mc.edu

The Family Journal: Counseling and
Therapy for Couples and Families
19(3) 246-262
ª The Author(s) 2011
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dyspareunia and vaginismus. Lack of interest in sex, including

sexual desire discrepancies in couples, affected 16% of men and
33% of women (Maurice, 2007, p. 187). A total of 35% of men
reported at least one sexual problem in the last year (Mercer

et al.,

2003).

Although there are problems with the diagnostic criteria for

sexual disorders, as many as 30% of men report concerns with
rapid or premature ejaculation (Althof, 2007, pp. 217–220).

Approximately 8% of male respondents reported not being able
to achieve an orgasm (Laumann et al., 1999). Rosen (2005)

indicated that prevalence of erectile dysfunction (ED)

increased with age with as few as 7% of men under 30 years
of age presenting ED and more than 50% of men older than
Age 60. Qualitative research (e.g., Symonds, Roblin, Hart, &

Althof, 2003) established that male sexual dysfunction contrib-

uted to lack of self-confidence, embarrassment, avoidance of

sexual outlet, and fears about losing one’s sexual partner. Sex-

ual problems increase with age; however, worries and concerns

about sexual performance contribute psychogenic and rela-

tional factors to the mix of etiological factors.

Concurrent with increasing use of selective serotonin uptake

inhibitors (SSRIs), such as fluvoxatine (Prozac), for depres-

sion, anxiety, and other emotional concerns, there were com-

plaints of sexual dysfunction, including inability to become

aroused or to experience orgasm. One study (Clayton, Keller,

& McGarvey, 2006) reported that 95.6% of women and
97.9% of men taking SSRIs exhibited impairment in at least
one phase of sexual functioning. There are also high rates of

sexual dysfunction in individuals receiving antipsychotic med-

ications (Dossenbach et al., 2005; Olfson, Uttaro, Carson, &

Tafesse, 2005). Generally, sexual dysfunction rates increase

with chronic illness, including diabetes and cardiovascular dis-

ease (Hayes & Dennerstein, 2005; Jack, 2005; Jackson, Rosen,

Kloner, & Kostis, 2006; West, Vinikoor, & Zolnoun, 2004).

Cancer survivors and their partners are especially likely to

experience compromised sexual functioning (Lagana et al.,

2005; Navon & Morag, 2003). Informed and empathic sexolo-

gists have even addressed the sexual needs of terminally ill per-

sons involved in palliative care (Redelman, 2008).

The most recent trend in the emerging field of sexual med-

icine is to define sexual problems in biological terms, reclassify

complaints according to diagnoses that demand medical atten-

tion, develop consensus-based treatment guidelines, and treat

sexual disorders with medications (Jackson et al., 2006; Lewis

et al., 2004; Lue et al., 2004). Based upon the success of silde-

nafil (Viagra) in treating ED, clinicians and researchers have

attempted with some success to reconceptualize female sexual

dysfunction in such a manner that medication is warranted

(e.g., Dennerstein & Goldstein, 2005; Dennerstein & Hayes,

2005; Rosen, 2002). However, feminists are sensitizing profes-

sionals in the field to pitfalls involved with the disease-oriented

‘‘hunt for pink Viagra’’ (Hartley, 2006).

Some sex therapists (e.g., Bancroft et al., 2003) have

responded to medicalization of the profession by asserting that

emotional factors, such as sense of well-being and relationship

with one’s sexual partner, contribute more than genital

functioning to distress about sex. If sexual satisfaction is

dependent upon relational factors (McConaghy, 2004), sex

therapy, which has been since its origin relational in orientation,

has a place in the contemporary treatment of sexual concerns.

Definitions of women’s sexual dysfunctions can be reconsidered

without resorting to overmedicalization. Recommended changes

to classification should take into account contextual factors and

degree of reported distress (Basson et al., 2003). Since there exist

some empirically supported or evidenced-based treatments for

sexual dysfunction (Baucom, Shoham, Mueser, Daiuto, &

Stickle, 1998; Heiman, 2002a, 2002b; Segraves & Althof,

2002), sex therapy will likely be included in emerging integrative

biopsychosocial models of care.

The dominant emerging model for sexuality is a focus on

achieving or maintaining sexual health. Sexual health repre-

sents more than the relative absence of symptoms, duress, or

impairment. Instead, the construct of sexual health takes into

account increasing opportunities to find fulfillment and make

meaning from sexuality.

Sexuality is a central aspect of being human throughout life and

encompasses sex, gender identities and roles, sexual orienta-

tion, eroticism, pleasure, intimacy, and reproduction. Sexuality

is experienced and expressed in thoughts, fantasies, desires,

beliefs, attitudes, values, behaviors, practices, roles, relation-

ships, and so on. Sexuality is influenced by the interaction of

biological, psychological, social, economic, political, cultural,

legal, historical, religious, and spiritual factors (World Health

Organization conference on sexual health, January 2002).

Similarly, sexual health affords a goal or ideal for organizing

various aspects of intimacy in an intentional pair-bond or

relationship.

Sexual health is the integration of the somatic, emotional,

intellectual, and social aspects of sexual well-being, in ways

that are positively enriching and that enhance personality, com-

munication, and love (World Health Organization in Firestone,

Firestone, & Catlett, 2006, p. 11).

Sexual health exists within the individual and is shared by a

loving couple with a supportive community. A sexually healthy

adult expresses one’s sexual preferences, which are congruent

with personal values while respecting the rights of others.

Healthy sexualities may include the absence of genital sexual

activity and reproduction and increase love, intimacy, and joy

in relationships. Sexuality counseling, which takes into account

the developmental significance of individual sexual fulfillment

and opportunities for intimate relationships, is especially well

suited to advance sexual health in the next millennium.

Historical Overview: From Sex Therapy
to Sexuality Counseling

Sexuality counseling is a professional specialization in transi-

tion. During a relatively brief modern history of approximately

Southern and Cade 247

40 years, the overall field of sex therapy has experienced major

paradigm shifts. Originally, sex therapy was within the domain

of psychoanalysis, though it was not identified as sex therapy at

the time. Freud and his followers provided psychoanalytic ther-

apy from a psychosexual perspective whereby sexual problems

were viewed as symptoms of neuroses and manifestations of a

deeper conflict in the individual. Problems in psychosexual

development interfered with the unfolding of sexual maturity,

which was signified in the capacity to experience orgasm in

heterosexual vaginal intercourse (Person, 2005). Freud and his

students offered psychoanalysis, a technique that addressed

only indirectly the sexual experiences of patients. His tech-

niques were revolutionary and controversial in Victorian times.

Transference, countertransference, and the development of

insight were the catalysts for change in this theoretical orienta-

tion. The psychoanalytic approach was both cost and time

intensive and was not known for its effectiveness (Kleinplatz,

2003).

Classic Models

Kinsey and colleagues (Kinsey, Pomeroy, & Martin, 1948;

Kinsey, Pomeroy, Martin, & Gebhard, 1953) advanced

knowledge about a wide range of sexual behavior through

sexual history, interview, correspondence, pornography, and

self-exploration through large-scale surveys about sexual beha-

vior in the 1940s. His surveys were the first of their kind and the

data obtained from the surveys allowed Kinsey to draw a distinc-

tion between what society deemed to be normal and what people

actually did sexually (Goodwach, 2005). The published results

of Kinsey’s studies informed professional and lay audiences

about the prevalence of sexual variance in the population.

Masters pioneered hormone replacement therapy and estab-

lished an extensive research program in human sexual func-

tioning. In the laboratory, he monitored physiological

changes during masturbation and intercourse. Later, Masters

developed with Virginia Johnson sex therapy. This therapy was

more short-term in comparison to psychotherapy approaches,

included both partners in a couple, and the therapy was con-

ducted by a male–female cotherapy team to reduce risk of

transference. Masters and Johnson applied their research from

the laboratory to the development of sex therapy techniques

that remain the foundation for treatment of sexual dysfunction

and dissatisfaction. The classics, Human Sexual Response, was

published in 1966, while Human Sexual Inadequacy introduced

sex therapy in 1970. The evolution of the Masters and Johnson

Institute model for sexuality, from laboratory research to brief

conjoint sex therapy has been described in detail (Maier, 2009).

Sex Therapy Ascends

During the 1970s, LoPiccolo and LoPiccolo (1978) and other

behavior therapists applied principles of counterconditioning

to sex therapy techniques. Another notable figure during this

time was Dr. Helen Singer Kaplan who integrated medical

practice, psychotherapy, and sex therapy. Considered a bridge

between psychoanalytic treatment and the more modern

behavioral methods, Kaplan’s model (1974) emphasized the

role of immediate symptoms that the clients were presenting

for treatment (Bradley & Fine, 2009). Kaplan utilized an active

and direct approach to symptoms and if this was met with resis-

tance or was unsuccessful, she would turn to psychodynamic

theory to consider deeper issues. In 1979, Kaplan pioneered

treatment of sexual desire disorders, including couple desire

discrepancies, at multiple causal levels, anticipating popular

systemic and multimodality approaches. She also introduced

medication, especially SSRI antidepressants, as an aid to over-

coming sexual phobias (Kaplan, 1979, 1983, 1987). As sex

therapies emphasized relationships in the healing process, there

was a noticeable increase in mass media attention to the issues

of sexual dysfunction

(Bradley & Fine, 2009).

Sexual Explorations

Since the 1980s, popular publications such as Cosmopolitan,

Redbook, and other mainstream magazines published articles

about such topics as orgasm, sexual satisfaction, and ways to

achieve both (Bradley & Fine, 2009). Similarly, self-help

books and non-Western sexual disciplines (i.e., Kundalini yoga

and Kama Sutra) aimed at improving sexual functioning gained

attention and popularity. This mass media attention and cul-

tural changes allowed adults to address their own sexual diffi-

culties and resulted in decreased demand for sex therapy

(Bradley & Fine, 2009).

A decade later, expansion of the Internet contributed to eas-

ily accessible content from sex information to sexual advocacy.

Individuals were free to explore their sexualities and to obtain

information and interaction related to sexual expression. While

ease of access to the Internet hastened the self-help revolution in

sexual health, anonymity, and affordability also contributed to

compulsive cybersex (Carnes, Delmonico, Griffin, & Moriarty,

2004; Cooper, 2004; Cooper, Delmonico, Griffin-Shelley, &

Mathy, 2004; Cooper, McLoughlin, Reich, & Kent-Ferraro,

2002; Cooper, Scherer, Boies, & Gordon, 1999; Southern, 2008).

In the 1990s, the term sexual addiction was coined and the

increased use of Internet-based pornography became more

omnipresent (Bradley & Fine, 2009) fueling sexual variance and

some predatory sexual activity (Carnes et al., 2004). This led to

changes in the nature of clients seeking sex therapy. The propor-

tion of clients with more pervasive and chronic sexual problems

increased while the proportion of clients needing education

dwindled (Wiederman, 1998). Serious sexual problems, resis-

tant to change through education and advocacy, were frequently

associated with a history of sexual abuse or premature erotic

awakening (Schwartz, 1996; Schwartz, Galperin, & Masters,

1995; Schwartz & Masters, 1988; Schwartz & South

ern, 1999).

Back to the Future: Recovering
Psychodynamics

The role of early sexual abuse has received considerable atten-

tion in sex therapy as well as psychotherapy in general. During

248 The Family Journal: Counseling and Therapy for Couples and Families 19(3)

the 1980s and 1990s, sex therapists were rediscovering the

contributions of psychodynamics to sexual issues. Several contri-

butors integrated sex therapy with object relations approaches

(e.g., Scharff, 1982, 1988; Scharff & Scharff, 1987). Apfelbaum

(1984, 1988, 1989) expressed an ego-analytic model of sex ther-

apy. Schnarch (1991) shifted away from a genital model of sex

therapy toward a dyadic, systems-oriented intimacy model.

Schnarch advanced the concept of the sexual crucible in which

attachment theory, individual psychodynamics, family of origin

issues, marital and family systems perspectives, and spiritual mat-

ters may be addressed in a unifying manner.

Each of the contributions to contemporary sex therapy

employed the ‘‘back to the future’’ approach by incorporating

elements of psychodynamic models to address sexual concerns

in the context of intimacy disorder. Theories have also become

more complex, integrative, or postmodern (Wiederman, 1998).

Schwartz, formerly the director of psychosexual research,

expanded the work of Masters and Johnson Institute to address

a wide range of intimacy dysfunction and trauma-based disorders

(e.g., Schwartz & Cohn, 1993; Schwartz & Southern, 1999).

A recent comprehensive model of sex therapy, exploring aspects

of intimacy dysfunction arising from negative sexual develop-

ment, was built on the structures of the psychotherapy integration

movement.

Firestone and colleagues developed a voice therapy from

depth-oriented psychodynamic therapy to address self-

destructive behaviors, overcome psychological defenses, and

free sexuality. They described in Sex and Love in Intimate

Relationships (Firestone et al., 2006) cognitive–affective–

behavioral techniques for accessing and changing the inner

voices that interfere with the development of intimacy and the

expression of sexuality in loving relationships. Thus, sex thera-

pists employ a broad range of therapeutic approaches and treat-

ment modalities.

Medicalization: Chasing Diseased Dollars

As theoretical approaches and the nature of client issues chan-

ged, so too has the role of medicine in the conceptualization

and treatment of sexual dysfunction. Leiblum and Rosen

(2000) noted the field of sex therapy has been marked by a

trend toward greater medicalization and an increasing empha-

sis upon pharmacological intervention. Recent years have

demonstrated both an increase in the number of medications

available by prescription to address the symptoms of sexual

dysfunction as well as a dramatic increase in media advertising

regarding pharmacological remedies (Bradley & Fine, 2009).

A night of television commercials for Viagra, Levitra, and

Cialis provides ample evidence of the direct marketing of

men’s sexual rehabilitation services. In addition to advertising

pharmacological options for improving sexual functioning,

these commercials normalize older people’s continuing interest

in sex (Goodwach, 2005).

The growing popularity of medical intervention for sexual

dysfunction can be attributed to a number of factors. The

growth of managed health care has contributed to an emphasis

on short-term treatments. Empirically supported treatment

(EST) research has contributed to evidence-based practice

(EBP) in all approaches to therapy. These studies are supported

by the pharmaceutical industry and encouraged by Health

Maintenance Organizations (HMOs; Kleinplatz, 2003). Insur-

ance companies are more likely to reimburse for interventions

provided by urologists and gynecologists than from sex

therapists (Wiederman, 1998). Sociocultural issues may also

promote medical intervention as opposed to therapeutic inter-

ventions for sexual dysfunction. Clients may avoid the social

stigma of a psychological basis of their sexual dysfunction and

sex therapy by seeking medical intervention and pharmaceuti-

cal treatment for their ‘‘medical disorder.’’ Since there exist

some empirically supported or evidenced-based treatments for

sexual dysfunction (Baucom et al., 1998; Heiman, 2002a,

2002b; Segraves & Althof, 2002), sex therapy will likely be

included in emerging integrative biopsychosocial models of

care. The result of these factors is that medical treatments

have been at least tried with virtually all sexual dysfunctions

(Leiblum, 2007; Wiederman, 1998).

Men Like Quick Fixes

Many individuals, especially men, attempt to avoid the

demands of intimacy and true relational therapy by seeking a

self-administered ‘‘quick fix.’’ Men have used desensitizing

gels in misguided attempts to delay ejaculation, rubber bands

and rings to prolong erection and intercourse, and various her-

bal and over-the-counter remedies to recover ‘‘potency’’; all of

which focus solely on the mechanics or hydraulics of sex. Since

male sexuality appears inexorably linked to power through

competition and conquest, it is easy to understand the allure

of sildenafil citrate (Viagra) and other effective medications.

Sexually anxious men could regain their confidence through

administration of the ‘‘little blue pill.’’ In this scenario, it would

be unnecessary to experience vulnerability, communicate one’s

feelings to a partner, or collaborate with another human being

in a course of intimacy-enhancing sex therapy. Viagra may fix

the functioning of the penis but does not fix the functioning of

the relationship, which may come as a surprise to many men.

The medicalization of sex therapy is a trend with much crit-

icism. In the medical model, the person becomes a patient and

is fixed with a procedure or pill by a medical professional

(Sheppard, Hallam-Jones, & Wylie, 2008). Kleinplatz (2003)

criticized the medical model for its emphasis on quantity, per-

formance, and objective measures (e.g., frequency and firm-

ness of erections) as opposed to the quality of sex and

measures of subjective experience (e.g., pleasure, satisfaction,

intimacy). Leiblum and Rosen (2000) warned ‘‘with the suc-

cess of new pharmacological agents, there is an inevitable

focus on biological causes for sexual dysfunction and a ten-

dency to seek simple medical solutions for more complex indi-

vidual or couples’ problems’’ (p. 11). In the most recent edition

of Principles and Practice of Sex Therapy, Leiblum (2007)

expressed the major synthesis of perspectives in sex therapy.

She noted that diagnosis and pharmacological innovations were

Southern and Cade 249

less important than cultural factors, lifestyle choices, and

integrative treatment. Leiblum (2007) concluded that the most

important goal of contemporary sex therapy is

. . . helping our patients achieve a more satisfying relationship

and quality of life using the most effective and least costly

means rather than any predetermined set of objective sexual

criteria (p. 17, italics by author).

Paradoxically, the search for the ‘‘quick fix’’ in the medicaliza-

tion of sex therapy affords opportunities for effective brief

therapies for sexual difficulties (Green & Flemons, 2004).

Victor Frankl, founder of logotherapy, actually began to

describe in the 1940s successful applications of two strategic

techniques for alleviating sexual problems, such as impotence

and frigidity (obviously the old terms with negative connota-

tions): paradoxical intention and dereflection (Frankl, 1978,

pp. 152–158). The techniques involved either prescribing the

symptom or restraining performance, respectively. The author-

itative pronouncement in the Masters and Johnson model of

treatment enlisted a directive that the couple refrain from

sexual outlet while focusing on nondemand sensual pleasuring.

Such directives can contribute to sexual intercourse in approx-

imately 30% of cases. Clearly, clients in logotherapy and sex
therapy were anticipating a quick fix in order to resume sexual

interactions.

Expectations of clients, especially in initial interactions with

caregivers, determine the future success of clinical work for

sexual problems (Miller, Donahey, & Hubble, 2004). Rather

than viewing sex therapy clients as resistant, therapists can

help clients obtain good results by joining with their view of the

problem, using the client’s language system to address matters

instead of diagnostic categories, engendering hope and expec-

tancy for beneficial change, planning for between session and

extratherapeutic contributions to change, and taking into

account the client’s stage of readiness for action (Hubble,

Duncan, & Miller, 1999; Miller, Duncan, & Hubble, 1997;

Miller et al., 2004). Stage-specific change strategies focus on

the readiness of the client to become actively engaged in the

change process.

Six distinct stages for change were identified by Prochaska

(1999) and colleagues: precontemplation, contemplation, pre-

paration, action, maintenance, and termination. During the pre-

contemplation stage, the therapist joins with the clients and

provides helpful information. Contemplation involves the

examination of potential costs and benefits of changing or

remaining the same. Stage-oriented sex therapists tailor home-

work exercises to accommodate clients who are just contem-

plating change. The therapist may suggest that clients ‘‘go

slow’’ and ask them to consider ‘‘dangers of improvement’’

(Miller et al., 2004, pp. 32–33). The stage of preparation builds

upon the slow change process introducing values, cultural con-

texts, and relationship factors. Client choices about homework

are respected and the couple engages in relationship building.

Action is the typical focus of sex therapy. In this stage, the

formerly contemplative, well-prepared couple has good

anticipation and expectation for beneficial change. They are

able to complete meaningful homework exercises between

sessions and to share their experiences with the collaborating

therapist. In the maintenance stage, the therapist helps the

couple avoid relapse by anticipating challenges. They may

make plans for ongoing exploration and growth in their sex

lives. Upon termination, the couple is ready to self-direct the

change efforts, but informed of opportunities for booster

sessions and follow-up consultation (Miller et al., 2004).

New View: Women Save Sex Therapy

Women do not want a ‘‘little pink pill’’ to fix their sexual

concerns (Hartley, 2006). Men, who stereotypically seek a

quick fix in which relational issues are bypassed, were easily

influenced by media and pharmaceutical companies to embrace

the ‘‘little blue pill.’’ Interventions such as use of Viagra limit

sex therapy to genital sexual functioning. Feminists in sex ther-

apy and related professions have articulated a New View in

which individual choice, relationship factors, and cultural val-

ues are emphasized.

Tiefer and others rejected the overmedicalization of sex

therapy, articulating instead the New View of female sexuality

(Kaschak & Tiefer, 2001; Tiefer, 2000, 2001, 2002; Tiefer,

Hall, & Tavris, 2002). Social constructionism is the most recent

and promising approach to contemporary sex therapy. As a

postmodern development, A New View of Women’s Sexual

Problems (Kaschak & Tiefer, 2001), a manifesto written by

12 clinicians and social scientists, calls into question the

disease-oriented, diagnosis-dependent, overmedicalized, and

patriarchal model of sex therapy. Tiefer (2000, 2001, 2002),

in particular, has been a persuasive critic of attempts by phar-

maceutical companies to define sexuality in terms of biological

reductionism. The feminist movement implicit in the New

View arose after the success of Viagra in treating male sexual

dysfunction. Subsequently, there was much more attention and

research directed at women’s sexual disorders. However,

Tiefer and colleagues resisted the attempts to find a ‘‘little pink

pill’’ (i.e., female Viagra or another quick fix pharmaceutical)

and ultimately challenged the validity of the disease-oriented

diagnostic criteria of the DSM-IV-TR (American Psychiatric

Association, 2000).

The New View begins with a woman-centered definition of

sexual problems: ‘‘discontent or dissatisfaction with any emo-

tional, physical, or relational aspect of sexual experience

(Kaschak & Tiefer, 2001, pp. 228–229). The New View

emphasizes the social and contextual when attempting to

describe or understand sexual concerns. Causal and curative

factors may occur in one or more of the following categories:

(a) sociocultural, political, or economic factors; (b) partner and

relationship factors; (c) psychological factors; and (d) medical

factors. Even the descending order of the categories helps to

restore balance in contemporary sex therapy. The New View

categories have validity and fit the lived experiences of women

and their partners (Nicholls, 2008). The evolution of the New

View campaign has been described in detail (Tiefer, 2008).

250 The Family Journal: Counseling and Therapy for Couples and Families 19(3)

Postmodern sex therapy will be concerned with the meaning

people make from their sex lives. Solutions to sexual concerns

may be found in one or more systems of intervention, including

the medical model of diagnosis and medication. However,

postmodern sex therapists will resist the dehumanization and

reductionism that diminish human beings to passive consumers

of new technologies and pills. If Viagra killed relationship-

oriented sex therapy, then the New View may resurrect an

inclusive, person-centered biopsychosocial approach to sexual

healing. The New View is the cornerstone of a contemporary,

integrative sexuality

counseling.

A Model for Sexuality Counseling

A clinically relevant model for sexuality counseling takes into

account classic approaches, evidence-based practices, medical

advances, and postmodern corrections to the medicalization of

sex therapy. The classic model of Annon (1976) has provided a

basic structure for the provision of sexual health services. His

PLISSIT model outlines the potential levels of intervention for

clinical decision-making. The PLISSIT model is presented

below with special attention to the stages of change in sexuality

counseling (see Miller et al., 2004).

P––Permission to talk about sexuality and sexual issues;

empathy and encouragement; empowerment to make

choices about sexual changes. (This level of the model

seems well-suited to the precontemplation and contem-

plation stages

of change.)

LI––Limited information; sex education; exploration and

clarification of gender and sexual myths and stereotypes;

information about prevalence and etiology of problems

as appropriate. (This level corresponds to the contempla-

tion and preparation stages of change.)

SS––Specific Suggestions; particular interventions, includ-

ing medical, psychological, and relational factors unique

to the case; providing contexts of choice and respect for

cultural considerations. (This level of the model

addresses the needs of the preparation and action stages

of change.)

IT––Intensive Therapy; ongoing engagement of the couple

in systematic individual and conjoint services focusing

on relationship dynamics, psychological concerns, and

complex presenting problems. (This level recognizes the

need for in-depth sexual health services to promote

maintenance of treatment gains.)

In a recent textbook, Sexuality Counseling: An Integrative

Approach (Long, Burnett, & Thomas, 2006, p. 18), the PLIS-

SIT model was used to determine who could provide the four

services. Long and colleagues observed that counselors from

marriage and family or mental health counseling training pro-

grams may be equipped by the education and clinical training

to provide Permission and Limited Information. They stated

that Specific Suggestions (i.e., typical sex therapy exercises)

and Intensive Therapy should only be performed by clinicians

whose licenses or specialized training demonstrates advanced

competency in sex therapy or supervision. Otherwise, the

authors recommended that the counselor refer to a sexuality

health care provider who presents in-depth training sufficient

to deal with the intensity of complex cases.

Two physicians (Stevenson & Elliott, 2007) organized treat-

ment recommendations according to the PLISSIT model. They

presented some of the most complex cases involving physical,

psychological, and relational factors affecting sexuality in

couples living with illness. They included most medical and

psychological interventions, including medication and injec-

tion, under the Specific Suggestions heading. Permission and

Limited Information could be provided by a nonspecialist, while

individual and marital/couples counseling and sex therapy

interventions were classified as Intensive Therapy (p. 343).

Clearly, these physicians valued the specialized training and

relational perspective of marriage and family counselors.

Referral to a Sexuality Counselor

Sexuality counseling is a specialty area in professional counsel-

ing, and therefore, it is essential to refer to a clinician with an

appropriate educational background, credentials (e.g., certifi-

cation, licensure) and advanced training and supervision in

sexuality. In addition, the sexuality counselor would require

specialized knowledge of how other clinicians’ interventions

(e.g., treatment of depression, diabetes, cardiovascular disease,

cancer) affect, engender, or exacerbate sexual problems

(Kleinplatz, 2009).

Nathan (1986) defined four levels of expertise on sexual

issues: (a) Level 1: comfort in discussing sexual material

and/or sexuality, (b) Level 2: recognition of sexual problems,

(c) Level 3: evaluation of sexual problems for intervention or

referral, and (d) Level 4: treatment of severe sexual problems.

Many clinicians are too embarrassed, uncomfortable, or wor-

ried about their lack of ability to help their clients with sexual

issues at Level 1 and so they avoid the topic altogether with

clients. Other clinicians may comfortably operate at Level 1 and

Level 2 and then make an appropriate referral for Levels 3 and 4.

Unfortunately, there are a number of well-meaning clincians with

good intentions who try to offer interventions at Levels 3 or 4 but

are simply not qualified.

In a recent study of factors contributing to the readiness of

rehabilitation counselors to address sexuality issues with their

clients, willingness to discuss sexuality was associated with

knowledge of sexuality and comfort with sexuality (Juergens,

Smedema, & Berven, 2009). Addressing even the initial levels

or stages of sexual issues required specialized training and

comfort of the counselor in general with addressing sexual

issues. Another study investigated the current status of practi-

cing clinical psychologists as sexual healthcare providers.

Reissing and Giulio (2010) surveyed 188 professional psychol-

ogists in a metropolitan Canadian city. They found that 60% of
clinicians rarely if ever asked their patients questions related to

sexuality. They concluded that the lack of sensitivity and clin-

ical involvement reflected lack of knowledge and comfort

Southern and Cade 251

arising from nonexistent to insufficient training. The psycholo-

gists recommended specialized training in sexuality and ther-

apy techniques within the clinical psychology graduate

curriculum. In addition, they recommended workshops and

continuing education in assessment and intervention tech-

niques to prepare practicing psychologists to deal with the

sexuality issues of patients. Reissing and Giulio cautioned that

psychologists who offer sexuality treatment without adequate

training and supervision could be violating ethical standards

and potentially harming the persons they intended to serve.

Sex counseling and therapy were addressed early in the coun-

seling profession (Masters & Johnson, 1976; Schiller, 1976).

Kilpatrick (1980) summarized what counselors needed to know

about human sexuality. Fyfe (1980) introduced an early training

model for human sexuality counseling. The Association for

Counselor Education and Supervision (ACES, 1990) began to

collect and share sexuality course syllabi and audiovisual mate-

rials. Gray, House, and Eicken (1996) emphasized human sexu-

ality instruction for marriage and family counselor educators.

Humphrey (2000) advocated the study of sexuality counseling

in counselor preparation programs. Harris and Hays (2008) rec-

ommended sexuality education and supervision to help clinical

members of the American Association for Marriage and Family

Therapy discuss comfortably sexual issues with their clients.

Instruction and supervision is human sexuality has been

advocated for over 35 years. Most mental health professionals

lack specialized training and experience; therefore, they are not

adequately prepared to discuss these important life concerns

with their clients. Sexual concerns are common, but the clini-

cian’s lack of information and comfort may interfere with the

disclosure and healing process. Human sexuality should be

addressed in training programs for professional counselors.

Some mental health and marriage and family counselors may

pursue specialized training required to embrace the full range

of opportunities for facilitating sexual health in clients.

Listings or directories of qualified professionals can be

found through organizations such as the Society of Sex Ther-

apy and Research (SSTAR) or American Association of Sexu-

ality Educators, Counselors and Therapists (AASECT).

Sexuality Counseling as a Process

The process of sexuality counseling begins with listening care-

fully to each member of the couple. The attuned sexuality

counselor will facilitate the clients constructing their own story

about their sexual concerns: expressing dissatisfaction, dys-

function, or distress in their own words (see Doan, 2004). The

counselor starts the process of applying lenses from a multicon-

textual perspective (Carter, 1993; Carter & McGoldrick, 1999)

to identify resources and stressors from the individual to com-

munity level, including sociocultural, spiritual, and especially

developmental contexts. The counseling profession has always

valued the developmental perspective in which one looks

beyond present difficulties to possibilities for ongoing growth

and fulfillment. The initial process of joining with the couple

sets the stage for relational assessment and introduction of the

early stages of change.

Nonpatriarchal Assessment: No Hard
or Fast Diagnoses

A relational approach sets the backdrop against which other

data may be gathered and evaluated. Flemons and Green

(2007) described the role of the curious observer who moves

among various roles, assessing and participating along the way.

They identified five relationships of particular importance in

the assessment.

1. The relationship between you and your clients.

2. The relationship between your clients.

3. The relationships between your clients and sexuality.

4. The relationship between you and your sexuality.

5. The relationships between your clients and their problems

(Flemons & Green, 2007, p. 130).

The relational approach to formulation reminds the counselor

of the centrality of relationship in sexuality while facilitating

the counselor’s examination of biases, assumptions, and expec-

tations in the intake process. Now the sexuality counselor is

ready to apply the New View.

The New View campaign for rejection of DSM diagnoses

(APA, 2000) and medicalization of women’s sexual concerns

resulted in a friendly, multicontextual framework for classify-

ing sexual problems. The classification framework confronted

the false notion that the sexual experiences of men and women

were basically equivalent. The framework rejected the human

sexual response cycle model of Masters and Johnson (1966,

1970) as the basis for diagnosis according to phase in the cycle.

Finally, the framework challenged the one-size-fits-all treat-

ment bias of medicalization. The working group countered the

focus on genital responses by emphasizing relational and socio-

cultural dimensions. (Nicholls, 2008; Tiefer, 2004).

The New View of Sexual Problems

I. Sexual problems due to sociocultural, political, or economic

factors. (20% of problems according to Nicholls, 2008)
A. Ignorance and anxiety due to inadequate sex education,

lack of access to health services, or other social

constraints.

B. Sexual avoidance or distress due to perceived inability to

meet cultural norms regarding correct or ideal sexuality.

C. Inhibitions due to conflict between the sexual norms

of one’s subculture or culture of origin and those of the

dominant culture.

D. Lack of interest, fatigue, or lack of time due to family

or work obligations.

II. Sexual problems relating to partner or relationship (65%
of problems).

A. Inhibition, avoidance, or distress arising from

betrayal, dislike, or fear of partner, partner’s abuse

252 The Family Journal: Counseling and Therapy for Couples and Families 19(3)

or couple’s unequal power, or arising from partner’s

negative patterns of communication.

B. Discrepancies in desire for sexual activity or in pre-

ferences for various sexual activities.

C. Ignorance or inhibition about communicating prefer-

ences or initiating, pacing, or shaping sexual activities.

D. Loss of sexual interest and reciprocity as a result of

conflicts over commonplace issues such as money,

schedules, or relatives, or resulting from traumatic

experiences, for example, infertility or the death of a

child.

E. Inhibitions in arousal or spontaneity due to partner’s

health status or sexual.

III. Sexual problems due to psychological factors (8% of
problems).

A. Sexual aversion, mistrust, or inhibition of sexual

pleasure due to past abuse, general personality

problems with attachment, rejection, cooperation,

or entitlement.

B. Sexual inhibition due to fear of sexual acts or of their

possible consequences, for example, pain during

intercourse, pregnancy, sexually transmitted disease,

loss of partner, loss of reputation.

IV. Sexual problems due to medical factors (7% of
problems).

A. Numerous local or systemic medical conditions

affecting neurological, neurovascular, circulatory,

endocrine, or other systems of the body.

B. Pregnancy, sexually transmitted diseases, or other

sex-related conditions.

C. Side effects of many drugs, medications, or medical

treatments.

D. Iatrogenic conditions (Working Group on a New View

of Women’s Sexual Problems in Tiefer, 2004,

pp. 254–256; retrieved from http://newviewcampaign.

org/manifesto.asp).

The percentages of women’s problems according to the

accounts by women, analyzed by Nicholls (2008), reinforces

the primacy of relational issues in sexual concerns, highlights

the significance of sociocultural factors, and turns upside down

the conventional, patriarchal view of the importance of medical

and psychological contributing factors. Nevertheless, medical

evaluation and diagnosis retain a place in the assessment

process of sexuality counseling.

Traditional Approaches to Assessment and
Diagnosis

Assessment and diagnosis of sexual problems frequently

begins by ruling out medical factors or clarifying health

problems and organic contributions. The sexuality counse-

lor should encourage a basic medical screening for clients.

However, the referral to another healthcare professional

should be made only after establishing an adequate rela-

tionship, providing permission and encouragement,

offering accurate information, and completing the multi-

contextual, relational assessment described in the previous

section.

Given the biopsychosocial nature of sexual disorders, an

individual or couple presenting sexual concerns should com-

plete a medical history and physical examination with a

physician or nurse practitioner. If indicated, relevant labora-

tory tests, such as hormonal profiles, can be completed.

Sexual dysfunction may be secondary to a known or undiag-

nosed medical condition and thus is becomes important to

investigate. Psychotropic medications or other medications

are used frequently by patients and the side effects of phar-

macotherapy may include sexual problems. Medication,

such as antidepressants, antipsychotics, and antihyperten-

sives, can cause sexual difficulties. Alcohol, cigarettes,

methadone, and nonprescription drugs, including antihista-

mines and topical vaginal medications, can also cause prob-

lems (Goodwach, 2005). Therefore, it is essential in

contemporary sex therapy practice to insure that patients

consult their family doctors or receive referral to physicians

early in the process. Frequently, it is possible for the sex

therapist and health provider to work collaboratively (South-

ern, 1999).

After health status has been determined and organic contri-

buting factors have been addressed, a comprehensive sex his-

tory should be completed. In their pioneering effort, Masters

and Johnson (1970) completed in-depth sex histories and inter-

views with both members of the ‘‘marital unit.’’ Assessment

culminated in a roundtable discussion before the implementa-

tion of an intervention tailored to the couple’s needs. Kaplan

(1983) also provided a framework for conducting a comprehen-

sive evaluation of sexual disorders, including clinical decision

trees or flow charts. The sexuality history should include the

following domains (see Carter & McGoldrick, 1999; Hertlein

& Weeks, 2009; Iasenza, 2004; Leiblum & Rosen, 1984;

Sternberg, 1986) addressed in individual, conjoint, and

roundtable formats.

1. Current sexual preferences, functioning, and satisfaction

for both partners.

2. Family of origin messages and sexual practices for the

families of both partners (possibly including a sexual

genogram).

3. Spiritual and cultural values for sexual activities (empha-

sizing embodiment and assessing shame).

4. Individual developmental history including childhood,

adolescence, and adulthood (creating safe conditions for

disclosure of abuse experiences).

5. Relationship history including major events (i.e.,

separation, onset of serious illness, pregnancies, and so

on).

6. Effects of contraception, pregnancy, illness, medication,

and the aging process.

7. Current sexual and relationship contexts regarding com-

mitment, intimacy, and passion,

Southern and Cade 253

After obtaining data about each partner’s sexual concerns, the

sexuality counselor integrates the individual presentations and

develops clinical hypotheses related to sociocultural, psycholo-

gical and relational factors in the emerging clinical portrait. In

addition, a thorough clinical assessment establishes the exper-

tise of the sexuality counselor; demystifies the sexual concerns

and reduces shameful avoidance; clarifies the particulars of the

presenting problem; and engenders hope and positive outcome

expectancies for ongoing movement through the stages of

change toward meaningful shared sexuality.

Types of Dysfunction

Although the New View (Tiefer, 1991) has contradicted the

human sexual response cycle identified initially by Masters and

Johnson (1966, 1970), it remains a central organizing construct

for understanding sexual activity, especially heterosexual inter-

course. The classic model for the sexual response cycle was

augmented by Kaplan (1974, 1979, 1983). Dysfunction accord-

ing to phase in sexual response cycle was embedded in the

Diagnostic and Statistical Manual (APA, 2000). Therefore, it

may be useful to understand the more traditional typology

while applying the New View corrections to its excesses and

potential abuses. Particular disorders for males and females

may exist in each of the phases of the sexual response cycle,

which consists of desire, arousal, orgasm, and resolution. Any

of these phase disorders can interfere with pursuit of intimate,

partner-oriented sexual expression. The following classifica-

tion system was derived from training at Masters and Johnson

Institute and the clinical practice perspective of Southern

(1999) and is intended as an aid to problem specification at the

individual level of assessment. Occasionally, there are comple-

mentary disorders presented by couples (e.g., rapid ejaculation

and anorgasmia or preorgasm). The types of dysfunction

depicted in Table 1 represent conditions specific to phases in

the sexual response cycle according to gender.

Goodwach (2005) offers three areas of criticism of the DSM

categories. First, the declassification of homosexuality as a sex-

ual disorder illustrated that diagnoses are not simply medically

based but are influenced by prevailing social mores. Secondly,

treatment based on DSM categories is problematic because

symptom removal in one partner does not necessarily translate

into sexual pleasure and satisfaction for both. And finally, this

nomenclature of sexual diagnoses has become a key contribu-

tor to reductionist thinking in the area of sexual difficulties,

because it does not reflect the complexity of sexuality, sexual

desire, or the intimate relationship.

The potential value of an outmoded, patriarchal, heterosexist

model for the human sexual response cycle (Masters & Johnson,

1966, 1970) and the diagnoses derived from it (e.g., American

Psychiatric Association, 2000; Southern, 1999) is its utility. Most

extant interventions follow differential diagnosis and various

treatments are associated with the particular diagnoses. Two pro-

minent references, Principles and Practice of Sex Therapy (Lei-

blum, 2007) and Systemic Sex Therapy (Hertlein, Weeks, &

Gambescia, 2009), are organized according to traditional

diagnosis of sexual disorder. Interventions were matched with

phase of disorder in a recent textbook, Sexuality Counseling:

An Integrative Approach (Long et al., 2006) for female sexuality

(pp. 101–102) and male sexuality (pp. 126–127). Specific Sug-

gestions and Intensive Therapy (from the PLISSIT model)

address specifically the aforementioned sexual disorders. How-

ever, an integrative model offers a framework for organizing the

ongoing clinical judgment process.

Scaffolding for Sexuality Counseling

Couples are prepared for sequential development of sexual

knowledge, skill, comfort, and meaning by exposure to sufficient

support afforded through the interventions of the sexuality coun-

selor. The framework provided by the counselor provides a tran-

sitional support for construction in process. Expert scaffolding

involves strategies and techniques that activate existing knowl-

edge, provide context and motivation, and introduce new subject

matter. Reviewing media, role playing, asking leading questions,

thinking aloud, and storytelling assist the couple to consider new

possibilities for their sexual relationship.

According to Vygotsky’s (1987) model for scaffolding, the

learner has a zone of proximal development, which is the differ-

ence between what the learner can do without help and what

can be done with help and collaboration. Our model for sexu-

ality counseling is based on the idea that the professional coun-

selor facilitates the sexual development of a couple by

introducing information and interventions that fit the current

zone or level, yet challenges them to move toward greater

self-direction, competence, flexibility, and meaning-making.

Selected interventions seem to fit initial, middle, and final

interventions in sequence (Table 2).

It is beyond the scope of even this lengthy review to describe

in detail the interventions or techniques; however, the afore-

mentioned framework provides direction for additional review.

Table 1. Types of Dysfunction by Sexual Response Cycle Phase

Type of Dysfunction

Phase Male Female

Desire Hypoactive sexual esire Hypoactive sexual
desire

Sexual aversion Sexual aversion
Sexual desire

discrepancy
Sexual desire

discrepancy
Sexual compulsion Sexual compulsion
Paraphilia Paraphilia

Arousal Erectile dysfunction Sexual arousal disorder
Orgasm Delayed ejaculation Anorgasmia/preorgasm

Rapid ejaculation
Resolution Pain Pain

Sexual compulsion Sexual compulsion
Sexual dissatisfaction Sexual dissatisfaction

Note: Common or typical presenting problems are highlighted in boldface. Pain
may be encountered in several phases, depending upon etiology, although the
conditions are reported typically during attempts at penetration or following
penetration.

254 The Family Journal: Counseling and Therapy for Couples and Families 19(3)

Techniques corresponding to three stages (precontemplation,

preparation, and action) are briefly described in the following

sections with an emphasis upon sensate focus as a core sexual-

ity counseling technique.

Bedtime Stories

The narrative approach to sexuality counseling has wide

applicability starting with the initial intake session, extending

throughout the middle or working stages, and concluding with

the couple’s optimal view of their satisfying sex life (see Doan,

2004). Initially, it is helpful to listen carefully to each member

of the couple as the story of the problem emerges. The extent to

which the couple moves toward a shared understanding of what

is changeworthy may be predictive of the course of counseling

or consultation. Ideally, they will co-construct a story, consist-

ing in a concrete image or vignette, of the problem. The sexu-

ality counselor should possess multicultural competencies and

willingness to join with the lived experiences of the client

couple. It is helpful to be familiar with actual accounts of sexual

experiences and their meanings. Sexuality counselors could be

prepared to receive and share in their clients’ stories by becoming

familiar with such works as Why Women Have Sex: Understand-

ing Sexual Motivations from Adventure and Revenge (and Every-

thing in Between) by Meston and Buss (2009).

A key component of narrative therapy involves externaliz-

ing the problem, in which a problem, formally assigned to a

member of the couple or perceived to exist inside a person, is

characterized as an intruder into the relationship (Doan,

2004; White & Epston, 1990). This permits the couple to col-

laborate in innovating a solution in which a new or preferred

story replaces an old, problematic story. Frequently, couples

use creativity and humor to banish the intruder from the bed-

room. The sexuality counselor helps the couple construct their

new story through careful questioning and understanding

responses with an open mind. Bedtime stories may be sufficient

to move the couple from precontemplation toward revolution-

ary action in which the relationship is transformed.

Sensate Focus: Out of the Head and
Into the Bed

The cornerstone of sex therapy from Masters and Johnson Insti-

tute was the assertion that ‘‘Sex is a natural function’’ (Masters

& Johnson, 1970).The goal of direct sex therapy within the

Institute’s model involved removing roadblocks to the natural

expression of sexuality within an intimate relationship.

Although Schnarch (2000) warned that ‘‘first-generation’’

approaches, emphasizing the natural function of sex and the

blockage model of treatment, could lead to pathologizing and

stuckness in individual diagnosis, direct sex therapy

Table 2. Selected Interventions in Sexuality Counseling by Stage

Stage Global Intervention Specific Techniques

Precontemplation Permission to talk about sex Possibility/solution focused therapy approaches
Encouragement
Joining and empathy Narrative/storytelling approaches
Empowerment Relaxation training

Contemplation Sex information/education Internet/media/virtual reality
Psychoeducation

Normalizing, reframing Restraining change
Paradoxical intention, dereflection

Deconstructing gender New View classification
Prevalence and etiology Differential diagnosis

Preparation Sexuality assessment Sexuality history
Multicontextual assessment Relationship assessment

Sexual genogram
Skills training Courtship recommendations

Sensate focus
Action Referral Medical history and physical

Medical intervention Examination
Collaboration Medication adjustment

Hormonal therapy
Medical/surgical intervention

Intensive therapy Couple therapy
Cognitive/voices therapy
Psychodynamic therapy

Maintenance Retention Relapse prevention
Generalization Intimacy enhancement

Optimal sexual health
Termination Celebration Ritual enactment

Follow-up Booster sessions

Southern and Cade 255

intervention is indicated for simple case presentations and to

catalyze issues for ‘‘second-generation’’ intimacy enhance-

ment. Similarly, Tiefer (2004) called into question the assertion

of sex as a natural function in her critique of biology in favor of

choice, turning the medicalization of sexual health on its head.

Sensate focus techniques are still used extensively in sex

therapy and self-help approaches. A recent review of sensate

focus (Weeks & Gambescia, 2009) brings the technique from

its biased, historical context into an enlightened, systemic

approach. They identified nine functions of sensate focus.

1. Help each partner become more aware of his or her own

sensations.

2. Focus on one’s needs for pleasure and worry less about the

problem or the partner.

3. Communicate sensual and sexual needs, wishes, and

desires.

4. Increase awareness of the partner’s sensual and sexual

needs.

5. Expand the repertoire of intimate, sensual behaviors.

6. Learn to appreciate foreplay as a goal start rather than a

means to an end.

7. Create positive relational experiences.

8. Build sexual desire.

9. Enhance the level of love, caring, commitment, intimacy,

cooperation, and sexual interest in the relationship (Weeks

& Gambescia, 2009, pp. 348–353).

These functions shift client perceptions from immediate gains

in sensual experiences toward what is possible in an intimate

relationship.

The shift in perception or focus affords a corresponding

shift from first-order toward more meaningful second-order

change, a characteristic of successful systemic interventions (see

Watzlawick, Weakland, & Fisch, 1974). Second-order change

takes into account the views and biases of the counselor–observer,

whose participation in the process transforms the shared

relationship.

First-order change refers to change within the normal defi-

nitions, understandings, premises, rules, and practices of a

given system . . . . Second-order change is a change of the

premises, definitions, practices, and traditions of a given

system of relationships. It most often represents a counterin-

tuitive stepping out or a reversal of the commonly held ideas

on the nature of the situation and its logical and reasonable

solutions. It has been described as paradoxical or ironic

(Fraser & Solovey, 2004, pp. 194–196).

Sensate focus starts in the body and arrives in the context of the

relationship.

The Masters and Johnson (1970) model for sex therapy

involved intensive treatment of couples experiencing sexual

dysfunction. The treatment would be offered daily over a

10–14-day period by a dual-gender, co-therapy team. Daily

continuity of treatment facilitated removal from environmental

distractions, recovery of courtship experience, and realization

of incremental gains. Over the years, the treatment model was

adapted to include ‘‘weekend intensives’’ and weekly outpati-

ent visits. However, the efficacy of some of the techniques

could decrease with changes in the original format (Masters

& Johnson, 1970; Schwartz & Masters, 1988).

Although the Masters and Johnson Institute model pre-

scribed specific homework exercises for particular types of

sexual dysfunction, there were several common interventions.

Through the authoritative pronouncement (Masters & Johnson,

1970, pp. 287–290), the couple is asked to refrain from sexual

outlet during the initial touching exercises. Shifting the focus

away from the demands of sexual performance enables the cou-

ple to engage in intimate conversation and courtship. Another

common intervention involves the roundtable (Masters &

Johnson, 1970, pp. 57–78) in which the results of assessment

can be discussed while sex education is initiated. A central

component of intensive sex therapy involves the famous sen-

sate focus exercises (Masters & Johnson, 1970, pp. 66–85).

Sensate focus encourages concentration on the here-and-

now sensations involved in intimate, nonsexual contact.

Initially, each member of the couple engages in ‘‘selfish touch-

ing,’’ in which touch is guided by one’s genuine interests rather

than trying to produce a response from one’s partner. If the

partner feels any discomfort or wishes to redirect the one doing

the touching, then that individual places her or his hand on top

of the partner’s hand. This practice, like other techniques in the

Masters and Johnson model, establishes the foundation for sex-

ual self-responsibility. Components of the sensate focus home-

work address such roadblocks as sexual withdrawal and

performance pressure. In this manner, the dissatisfied or dys-

functional individual becomes a participant in ongoing sexual

intimacy, rather than an anxious observer or a dehumanized sex

object.

Sensate focus and nondemand pleasuring encourage sexual

sharing within the context of intimacy. Sexual self-

responsibility contributes to assertion and active involvement

rather than spectatoring (e.g., attempting to observe one’s sex-

ual performance) or passive frustration. Each partner is treated

as the expert of one’s own body. Predictable gender differences

establish that no man will ever understand fully a woman’s

sexuality and no woman can appreciate all the connotations

of a man’s sexual experiences. Some couples may share a

heightened awareness or empathy; however, each member of

an intimate couple is first an autonomous and unique

individual.

The sensate focus homework exercises involve sensual

touching in the privacy of one’s home. Three exercises are typi-

cally completed: breasts and genitals off limits, breasts and

genitals on limits, and full body touching with opportunity for

sexual outlet through self-guided manual stimulation. When

the sensate focus exercises have been completed, the couple

is ready to address particular types of sexual dysfunction or

dissatisfaction through specific techniques. Another technique

that fits the action stage of change involves a psychodynamic

approach called voice therapy.

256 The Family Journal: Counseling and Therapy for Couples and Families 19(3)

Quieting the Voices

Some couples will require in-depth therapy addressing family

of origin issues and current couple conflicts in order to free the

sexual relationship from the pain and shame of the past. Family

of origin issues can be addressed productively in ongoing rela-

tional and individual sessions. Therapy can help the growing

individuals neutralize or counteract the inner voices that inhibit

sexual expression (Firestone et al., 2006). As Schnarch (2000)

demonstrated, sexual desire disorders, especially desire discre-

pancies, function to set limits on the capacity for genuine inti-

macy, given the current levels of differentiation and abilities to

self-soothe.

There are a number of factors, both static and dynamic, that

can contribute to intimacy dysfunction. For some clients,

trauma, especially physical and sexual abuse interferes with

intimacy and sexual functioning. Sex-negative environments

and family-of-origin messages about sex can also influence

sexual functioning and intimacy. According to Weeks (2005):

Some families are silent on the issue of sexuality. Children in

these families sometimes internalize this silence as meaning

that something is bad or wrong with sexuality. The parents do

not help them make sense of relationships or sexuality as they

mature and particularly as they become adolescents and strug-

gle with biological and emotional changes. Other families are

more toxic in the messages they transmit to their children

through their actions and words (pp. 94–95).

Messages received in childhood are internalized and can be

repeated throughout adulthood. Weeks (2005) provides two

examples family of origin messages. The first example is of

women saying their mothers told them that sex was just some-

thing that a woman had to grin and bear because it was her

duty to her husband. Another example is of a sexual lesson

passed from father to son. A man presented with an ED just

a few days after his 40th birthday. His father had made some

reference to the fact that when a man reaches 40 he loses’’it.’’

Family-of-origin messages can also stifle natural expression of

sexual exploration and curiosity. Such expressions have been

associated with punishment or ridicule leaving feelings of

shame and guilt.

Contemporary psychodynamic approaches (e.g., Althof,

1999, 2000; McDougall, 1995; Scharff, 1982; Southern,

2002) recognize the self-defeating and sadomasochistic origins

of many sexual symptoms. The sexual problems fail to

remit and the patients resist change because the symptoms are

overdetermined (i.e., have several remote and recent functions)

and frequently represent best efforts to reenact unfinished

business through the mechanism of repetition compulsion.

According to the psychodynamic perspective, meaningful

change comes slowly after examining patterns of behaviors,

meanings associated with the symptoms, and resistances to

complete homework, such as failing to complete a touching

exercise.

According to Schnarch’s (1991) sexual crucible approach,

based on Bowen’s (1978) model of family systemic

functioning, neither partner will be able to sustain true intimacy

and mutuality until each person differentiates or grows toward

a more resilient sense of self. The sexual crucible helps a cou-

ple mature during a brief, intense exposure to anxieties about

their relationship. By balancing the desire for communion with

another person and the desire to become autonomous, partners

are able to participate in a sexual relationship based on fulfill-

ment rather than a false love based on fear of emptiness.

Firestone et al. (2006) developed a powerful voice therapy

that combines psychodynamic insights with practical cogni-

tive interventions. They articulated a series of questions and

accusations that help to unearth or reveal the unhealthy

messages arising from dysfunctions in the family of origin.

Inner ‘‘voices’’ before, during, and after sex interfere with

sexual functioning and satisfaction (Firestone et al., 2006,

pp. 229–262).

Why would he want to be in a relationship with you?

She is trying to control me.

Your penis is too small.

Your breasts are not like other women’s.

Don’t have oral sex, he’ll be repulsed.

You won’t be able to satisfy her.

He’ll think you are a slut.

You’re hurting her.

She’s too needy.

He’s unreliable.

You always give in; you have no dignity.

How do you know she had an orgasm?

These inner voices can be quieted by confronting and disputing

them in the safe haven or holding environment of the therapy

session.

1. Each partner formulates the problem that he or she believes

is limiting the sexual relationship.

2. Partners give voice to self-critical and negative partner

perceptions.

3. They must contain (typically with the help of a therapist)

the anger or sadness associated with verbalizing the inner

voice.

4. Now the couple is free to explore the origins of negative

cognitions, correcting early mistakes and distorted beliefs.

5. They plan together ways to change behaviors and commu-

nications in order to counteract the old dictates of their

voices and to move toward mutually acceptable goals.

6. They may change contexts and circumstances associated

with maintaining the voices.

7. The couple can expect some strong ‘‘voice attacks’’ as they

move toward sexual fulfillment (Firestone et al., 2006,

pp. 235–237).

Intensive depth-oriented therapies are reserved for cases in

which permission and encouragement, sex information, and

specific suggestions (including the sensate focus exercises) fail

to catalyze the sexual growth process. Intensive psychotherapy

Southern and Cade 257

can be helpful in removing roadblocks that will not budge.

Repeated attempts to use rational problem solving or brief stra-

tegic interventions may be insufficient to help, leading to a

greater sense of hopeless, resignation, and withdrawal.

Removing the Roadblocks: On the
Road to Optimal Sexual Health

Sexuality counseling techniques can be used not only to

remove roadblocks linked to specific sexual disorders but also

to strengthen intimacy in committed relationships. After a

shared definition of the problem has been established, the cou-

ple can move away from blame, shame, and guilt and move

toward their goals in sexuality counseling. Couples may choose

to expand sexual scripts or schemas to tolerate change and

embrace innovation in their sexual functioning. Play, including

leisure, loving play, and sexual play can be introduced or rees-

tablished between partners. The ability to express desires and to

explore sexual fantasies and preferences may be part of the

treatment process. Goals can also include time management

and an increase in intimate partner time, challenging family

of origin messages, or making specific behavioral changes in

sexual behavior.

It is possible to identify some aspirations for the life beha-

viors of a sexually healthy adult. The following list was com-

piled by the Sexuality Information and Education Council of

the United States (SIECUS, n.d.).

� Appreciate one’s own body.
� Affirms that sexual development may or may not include

reproduction or genital sexual experience.

� Interact with both genders in respectful and appropriate
ways.

� Affirm one’s own sexual orientation and respect the sexual
orientation of others.

� Express love and intimacy in appropriate ways.
� Develop and maintain meaningful relationships.
� Avoid exploitative and manipulative relationships.
� Make informed choices about family options and lifestyles.
� Exhibit skills that enhance personal relationships.
� Discriminate between life enhancing sexual behaviors and

those that are harmful to self and/or others.

� Express one’s sexuality while respecting the sexual rights
of others.

� Express one’s sexuality in ways congruent with one’s
values.

This list of sexually healthy life behaviors affords direction for

the emerging professional specialization of sexuality

counseling.

This overview of sexuality counseling places the specializa-

tion in a historical content and between two competing para-

digms. The original thesis of classic models of sex therapy

converged on a contemporary patriarchal paradigm called med-

icalization. The antithesis of this patriarchal view, in which

male sexual functioning was emphasized, is the New View, a

feminist model reclaiming the centrality of relational and

sociocultural factors in sexual satisfaction. An integrative

sexual health perspective affords the synthesis upon which

the emerging specialization of sexuality counseling may con-

tinue to grow and flourish.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to

the research, authorship,

and/or publication of this article.

Funding

The authors received no financial support for the research, authorship,

and/or publication of this article.

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counseling.org

2014
ACA

Code of Ethics
As approved by the ACA Governing Council

AMERICAN COUNSELING
ASSOCIATION

•  2  •

© 2014 by the American Counseling Association.
All rights reserved. Note: This document may be reproduced in its entirety without permission for non-commercial
purposes only.

ACA Code of Ethics Preamble • 3
ACA Code of Ethics Purpose • 3

Section A
The Counseling Relationship • 4

Section B
Confidentiality and Privacy • 6

Section C
Professional Responsibility • 8

Section D
Relationships With Other Professionals • 10

Section E
Evaluation, Assessment, and

Interpretation • 11

Section F
Supervision, Training, and Teaching • 12

Section G
Research and Publication • 15

Section H
Distance Counseling, Technology,

and Social Media • 17

Section I
Resolving Ethical Issues • 18

Glossary of Terms • 20

Index • 21

Mission
The mission of the American Counseling Association
is to enhance the quality of life in society by promoting
the development of professional counselors, advancing
the counseling profession, and using the profession and
practice of counseling to promote respect for human
dignity and diversity.

Contents

•  3  •

ACA Code of Ethics Purpose
The ACA Code of Ethics serves six main purposes:

1. The Code sets forth the ethical obligations of ACA members and provides guidance intended to inform the ethical
practice of professional counselors.

2. The Code identifies ethical considerations relevant to professional counselors and counselors-in-training.
3. The Code enables the association to clarify for current and prospective members, and for those served by members,

the nature of the ethical responsibilities held in common by its members.
4. The Code serves as an ethical guide designed to assist members in constructing a course of action that best serves

those utilizing counseling services and establishes expectations of conduct with a primary emphasis on the role of
the professional counselor.

5. The Code helps to support the mission of ACA.
6. The standards contained in this Code serve as the basis for processing inquiries and ethics complaints

concerning ACA members.

The ACA Code of Ethics contains nine main sections that ad-
dress the following areas:

Section A: The Counseling Relationship
Section B: Confidentiality

and Privacy

Section C: Professional

Responsibility

Section D: Relationships With Other Professionals
Section E: Evaluation, Assessment, and Interpretation
Section F: Supervision, Training, and Teaching
Section G: Research and Publication
Section H: Distance Counseling, Technology, and
Social Media
Section I: Resolving Ethical Issues

Each section of the ACA Code of Ethics begins with an
introduction. The introduction to each section describes the
ethical behavior and responsibility to which counselors aspire.
The introductions help set the tone for each particular sec-
tion and provide a starting point that invites reflection on the
ethical standards contained in each part of the ACA Code of
Ethics. The standards outline professional responsibilities and
provide direction for fulfilling those ethical responsibilities.

When counselors are faced with ethical dilemmas that
are difficult to resolve, they are expected to engage in a care-
fully considered ethical decision-making process, consulting
available resources as needed. Counselors acknowledge
that resolving ethical issues is a process; ethical reasoning
includes consideration of professional values, professional
ethical principles, and ethical standards.

Counselors’ actions should be consistent with the spirit
as well as the letter of these ethical standards. No specific
ethical decision-making model is always most effective, so
counselors are expected to use a credible model of deci-
sion making that can bear public scrutiny of its applica-
tion. Through a chosen ethical decision-making process
and evaluation of the context of the situation, counselors
work collaboratively with clients to make decisions that
promote clients’ growth and development. A breach of the
standards and principles provided herein does not neces-
sarily constitute legal liability or violation of the law; such
action is established in legal and judicial proceedings.

The glossary at the end of the Code provides a concise
description of some of the terms used in the ACA Code
of Ethics.

ACA Code of Ethics Preamble
The American Counseling Association (ACA) is an educational, scientific, and professional organization whose members
work in a variety of settings and serve in multiple capacities. Counseling is a professional relationship that empowers diverse
individuals, families, and groups to accomplish mental health, wellness, education, and career goals.

Professional values are an important way of living out an ethical commitment. The following are core professional values
of the counseling profession:

1. enhancing human development throughout the life span;
2. honoring diversity and embracing a multicultural approach in support of the worth, dignity, potential, and

uniqueness of people within their social and cultural contexts;
3. promoting social justice;
4. safeguarding the integrity of the counselor–client relationship; and
5. practicing in a competent and ethical manner.

These professional values provide a conceptual basis for the ethical principles enumerated below. These principles are
the foundation for ethical behavior and decision making. The fundamental principles of professional ethical behavior are

• autonomy, or fostering the right to control the direction of one’s life;
• nonmaleficence, or avoiding actions that cause harm;
• beneficence, or working for the good of the individual and society by promoting mental health and well-being;
• justice, or treating individuals equitably and fostering fairness and equality;
• fidelity, or honoring commitments and keeping promises, including fulfilling one’s responsibilities of trust in

professional relationships; and
• veracity, or dealing truthfully with individuals with whom counselors come into professional contact.

• ACA Code of Ethics •

•  4  •

A.2.c. Developmental and
Cultural Sensitivity

Counselors communicate information
in ways that are both developmentally
and culturally appropriate. Counselors
use clear and understandable language
when discussing issues related to
informed consent. When clients have
difficulty understanding the language
that counselors use, counselors provide
necessary services (e.g., arranging for
a qualified interpreter or translator)
to ensure comprehension by clients.
In collaboration with clients, coun-
selors consider cultural implications
of informed consent procedures and,
where possible, counselors adjust their
practices accordingly.

A.2.d. Inability to Give Consent
When counseling minors, incapaci-
tated adults, or other persons unable
to give voluntary consent, counselors
seek the assent of clients to services
and include them in decision making
as appropriate. Counselors recognize
the need to balance the ethical rights
of clients to make choices, their capac-
ity to give consent or assent to receive
services, and parental or familial legal
rights and responsibilities to protect
these clients and make decisions on
their behalf.

A.2.e. Mandated Clients
C o u n s e l o r s d i s c u s s t h e re q u i re d
limitations to confidentiality when
working with clients who have been
mandated for counseling services.
Counselors also explain what type
of information and with whom that
information is shared prior to the
beginning of counseling. The client
may choose to refuse services. In this
case, counselors will, to the best of
their ability, discuss with the client
the potential consequences of refusing
counseling services.

A.3. Clients Served by Others
When counselors learn that their clients
are in a professional relationship with
other mental health professionals, they
request release from clients to inform
the other professionals and strive to
establish positive and collaborative
professional relationships.

A.4. Avoiding Harm and
Imposing Values

A.4.a. Avoiding Harm
Counselors act to avoid harming their
clients, trainees, and research par-
ticipants and to minimize or to remedy
unavoidable or unanticipated harm.

A.1.d. Support Network
Involvement

Counselors recognize that support
networks hold various meanings in
the lives of clients and consider en-
listing the support, understanding,
and involvement of others (e.g., reli-
gious/spiritual/community leaders,
family members, friends) as positive
resources, when appropriate, with
client consent.

A.2. Informed Consent
in the Counseling

Relationship

A.2.a. Informed Consent
Clients have the freedom to choose
whether to enter into or remain in
a counseling relationship and need
a d e q u a t e i n f o r m a t i o n a b o u t t h e
counseling process and the counselor.
Counselors have an obligation to re-
view in writing and verbally with cli-
ents the rights and responsibilities of
both counselors and clients. Informed
consent is an ongoing part of the
counseling process, and counselors
appropriately document discussions
of informed consent throughout the
counseling relationship.

A.2.b. Types of Information
Needed

Counselors explicitly explain to clients
the nature of all services provided.
They inform clients about issues such
as, but not limited to, the follow-
ing: the purposes, goals, techniques,
procedures, limitations, potential
risks, and benefits of services; the
counselor ’s qualifications, credentials,
relevant experience, and approach to
counseling; continuation of services
upon the incapacitation or death of
the counselor; the role of technol-
ogy; and other pertinent information.
Counselors take steps to ensure that
clients understand the implications of
diagnosis and the intended use of tests
and reports. Additionally, counselors
inform clients about fees and billing
arrangements, including procedures
for nonpayment of fees. Clients have
the right to confidentiality and to be
provided with an explanation of its
limits (including how supervisors
and/or treatment or interdisciplinary
team professionals are involved), to
obtain clear information about their
records, to participate in the ongoing
counseling plans, and to refuse any
services or modality changes and to
be advised of the consequences of
such refusal.

Section A
The Counseling

Relationship

Introduction
Counselors facilitate client growth
and development in ways that foster
the interest and welfare of clients and
promote formation of healthy relation-
ships. Trust is the cornerstone of the
counseling relationship, and counselors
have the responsibility to respect and
safeguard the client’s right to privacy
and confidentiality. Counselors actively
attempt to understand the diverse cul-
tural backgrounds of the clients they
serve. Counselors also explore their own
cultural identities and how these affect
their values and beliefs about the coun-
seling process. Additionally, counselors
are encouraged to contribute to society
by devoting a portion of their profes-
sional activities for little or no financial
return (pro bono publico).

A.1. Client Welfare
A.1.a. Primary Responsibility

The primary responsibility of counsel-
ors is to respect the dignity and promote
the welfare of clients.

A.1.b. Records and
Documentation

Counselors create, safeguard, and
maintain documentation necessary
for rendering professional services.
Regardless of the medium, counselors
include sufficient and timely docu-
mentation to facilitate the delivery and
continuity of services. Counselors
take reasonable steps to ensure that
documentation accurately reflects cli-
ent progress and services provided.
If amendments are made to records
and documentation, counselors take
steps to properly note the amendments
according to agency or institutional
policies.

A.1.c. Counseling Plans
Counselors and their clients work
jointly in devising counseling plans
t h a t o ff e r re a s o n a b l e p ro m i s e o f
success and are consistent with the
abilities, temperament, developmental
level, and circumstances of clients.
Counselors and clients regularly re-
view and revise counseling plans to
assess their continued viability and
effectiveness, respecting clients’ free-
dom of choice.

• ACA Code of Ethics •

•  5  •

A.4.b. Personal Values
Counselors are aware of—and avoid
imposing—their own values, attitudes,
beliefs, and behaviors. Counselors
respect the diversity of clients, train-
ees, 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 discrimina-
tory in nature.

A.5. Prohibited
Noncounseling Roles
and Relationships

A.5.a. Sexual and/or
Romantic Relationships
Prohibited

Sexual and/or romantic counselor–
client interactions or relationships with
current clients, their romantic partners,
or their family members are prohibited.
This prohibition applies to both in-
person and electronic interactions or
relationships.

A.5.b. Previous Sexual and/or
Romantic Relationships

Counselors are prohibited from engag-
ing in counseling relationships with
persons with whom they have had
a previous sexual and/or romantic
relationship.

A.5.c. Sexual and/or Romantic
Relationships With
Former Clients

Sexual and/or romantic counselor–
client interactions or relationships with
former clients, their romantic partners,
or their family members are prohibited
for a period of 5 years following the last
professional contact. This prohibition
applies to both in-person and electronic
interactions or relationships. Counsel-
ors, before engaging in sexual and/or
romantic interactions or relationships
with former clients, their romantic
partners, or their family members, dem-
onstrate forethought and document (in
written form) whether the interaction or
relationship can be viewed as exploitive
in any way and/or whether there is still
potential to harm the former client; in
cases of potential exploitation and/or
harm, the counselor avoids entering
into such an interaction or relationship.

A.5.d. Friends or Family
Members

Counselors are prohibited from engaging
in counseling relationships with friends
or family members with whom they have
an inability to remain objective.

A.5.e. Personal Virtual
Relationships With
Current Clients

C o u n s e l o r s a r e p r o h i b i t e d f r o m
engaging in a personal virtual re-
l a t i o n s h i p w i t h i n d i v i d u a l s w i t h
whom they have a current counseling
relationship (e.g., through social and
other media).

A.6. Managing and
Maintaining Boundaries
and Professional
Relationships

A.6.a. Previous Relationships
Counselors consider the risks and
benefits of accepting as clients those
with whom they have had a previous
relationship. These potential clients
may include individuals with whom
the counselor has had a casual, distant,
or past relationship. Examples include
mutual or past membership in a pro-
fessional association, organization, or
community. When counselors accept
these clients, they take appropriate pro-
fessional precautions such as informed
consent, consultation, supervision, and
documentation to ensure that judgment
is not impaired and no exploitation
occurs.

A.6.b. Extending Counseling
Boundaries

Counselors consider the risks and
benefits of extending current counsel-
ing relationships beyond conventional
parameters. Examples include attend-
ing a client’s formal ceremony (e.g., a
wedding/commitment ceremony or
graduation), purchasing a service or
product provided by a client (excepting
unrestricted bartering), and visiting a cli-
ent’s ill family member in the hospital. In
extending these boundaries, counselors
take appropriate professional precau-
tions such as informed consent, consul-
tation, supervision, and documentation
to ensure that judgment is not impaired
and no harm occurs.

A.6.c. Documenting Boundary
Extensions

If counselors extend boundaries as
described in A.6.a. and A.6.b., they
must officially document, prior to the
interaction (when feasible), the rationale
for such an interaction, the potential
benefit, and anticipated consequences
for the client or former client and other
individuals significantly involved with
the client or former client. When un-
intentional harm occurs to the client
or former client, or to an individual

significantly involved with the client
or former client, the counselor must
show evidence of an attempt to remedy
such harm.

A.6.d. Role Changes in the
Professional Relationship

When counselors change a role from
the original or most recent contracted
relationship, they obtain informed
consent from the client and explain the
client’s right to refuse services related
to the change. Examples of role changes
include, but are not limited to

1. changing from individual to re-
lationship or family counseling,
or vice versa;

2. changing from an evaluative
role to a therapeutic role, or vice
versa; and

3. changing from a counselor to a
mediator role, or vice versa.

Clients must be fully informed of
any anticipated consequences (e.g.,
financial, legal, personal, therapeutic)
of counselor role changes.

A.6.e. Nonprofessional
Interactions
or Relationships (Other
Than Sexual or Romantic
Interactions or
Relationships)

Counselors avoid entering into non-
professional relationships with former
clients, their romantic partners, or their
family members when the interaction is
potentially harmful to the client. This
applies to both in-person and electronic
interactions or relationships.

A.7. Roles and Relationships
at Individual, Group,
Institutional, and
Societal Levels

A.7.a. Advocacy
When appropriate, counselors advocate
at individual, group, institutional, and
societal levels to address potential bar-
riers and obstacles that inhibit access
and/or the growth and development
of clients.

A.7.b. Confidentiality and
Advocacy

Counselors obtain client consent prior
to engaging in advocacy efforts on be-
half of an identifiable client to improve
the provision of services and to work
toward removal of systemic barriers
or obstacles that inhibit client access,
growth, and development.

• ACA Code of Ethics •

•  6  •

being harmed by continued counseling.
Counselors may terminate counseling
when in jeopardy of harm by the client
or by another person with whom the cli-
ent has a relationship, or when clients do
not pay fees as agreed upon. Counselors
provide pretermination counseling and
recommend other service providers
when necessary.

A.11.d. Appropriate Transfer of
Services

When counselors transfer or refer clients
to other practitioners, they ensure that
appropriate clinical and administra-
tive processes are completed and open
communication is maintained with both
clients and practitioners.

A.12. Abandonment and
Client Neglect
Counselors do not abandon or neglect
clients in counseling. Counselors assist in
making appropriate arrangements for the
continuation of treatment, when neces-
sary, during interruptions such as vaca-
tions, illness, and following termination.

Section B
Confidentiality

and Privacy

Introduction
Counselors recognize that trust is a cor-
nerstone of the counseling relationship.
Counselors aspire to earn the trust of cli-
ents by creating an ongoing partnership,
establishing and upholding appropriate
boundaries, and maintaining confi-
dentiality. Counselors communicate
the parameters of confidentiality in a
culturally competent manner.

B.1. Respecting Client Rights
B.1.a. Multicultural/Diversity

Considerations
Counselors maintain awareness and sen-
sitivity regarding cultural meanings of
confidentiality and privacy. Counselors
respect differing views toward disclosure
of information. Counselors hold ongo-
ing discussions with clients as to how,
when, and with whom information is
to be shared.

B.1.b. Respect for Privacy
Counselors respect the privacy of
prospective and current clients. Coun-
selors request private information from
clients only when it is beneficial to the
counseling process.

A.8. Multiple Clients
When a counselor agrees to provide
counseling services to two or more
persons who have a relationship, the
counselor clarifies at the outset which
person or persons are clients and the
nature of the relationships the counselor
will have with each involved person. If
it becomes apparent that the counselor
may be called upon to perform poten-
tially conflicting roles, the counselor will
clarify, adjust, or withdraw from roles
appropriately.

A.9. Group Work
A.9.a. Screening

Counselors screen prospective group
counseling/therapy participants. To
the extent possible, counselors select
members whose needs and goals are
compatible with the goals of the group,
who will not impede the group process,
and whose well-being will not be jeop-
ardized by the group experience.

A.9.b. Protecting Clients
In a group setting, counselors take rea-
sonable precautions to protect clients
from physical, emotional, or psychologi-
cal trauma.

A.10. Fees and Business
Practices

A.10.a. Self-Referral
Counselors working in an organization
(e.g., school, agency, institution) that
provides counseling services do not
refer clients to their private practice
unless the policies of a particular orga-
nization make explicit provisions for
self-referrals. In such instances, the cli-
ents must be informed of other options
open to them should they seek private
counseling services.

A.10.b. Unacceptable Business
Practices

Counselors do not participate in fee
splitting, nor do they give or receive
commissions, rebates, or any other form
of remuneration when referring clients
for professional services.

A.10.c. Establishing Fees
In establishing fees for professional
counseling services, counselors con-
sider the financial status of clients and
locality. If a counselor’s usual fees cre-
ate undue hardship for the client, the
counselor may adjust fees, when legally
permissible, or assist the client in locat-
ing comparable, affordable services.

A.10.d. Nonpayment of Fees
If counselors intend to use collection
agencies or take legal measures to col-

lect fees from clients who do not pay for
services as agreed upon, they include
such information in their informed
consent documents and also inform
clients in a timely fashion of intended
actions and offer clients the opportunity
to make payment.

A.10.e. Bartering
Counselors may barter only if the bar-
tering does not result in exploitation
or harm, if the client requests it, and
if such arrangements are an accepted
practice among professionals in the
community. Counselors consider the
cultural implications of bartering and
discuss relevant concerns with clients
and document such agreements in a
clear written contract.

A.10.f. Receiving Gifts
Counselors understand the challenges
of accepting gifts from clients and rec-
ognize that in some cultures, small gifts
are a token of respect and gratitude.
When determining whether to accept
a gift from clients, counselors take into
account the therapeutic relationship, the
monetary value of the gift, the client’s
motivation for giving the gift, and the
counselor’s motivation for wanting to
accept or decline the gift.

A.11. Termination and
Referral

A.11.a. Competence Within
Termination and Referral

If counselors lack the competence to
be of professional assistance to clients,
they avoid entering or continuing
counseling relationships. Counselors
are knowledgeable about culturally and
clinically appropriate referral resources
and suggest these alternatives. If clients
decline the suggested referrals, counsel-
ors discontinue the relationship.

A.11.b. Values Within
Termination and Referral

Counselors refrain from referring pro-
spective and current clients based solely
on the counselor’s personally held val-
ues, attitudes, beliefs, and behaviors.
Counselors respect the diversity of
clients 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.11.c. Appropriate Termination
Counselors terminate a counseling re-
lationship when it becomes reasonably
apparent that the client no longer needs
assistance, is not likely to benefit, or is

• ACA Code of Ethics •

•  7  •

B.1.c. Respect for
Confidentiality

Counselors protect the confidential
information of prospective and current
clients. Counselors disclose information
only with appropriate consent or with
sound legal or ethical justification.

B.1.d. Explanation of
Limitations

At initiation and throughout the counsel-
ing process, counselors inform clients of
the limitations of confidentiality and seek
to identify situations in which confiden-
tiality must be breached.

B.2. Exceptions
B.2.a. Serious and Foreseeable

Harm and Legal
Requirements

The general requirement that counsel-
ors keep information confidential does
not apply when disclosure is required
to protect clients or identified others
from serious and foreseeable harm or
when legal requirements demand that
confidential information must be re-
vealed. Counselors consult with other
professionals when in doubt as to the
validity of an exception. Additional
considerations apply when addressing
end-of-life issues.

B.2.b. Confidentiality Regarding
End-of-Life Decisions

Counselors who provide services to
terminally ill individuals who are con-
sidering hastening their own deaths have
the option to maintain confidentiality,
depending on applicable laws and the
specific circumstances of the situation
and after seeking consultation or super-
vision from appropriate professional and
legal parties.

B.2.c. Contagious, Life-
Threatening Diseases

When clients disclose that they have a
disease commonly known to be both
communicable and life threatening,
counselors may be justified in disclos-
ing information to identifiable third
parties, if the parties are known to be
at serious and foreseeable risk of con-
tracting the disease. Prior to making a
disclosure, counselors assess the intent
of clients to inform the third parties
about their disease or to engage in
any behaviors that may be harmful to
an identifiable third party. Counselors
adhere to relevant state laws concern-
ing disclosure about disease status.

B.2.d. Court-Ordered Disclosure
When ordered by a court to release
confidential or privileged information

without a client’s permission, coun-
selors seek to obtain written, informed
consent from the client or take steps to
prohibit the disclosure or have it limited
as narrowly as possible because of po-
tential harm to the client or counseling
relationship.

B.2.e. Minimal Disclosure
To the extent possible, clients are
informed before confidential infor-
mation is disclosed and are involved
in the disclosure decision-making
process. When circumstances require
the disclosure of confidential infor-
mation, only essential information
is revealed.

B.3. Information Shared
With Others

B.3.a. Subordinates
Counselors make every effort to ensure
that privacy and confidentiality of
clients are maintained by subordi-
nates, including employees, supervisees,
s t u d e n t s , c l e r i c a l a s s i s t a n t s , a n d
volunteers.

B.3.b. Interdisciplinary Teams
When services provided to the client
involve participation by an interdisci-
plinary or treatment team, the client
will be informed of the team’s existence
and composition, information being
shared, and the purposes of sharing
such information.

B.3.c. Confidential Settings
Counselors discuss confidential infor-
mation only in settings in which they
can reasonably ensure client privacy.

B.3.d. Third-Party Payers
Counselors disclose information to
third-party payers only when clients
have authorized such disclosure.

B.3.e. Transmitting Confidential
Information

Counselors take precautions to ensure
the confidentiality of all information
transmitted through the use of any
medium.

B.3.f. Deceased Clients
Counselors protect the confidentiality
of deceased clients, consistent with le-
gal requirements and the documented
preferences of the client.

B.4. Groups and Families
B.4.a. Group Work

In group work, counselors clearly
explain the importance and param-
eters of confidentiality for the specific
group.

B.4.b. Couples and Family
Counseling

In couples and family counseling, coun-
selors clearly define who is considered
“the client” and discuss expectations and
limitations of confidentiality. Counselors
seek agreement and document in writing
such agreement among all involved parties
regarding the confidentiality of informa-
tion. In the absence of an agreement to the
contrary, the couple or family is considered
to be the client.

B.5. Clients Lacking Capacity
to Give Informed
Consent

B.5.a. Responsibility to Clients
When counseling minor clients or adult
clients who lack the capacity to give
voluntary, informed consent, counselors
protect the confidentiality of informa-
tion received—in any medium—in the
counseling relationship as specified by
federal and state laws, written policies,
and applicable ethical standards.

B.5.b. Responsibility to Parents
and Legal Guardians

Counselors inform parents and legal
guardians about the role of counselors
and the confidential nature of the coun-
seling relationship, consistent with cur-
rent legal and custodial arrangements.
Counselors are sensitive to the cultural
diversity of families and respect the
inherent rights and responsibilities of
parents/guardians regarding the wel-
fare of their children/charges according
to law. Counselors work to establish,
as appropriate, collaborative relation-
ships with parents/guardians to best
serve clients.

B.5.c. Release of Confidential
Information

When counseling minor clients or
adult clients who lack the capacity
to give voluntary consent to release
confidential information, counselors
seek permission from an appropriate
third party to disclose information.
In such instances, counselors inform
clients consistent with their level of
understanding and take appropriate
measures to safeguard client confi-
dentiality.

B.6. Records and
Documentation

B.6.a. Creating and Maintaining
Records and Documentation

Counselors create and maintain records
and documentation necessary for ren-
dering professional services.

• ACA Code of Ethics •

•  8  •

B.6.i. Reasonable Precautions
Counselors take reasonable precautions
to protect client confidentiality in the
event of the counselor’s termination of
practice, incapacity, or death and ap-
point a records custodian when identi-
fied as appropriate.

B.7. Case Consultation
B.7.a. Respect for Privacy

Information shared in a consulting
relationship is discussed for profes-
sional purposes only. Written and oral
reports present only data germane to the
purposes of the consultation, and every
effort is made to protect client identity
and to avoid undue invasion of privacy.

B.7.b. Disclosure of
Confidential Information

When consulting with colleagues,
counselors do not disclose confidential
information that reasonably could lead
to the identification of a client or other
person or organization with whom they
have a confidential relationship unless
they have obtained the prior consent
of the person or organization or the
disclosure cannot be avoided. They
disclose information only to the extent
necessary to achieve the purposes of the
consultation.

Section C
Professional

Responsibility

Introduction
Counselors aspire to open, honest,
and accurate communication in deal-
ing with the public and other profes-
sionals. Counselors facilitate access to
counseling services, and they practice
in a nondiscriminatory manner within
the boundaries of professional and
personal competence; they also have
a responsibility to abide by the ACA
Code of Ethics. Counselors actively
participate in local, state, and national
associations that foster the develop-
ment and improvement of counseling.
Counselors are expected to advocate
to promote changes at the individual,
group, institutional, and societal lev-
els that improve the quality of life for
individuals and groups and remove
potential barriers to the provision or
access of appropriate services being of-
fered. Counselors have a responsibility
to the public to engage in counseling
practices that are based on rigorous re-

B.6.b. Confidentiality of Records
and Documentation

Counselors ensure that records and
documentation kept in any medium are
secure and that only authorized persons
have access to them.

B.6.c. Permission to Record
Counselors obtain permission from cli-
ents prior to recording sessions through
electronic or other means.

B.6.d. Permission to Observe
Counselors obtain permission from cli-
ents prior to allowing any person to ob-
serve counseling sessions, review session
transcripts, or view recordings of sessions
with supervisors, faculty, peers, or others
within the training environment.

B.6.e. Client Access
Counselors provide reasonable access
to records and copies of records when
requested by competent clients. Coun-
selors limit the access of clients to their
records, or portions of their records,
only when there is compelling evidence
that such access would cause harm to
the client. Counselors document the
request of clients and the rationale for
withholding some or all of the records
in the files of clients. In situations
involving multiple clients, counselors
provide individual clients with only
those parts of records that relate directly
to them and do not include confidential
information related to any other client.

B.6.f. Assistance With Records
When clients request access to their re-
cords, counselors provide assistance and
consultation in interpreting counseling
records.

B.6.g. Disclosure or Transfer
Unless exceptions to confidentiality
exist, counselors obtain written permis-
sion from clients to disclose or transfer
records to legitimate third parties. Steps
are taken to ensure that receivers of
counseling records are sensitive to their
confidential nature.

B.6.h. Storage and Disposal
After Termination

Counselors store records following ter-
mination of services to ensure reasonable
future access, maintain records in ac-
cordance with federal and state laws and
statutes such as licensure laws and policies
governing records, and dispose of client
records and other sensitive materials in a
manner that protects client confidentiality.
Counselors apply careful discretion and
deliberation before destroying records
that may be needed by a court of law, such
as notes on child abuse, suicide, sexual
harassment, or violence.

search methodologies. Counselors are
encouraged to contribute to society by
devoting a portion of their professional
activity to services for which there is
little or no financial return (pro bono
publico). In addition, counselors engage
in self-care activities to maintain and
promote their own emotional, physical,
mental, and spiritual well-being to best
meet their professional responsibilities.

C.1. Knowledge of and
Compliance With
Standards
Counselors have a responsibility to
read, understand, and follow the ACA
Code of Ethics and adhere to applicable
laws and regulations.

C.2. Professional Competence
C.2.a. Boundaries of

Competence
Counselors practice only within the
boundaries of their competence, based
on their education, training, super-
vised experience, state and national
professional credentials, and appropri-
ate professional experience. Whereas
multicultural counseling competency is
required across all counseling specialties,
counselors gain knowledge, personal
awareness, sensitivity, dispositions, and
skills pertinent to being a culturally
competent counselor in working with a
diverse client population.

C.2.b. New Specialty Areas
of Practice

Counselors practice in specialty areas
new to them only after appropriate
education, training, and supervised
experience. While developing skills
in new specialty areas, counselors
take steps to ensure the competence
of their work and protect others from
possible harm.

C.2.c. Qualified for Employment
Counselors accept employment only
for positions for which they are quali-
fied given their education, training,
s u p e r v i s e d e x p e r i e n c e , s t a t e a n d
national professional credentials, and
appropriate professional experience.
Counselors hire for professional coun-
seling positions only individuals who
are qualified and competent for those
positions.

C.2.d. Monitor Effectiveness
Counselors continually monitor their effec-
tiveness as professionals and take steps to
improve when necessary. Counselors take
reasonable steps to seek peer supervision
to evaluate their efficacy as counselors.

• ACA Code of Ethics •

•  9  •

C.2.e. Consultations on
Ethical Obligations

Counselors take reasonable steps to
consult with other counselors, the
ACA Ethics and Professional Standards
Department, or related professionals
when they have questions regarding
their ethical obligations or professional
practice.

C.2.f. Continuing Education
Counselors recognize the need for con-
tinuing education to acquire and main-
tain a reasonable level of awareness
of current scientific and professional
information in their fields of activity.
Counselors maintain their competence
in the skills they use, are open to new
procedures, and remain informed re-
garding best practices for working with
diverse populations.

C.2.g. Impairment
Counselors monitor themselves for
signs of impairment from their own
physical, mental, or emotional problems
and refrain from offering or providing
professional services when impaired.
They seek assistance for problems that
reach the level of professional impair-
ment, and, if necessary, they limit,
suspend, or terminate their professional
responsibilities until it is determined
that they may safely resume their
work. Counselors assist colleagues or
supervisors in recognizing their own
professional impairment and provide
consultation and assistance when war-
ranted with colleagues or supervisors
showing signs of impairment and
intervene as appropriate to prevent
imminent harm to clients.

C.2.h. Counselor Incapacitation,
Death, Retirement, or
Termination of Practice

Counselors prepare a plan for the trans-
fer of clients and the dissemination of
records to an identified colleague or
records custodian in the case of the
counselor’s incapacitation, death, retire-
ment, or termination of practice.

C.3. Advertising and
Soliciting Clients

C.3.a. Accurate Advertising
When advertising or otherwise rep-
resenting their services to the public,
counselors identify their credentials
in an accurate manner that is not false,
misleading, deceptive, or fraudulent.

C.3.b. Testimonials
Counselors who use testimonials do
not solicit them from current clients,
former clients, or any other persons who

may be vulnerable to undue influence.
Counselors discuss with clients the
implications of and obtain permission
for the use of any testimonial.

C.3.c. Statements by Others
When feasible, counselors make reason-
able efforts to ensure that statements
made by others about them or about
the counseling profession are accurate.

C.3.d. Recruiting Through
Employment

Counselors do not use their places of
employment or institutional affiliation to
recruit clients, supervisors, or consultees
for their private practices.

C.3.e. Products and Training
Advertisements

Counselors who develop products
related to their profession or conduct
workshops or training events ensure
that the advertisements concerning
these products or events are accurate
and disclose adequate information for
consumers to make informed choices.

C.3.f. Promoting to Those Served
Counselors do not use counseling,
teaching, training, or supervisory rela-
tionships to promote their products or
training events in a manner that is de-
ceptive or would exert undue influence
on individuals who may be vulnerable.
However, counselor educators may
adopt textbooks they have authored for
instructional purposes.

C.4. Professional Qualifications
C.4.a. Accurate Representation

Counselors claim or imply only profes-
sional qualifications actually completed
and correct any known misrepresenta-
tions of their qualifications by others.
Counselors truthfully represent the qual-
ifications of their professional colleagues.
Counselors clearly distinguish between
paid and volunteer work experience
and accurately describe their continuing
education and specialized training.

C.4.b. Credentials
Counselors claim only licenses or certifica-
tions that are current and in good standing.

C.4.c. Educational Degrees
Counselors clearly differentiate be-
tween earned and honorary degrees.

C.4.d. Implying Doctoral-Level
Competence

Counselors clearly state their highest
earned degree in counseling or a closely
related field. Counselors do not imply
doctoral-level competence when pos-
sessing a master’s degree in counseling
or a related field by referring to them-

selves as “Dr.” in a counseling context
when their doctorate is not in counsel-
ing or a related field. Counselors do not
use “ABD” (all but dissertation) or other
such terms to imply competency.

C.4.e. Accreditation Status
Counselors accurately represent the
accreditation status of their degree pro-
gram and college/university.

C.4.f. Professional Membership
Counselors clearly differentiate between
current, active memberships and former
memberships in associations. Members
of ACA must clearly differentiate be-
tween professional membership, which
implies the possession of at least a mas-
ter’s degree in counseling, and regular
membership, which is open to indi-
viduals whose interests and activities are
consistent with those of ACA but are not
qualified for professional membership.

C.5. Nondiscrimination
Counselors do not condone or engage
in discrimination against prospective or
current clients, students, employees, su-
pervisees, or research participants based
on age, culture, disability, ethnicity, race,
religion/spirituality, gender, gender
identity, sexual orientation, marital/
partnership status, language preference,
socioeconomic status, immigration
status, or any basis proscribed by law.

C.6. Public Responsibility
C.6.a. Sexual Harassment

Counselors do not engage in or condone
sexual harassment. Sexual harassment
can consist of a single intense or severe act,
or multiple persistent or pervasive acts.

C.6.b. Reports to Third Parties
Counselors are accurate, honest, and
objective in reporting their professional
activities and judgments to appropriate
third parties, including courts, health
insurance companies, those who are
the recipients of evaluation reports,
and others.

C.6.c. Media Presentations
When counselors provide advice or com-
ment by means of public lectures, dem-
onstrations, radio or television programs,
recordings, technology-based applica-
tions, printed articles, mailed material,
or other media, they take reasonable
precautions to ensure that

1. the statements are based on ap-
propriate professional counsel-
ing literature and practice,

2. the statements are otherwise
consistent with the ACA Code of
Ethics, and

• ACA Code of Ethics •

•  10  •

3. the recipients of the information
are not encouraged to infer that a
professional counseling relation-
ship has been established.

C.6.d. Exploitation of Others
Counselors do not exploit others in their
professional relationships.

C.6.e. Contributing to the
Public Good
(Pro Bono Publico)

Counselors make a reasonable effort
to provide services to the public for
which there is little or no financial
return (e.g., speaking to groups, shar-
ing professional information, offering
reduced fees).

C.7. Treatment Modalities
C.7.a. Scientific Basis for

Treatment
When providing services, counselors use
techniques/procedures/modalities that
are grounded in theory and/or have an
empirical or scientific foundation.

C.7.b. Development and
Innovation

When counselors use developing or
innovative techniques/procedures/
modalities, they explain the potential
risks, benefits, and ethical considerations
of using such techniques/procedures/
modalities. Counselors work to minimize
any potential risks or harm when using
these techniques/procedures/modalities.

C.7.c. Harmful Practices
Counselors do not use techniques/pro-
cedures/modalities when substantial
evidence suggests harm, even if such
services are requested.

C.8. Responsibility to
Other Professionals

C.8.a. Personal Public
Statements

When making personal statements in a
public context, counselors clarify that they
are speaking from their personal perspec-
tives and that they are not speaking on
behalf of all counselors or the profession.

Section D
Relationships With
Other Professionals

Introduction
Professional counselors recognize
that the quality of their interactions

with colleagues can influence the
quality of services provided to clients.
They work to become knowledgeable
about colleagues within and outside
the field of counseling. Counselors
develop positive working relation-
ships and systems of communication
with colleagues to enhance services
to clients.

D.1. Relationships With
Colleagues, Employers,
and Employees

D.1.a. Different Approaches
Counselors are respectful of approaches
that are grounded in theory and/or
have an empirical or scientific founda-
tion but may differ from their own.
Counselors acknowledge the expertise
of other professional groups and are
respectful of their practices.

D.1.b. Forming Relationships
Counselors work to develop and
strengthen relationships with col-
leagues from other disciplines to best
serve clients.

D.1.c. Interdisciplinary
Teamwork

Counselors who are members of in-
terdisciplinary teams delivering mul-
tifaceted services to clients remain
focused on how to best serve clients.
They participate in and contribute to
decisions that affect the well-being of
clients by drawing on the perspectives,
values, and experiences of the counsel-
ing profession and those of colleagues
from other disciplines.

D.1.d. Establishing
Professional and
Ethical Obligations

Counselors who are members of inter-
disciplinary teams work together with
team members to clarify professional
and ethical obligations of the team as
a whole and of its individual members.
When a team decision raises ethical
concerns, counselors first attempt to
resolve the concern within the team.
If they cannot reach resolution among
team members, counselors pursue
other avenues to address their concerns
consistent with client well-being.

D.1.e. Confidentiality
When counselors are required by law,
institutional policy, or extraordinary
circumstances to serve in more than one
role in judicial or administrative pro-
ceedings, they clarify role expectations
and the parameters of confidentiality
with their colleagues.

D.1.f. Personnel Selection and
Assignment

When counselors are in a position
requiring personnel selection and/or
assigning of responsibilities to others,
they select competent staff and assign
responsibilities compatible with their
skills and experiences.

D.1.g. Employer Policies
The acceptance of employment in an
agency or institution implies that counsel-
ors are in agreement with its general poli-
cies and principles. Counselors strive to
reach agreement with employers regard-
ing acceptable standards of client care
and professional conduct that allow for
changes in institutional policy conducive
to the growth and development of clients.

D.1.h. Negative Conditions
Counselors alert their employers of inap-
propriate policies and practices. They
attempt to effect changes in such policies
or procedures through constructive action
within the organization. When such poli-
cies are potentially disruptive or damaging
to clients or may limit the effectiveness of
services provided and change cannot be af-
fected, counselors take appropriate further
action. Such action may include referral to
appropriate certification, accreditation, or
state licensure organizations, or voluntary
termination of employment.

D.1.i. Protection From
Punitive Action

Counselors do not harass a colleague
or employee or dismiss an employee
who has acted in a responsible and
ethical manner to expose inappropriate
employer policies or practices.

D.2. Provision of
Consultation Services

D.2.a. Consultant Competency
Counselors take reasonable steps to
ensure that they have the appropri-
ate resources and competencies when
providing consultation services. Coun-
selors provide appropriate referral
resources when requested or needed.

D.2.b. Informed Consent in
Formal Consultation

When providing formal consultation
services, counselors have an obligation to
review, in writing and verbally, the rights
and responsibilities of both counselors
and consultees. Counselors use clear
and understandable language to inform
all parties involved about the purpose
of the services to be provided, relevant
costs, potential risks and benefits, and
the limits of confidentiality.

• ACA Code of Ethics •

•  11  •

Section E
Evaluation, Assessment,

and Interpretation

Introduction
Counselors use assessment as one com-
ponent of the counseling process, taking
into account the clients’ personal and
cultural context. Counselors promote the
well-being of individual clients or groups
of clients by developing and using ap-
propriate educational, mental health,
psychological, and career assessments.

E.1. General
E.1.a. Assessment

The primary purpose of educational,
mental health, psychological, and career
assessment is to gather information
regarding the client for a variety of
purposes, including, but not limited
to, client decision making, treatment
planning, and forensic proceedings. As-
sessment may include both qualitative
and quantitative methodologies.

E.1.b. Client Welfare
Counselors do not misuse assessment
results and interpretations, and they
take reasonable steps to prevent others
from misusing the information pro-
vided. They respect the client’s right
to know the results, the interpretations
made, and the bases for counselors’
conclusions and recommendations.

E.2. Competence to Use and
Interpret Assessment
Instruments

E.2.a. Limits of Competence
Counselors use only those testing and as-
sessment services for which they have been
trained and are competent. Counselors
using technology-assisted test interpreta-
tions are trained in the construct being
measured and the specific instrument
being used prior to using its technology-
based application. Counselors take reason-
able measures to ensure the proper use of
assessment techniques by persons under
their supervision.

E.2.b. Appropriate Use
Counselors are responsible for the
appropriate application, scoring, inter-
pretation, and use of assessment instru-
ments relevant to the needs of the client,
whether they score and interpret such
assessments themselves or use technol-
ogy or other services.

E.2.c. Decisions Based on
Results

Counselors responsible for decisions
involving individuals or policies that are
based on assessment results have a thor-
ough understanding of psychometrics.

E.3. Informed Consent
in Assessment

E.3.a. Explanation to Clients
Prior to assessment, counselors explain
the nature and purposes of assessment
and the specific use of results by po-
tential recipients. The explanation will
be given in terms and language that
the client (or other legally authorized
person on behalf of the client) can
understand.

E.3.b. Recipients of Results
Counselors consider the client’s and/
or examinee’s welfare, explicit under-
standings, and prior agreements in de-
termining who receives the assessment
results. Counselors include accurate
and appropriate interpretations with
any release of individual or group as-
sessment results.

E.4. Release of Data to
Qualified Personnel
Counselors release assessment data in
which the client is identified only with
the consent of the client or the client’s
legal representative. Such data are
released only to persons recognized
by counselors as qualified to interpret
the data.

E.5. Diagnosis of
Mental Disorders

E.5.a. Proper Diagnosis
Counselors take special care to provide
proper diagnosis of mental disorders.
Assessment techniques (including
personal interviews) used to determine
client care (e.g., locus of treatment, type
of treatment, recommended follow-up)
are carefully selected and appropri-
ately used.

E.5.b. Cultural Sensitivity
Counselors recognize that culture
affects the manner in which clients’
problems are defined and experienced.
Clients’ socioeconomic and cultural
experiences are considered when diag-
nosing mental disorders.

E.5.c. Historical and Social
Prejudices in the
Diagnosis of Pathology

Counselors recognize historical and so-
cial prejudices in the misdiagnosis and

pathologizing of certain individuals and
groups and strive to become aware of
and address such biases in themselves
or others.

E.5.d. Refraining From
Diagnosis

Counselors may refrain from making
and/or reporting a diagnosis if they
believe that it would cause harm to the
client or others. Counselors carefully
consider both the positive and negative
implications of a diagnosis.

E.6. Instrument Selection
E.6.a. Appropriateness of

Instruments
Counselors carefully consider the
validity, reliability, psychometric limi-
tations, and appropriateness of instru-
ments when selecting assessments and,
when possible, use multiple forms of
assessment, data, and/or instruments
in forming conclusions, diagnoses, or
recommendations.

E.6.b. Referral Information
If a client is referred to a third party
for assessment, the counselor provides
specific referral questions and suf-
ficient objective data about the client
to ensure that appropriate assessment
instruments are utilized.

E.7. Conditions of
Assessment
Administration

E.7.a. Administration
Conditions

Counselors administer assessments
under the same conditions that were
established in their standardization.
When assessments are not administered
under standard conditions, as may be
necessary to accommodate clients with
disabilities, or when unusual behavior
or irregularities occur during the admin-
istration, those conditions are noted in
interpretation, and the results may be
designated as invalid or of question-
able validity.

E.7.b. Provision of Favorable
Conditions

Counselors provide an appropriate
environment for the administration
of assessments (e.g., privacy, comfort,
freedom from distraction).

E.7.c. Technological
Administration

Counselors ensure that technologi-
cally administered assessments func-
tion properly and provide clients with
accurate results.

• ACA Code of Ethics •

•  12  •

adults who lack the capacity to give
voluntary consent are being evaluated,
informed written consent is obtained
from a parent or guardian.

E.13.c. Client Evaluation
Prohibited

Counselors do not evaluate current or
former clients, clients’ romantic partners,
or clients’ family members for forensic
purposes. Counselors do not counsel
individuals they are evaluating.

E.13.d. Avoid Potentially
Harmful Relationships

Counselors who provide forensic
evaluations avoid potentially harmful
professional or personal relationships
with family members, romantic part-
ners, and close friends of individuals
they are evaluating or have evaluated
in the past.

Section F
Supervision, Training,

and Teaching

Introduction
Counselor supervisors, trainers, and
educators aspire to foster meaningful
and respectful professional relation-
ships and to maintain appropriate
boundaries with supervisees and
students in both face-to-face and elec-
tronic formats. They have theoretical
and pedagogical foundations for their
work; have knowledge of supervision
models; and aim to be fair, accurate,
and honest in their assessments of
counselors, students, and supervisees.

F.1. Counselor Supervision
and Client Welfare

F.1.a. Client Welfare
A primary obligation of counseling
supervisors is to monitor the services
provided by supervisees. Counseling
supervisors monitor client welfare and
supervisee performance and profes-
sional development. To fulfill these
obligations, supervisors meet regularly
with supervisees to review the super-
visees’ work and help them become
prepared to serve a range of diverse
clients. Supervisees have a responsibil-
ity to understand and follow the ACA
Code of Ethics.

F.1.b. Counselor Credentials
Counseling supervisors work to ensure
that supervisees communicate their

E.7.d. Unsupervised
Assessments

Unless the assessment instrument is
designed, intended, and validated for
self-administration and/or scoring,
counselors do not permit unsupervised
use.

E.8. Multicultural Issues/
Diversity in Assessment
Counselors select and use with cau-
tion assessment techniques normed
on populations other than that of the
client. Counselors recognize the effects
of age, color, culture, disability, ethnic
group, gender, race, language pref-
erence, religion, spirituality, sexual
orientation, and socioeconomic status
on test administration and interpre-
tation, and they place test results in
proper perspective with other relevant
factors.

E.9. Scoring and Interpretation
of Assessments

E.9.a. Reporting
When counselors report assessment re-
sults, they consider the client’s personal
and cultural background, the level of
the client’s understanding of the results,
and the impact of the results on the
client. In reporting assessment results,
counselors indicate reservations that
exist regarding validity or reliability
due to circumstances of the assessment
or inappropriateness of the norms for
the person tested.

E.9.b. Instruments With
Insufficient Empirical
Data

Counselors exercise caution when
interpreting the results of instruments
not having sufficient empirical data to
support respondent results. The specific
purposes for the use of such instruments
are stated explicitly to the examinee.
Counselors qualify any conclusions, di-
agnoses, or recommendations made that
are based on assessments or instruments
with questionable validity or reliability.

E.9.c. Assessment Services
Counselors who provide assessment,
scoring, and interpretation services to
support the assessment process confirm
the validity of such interpretations.
They accurately describe the purpose,
norms, validity, reliability, and applica-
tions of the procedures and any special
qualifications applicable to their use.
At all times, counselors maintain their
ethical responsibility to those being
assessed.

E.10. Assessment Security
Counselors maintain the integrity
and security of tests and assessments
consistent with legal and contractual
obligations. Counselors do not appro-
priate, reproduce, or modify published
assessments or parts thereof without
acknowledgment and permission from
the publisher.

E.11. Obsolete Assessment
and Outdated Results
Counselors do not use data or results
from assessments that are obsolete or
outdated for the current purpose (e.g.,
noncurrent versions of assessments/
instruments). Counselors make every
effort to prevent the misuse of obsolete
measures and assessment data by others.

E.12. Assessment
Construction
Counselors use established scientific
procedures, relevant standards, and
current professional knowledge for
assessment design in the development,
publication, and utilization of assess-
ment techniques.

E.13. Forensic Evaluation:
Evaluation for
Legal Proceedings

E.13.a. Primary Obligations
When providing forensic evaluations,
the primary obligation of counselors is
to produce objective findings that can be
substantiated based on information and
techniques appropriate to the evalua-
tion, which may include examination of
the individual and/or review of records.
Counselors form professional opinions
based on their professional knowledge
and expertise that can be supported
by the data gathered in evaluations.
Counselors define the limits of their
reports or testimony, especially when
an examination of the individual has
not been conducted.

E.13.b. Consent for Evaluation
Individuals being evaluated are in-
formed in writing that the relationship
is for the purposes of an evaluation and
is not therapeutic in nature, and enti-
ties or individuals who will receive the
evaluation report are identified. Coun-
selors who perform forensic evalua-
tions obtain written consent from those
being evaluated or from their legal
representative unless a court orders
evaluations to be conducted without
the written consent of the individuals
being evaluated. When children or

• ACA Code of Ethics •

•  13  •

qualifications to render services to their
clients.

F.1.c. Informed Consent and
Client Rights

Supervisors make supervisees aware of
client rights, including the protection
of client privacy and confidentiality in
the counseling relationship. Supervis-
ees provide clients with professional
disclosure information and inform
them of how the supervision process
influences the limits of confidential-
ity. Supervisees make clients aware of
who will have access to records of the
counseling relationship and how these
records will be stored, transmitted, or
otherwise reviewed.

F.2. Counselor Supervision
Competence

F.2.a. Supervisor Preparation
Prior to offering supervision services,
counselors are trained in supervision
methods and techniques. Counselors
who offer supervision services regularly
pursue continuing education activities,
including both counseling and supervi-
sion topics and skills.

F.2.b. Multicultural Issues/
Diversity in Supervision

Counseling supervisors are aware of and
address the role of multiculturalism/
diversity in the supervisory relationship.

F.2.c. Online Supervision
When using technology in supervision,
counselor supervisors are competent in
the use of those technologies. Supervi-
sors take the necessary precautions
to protect the confidentiality of all
information transmitted through any
electronic means.

F.3. Supervisory Relationship
F.3.a. Extending Conventional

Supervisory Relationships
Counseling supervisors clearly define
and maintain ethical professional,
personal, and social relationships with
their supervisees. Supervisors con-
sider the risks and benefits of extend-
ing current supervisory relationships
in any form beyond conventional
parameters. In extending these bound-
aries, supervisors take appropriate
professional precautions to ensure that
judgment is not impaired and that no
harm occurs.

F.3.b. Sexual Relationships
Sexual or romantic interactions or rela-
tionships with current supervisees are
prohibited. This prohibition applies to

both in-person and electronic interac-
tions or relationships.

F.3.c. Sexual Harassment
Counseling supervisors do not con-
done or subject supervisees to sexual
harassment.

F.3.d. Friends or Family
Members

Supervisors are prohibited from engag-
ing in supervisory relationships with
individuals with whom they have an
inability to remain objective.

F.4. Supervisor
Responsibilities

F.4.a. Informed Consent for
Supervision

Supervisors are responsible for incor-
porating into their supervision the
principles of informed consent and
participation. Supervisors inform su-
pervisees of the policies and procedures
to which supervisors are to adhere and
the mechanisms for due process appeal
of individual supervisor actions. The
issues unique to the use of distance
supervision are to be included in the
documentation as necessary.

F.4.b. Emergencies and
Absences

Supervisors establish and communi-
cate to supervisees procedures for con-
tacting supervisors or, in their absence,
alternative on-call supervisors to assist
in handling crises.

F.4.c. Standards for Supervisees
Supervisors make their supervisees
aware of professional and ethical
standards and legal responsibilities.

F.4.d. Termination of the
Supervisory Relationship

Supervisors or supervisees have the
right to terminate the supervisory
relationship with adequate notice. Rea-
sons for considering termination are
discussed, and both parties work to
resolve differences. When termination
is warranted, supervisors make appro-
priate referrals to possible alternative
supervisors.

F.5. Student and Supervisee
Responsibilities

F.5.a. Ethical Responsibilities
Students and supervisees have a re-
sponsibility to understand and follow
the ACA Code of Ethics. Students and
supervisees have the same obligation to
clients as those required of professional
counselors.

F.5.b. Impairment
Students and supervisees monitor
themselves for signs of impairment
from their own physical, mental, or
emotional problems and refrain from
offering or providing professional
services when such impairment is
likely to harm a client or others. They
notify their faculty and/or supervi-
sors and seek assistance for problems
that reach the level of professional
impairment, and, if necessary, they
limit, suspend, or terminate their
professional responsibilities until it
is determined that they may safely
resume their work.

F.5.c. Professional Disclosure
Before providing counseling services,
students and supervisees disclose
their status as supervisees and explain
how this status affects the limits of
confidentiality. Supervisors ensure
that clients are aware of the services
rendered and the qualifications of the
students and supervisees rendering
those services. Students and super-
visees obtain client permission before
they use any information concerning
the counseling relationship in the
training process.

F.6. Counseling Supervision
Evaluation, Remediation,
and Endorsement

F.6.a. Evaluation
Supervisors document and provide
supervisees with ongoing feedback
regard i ng t hei r p er for m anc e an d
schedule periodic formal evaluative
sessions throughout the supervisory
relationship.

F.6.b. Gatekeeping and
Remediation

Through initial and ongoing evalua-
tion, supervisors are aware of super-
visee limitations that might impede
performance. Supervisors assist su-
pervisees in securing remedial assis-
tance when needed. They recommend
dismissal from training programs,
applied counseling settings, and state
or voluntary professional credential-
ing processes when those supervisees
are unable to demonstrate that they
can provide competent professional
services to a range of diverse clients.
Supervisors seek consultation and
document their decisions to dismiss or
refer supervisees for assistance. They
ensure that supervisees are aware of
options available to them to address
such decisions.

• ACA Code of Ethics •

•  14  •

F.6.c. Counseling for
Supervisees

If supervisees request counseling, the
supervisor assists the supervisee in
identifying appropriate services. Su-
pervisors do not provide counseling
services to supervisees. Supervisors
address interpersonal competencies in
terms of the impact of these issues on
clients, the supervisory relationship,
and professional functioning.

F.6.d. Endorsements
Supervisors endorse supervisees for
certification, licensure, employment,
or completion of an academic or train-
ing program only when they believe
that supervisees are qualified for the
endorsement. Regardless of qualifi-
cations, supervisors do not endorse
supervisees whom they believe to be
impaired in any way that would inter-
fere with the performance of the duties
associated with the endorsement.

F.7. Responsibilities of
Counselor Educators

F.7.a. Counselor Educators
Counselor educators who are respon-
sible for developing, implementing,
and supervising educational programs
are skilled as teachers and practitio-
ners. They are knowledgeable regard-
ing the ethical, legal, and regulatory
aspects of the profession; are skilled
in applying that knowledge; and
make students and supervisees aware
of their responsibilities. Whether in
traditional, hybrid, and/or online
formats, counselor educators conduct
counselor education and training
programs in an ethical manner and
serve as role models for professional
behavior.

F.7.b. Counselor Educator
Competence

Counselors who function as counselor
educators or supervisors provide in-
struction within their areas of knowl-
edge and competence and provide
instruction based on current informa-
tion and knowledge available in the
profession. When using technology to
deliver instruction, counselor educators
develop competence in the use of the
technology.

F.7.c. Infusing Multicultural
Issues/Diversity

Counselor educators infuse material
related to multiculturalism/diver-
sity into all courses and workshops
for the development of professional
counselors.

F.7.d. Integration of Study
and Practice

In traditional, hybrid, and/or online
formats, counselor educators establish
education and training programs that
integrate academic study and super-
vised practice.

F.7.e. Teaching Ethics
Throughout the program, counselor
educators ensure that students are
aware of the ethical responsibilities
and standards of the profession and the
ethical responsibilities of students to the
profession. Counselor educators infuse
ethical considerations throughout the
curriculum.

F.7.f. Use of Case Examples
The use of client, student, or supervisee
information for the purposes of case ex-
amples in a lecture or classroom setting
is permissible only when (a) the client,
student, or supervisee has reviewed the
material and agreed to its presentation
or (b) the information has been suf-
ficiently modified to obscure identity.

F.7.g. Student-to-Student
Supervision and
Instruction

When students function in the role of
counselor educators or supervisors,
they understand that they have the
same ethical obligations as counselor
educators, trainers, and supervisors.
Counselor educators make every effort
to ensure that the rights of students are
not compromised when their peers lead
experiential counseling activities in tra-
ditional, hybrid, and/or online formats
(e.g., counseling groups, skills classes,
clinical supervision).

F.7.h. Innovative Theories and
Techniques

Counselor educators promote the use
of techniques/procedures/modalities
that are grounded in theory and/or
have an empirical or scientific founda-
tion. When counselor educators discuss
developing or innovative techniques/
procedures/modalities, they explain the
potential risks, benefits, and ethical con-
siderations of using such techniques/
procedures/modalities.

F.7.i. Field Placements
Counselor educators develop clear
policies and provide direct assistance
within their training programs regard-
ing appropriate field placement and
other clinical experiences. Counselor
educators provide clearly stated roles
and responsibilities for the student or
supervisee, the site supervisor, and the
program supervisor. They confirm that

site supervisors are qualified to provide
supervision in the formats in which
services are provided and inform site
supervisors of their professional and
ethical responsibilities in this role.

F.8. Student Welfare
F.8.a. Program Information and

Orientation
Counselor educators recognize that
program orientation is a developmen-
tal process that begins upon students’
initial contact with the counselor educa-
tion program and continues throughout
the educational and clinical training
of students. Counselor education fac-
ulty provide prospective and current
students with information about the
counselor education program’s expecta-
tions, including

1. the values and ethical principles
of the profession;

2. the type and level of skill and
knowledge acquisition required
for successful completion of the
training;

3. technology requirements;
4. program training goals, objectives,

and mission, and subject matter to
be covered;

5. bases for evaluation;
6. training components that encour-

age self-growth or self-disclosure
as part of the training process;

7. the type of supervision settings
and requirements of the sites for
required clinical field experiences;

8. student and supervisor evalua-
tion and dismissal policies and
procedures; and

9. up-to-date employment pros-
pects for graduates.

F.8.b. Student Career Advising
Counselor educators provide career
advisement for their students and make
them aware of opportunities in the field.

F.8.c. Self-Growth Experiences
Self-growth is an expected component
of counselor education. Counselor edu-
cators are mindful of ethical principles
when they require students to engage
in self-growth experiences. Counselor
educators and supervisors inform stu-
dents that they have a right to decide
what information will be shared or
withheld in class.

F.8.d. Addressing Personal
Concerns

Counselor educators may require stu-
dents to address any personal concerns
that have the potential to affect profes-
sional competency.

• ACA Code of Ethics •

•  15  •

F.11.b. Student Diversity
Counselor educators actively attempt
to recruit and retain a diverse student
body. Counselor educators demonstrate
commitment to multicultural/diversity
competence by recognizing and valuing
the diverse cultures and types of abili-
ties that students bring to the training
experience. Counselor educators pro-
vide appropriate accommodations that
enhance and support diverse student
well-being and academic performance.

F.11.c. Multicultural/Diversity
Competence

Counselor educators actively infuse
multicultural/diversity competency in
their training and supervision practices.
They actively train students to gain
awareness, knowledge, and skills in the
competencies of multicultural practice.

Section G
Research and
Publication

Introduction
Counselors who conduct research are
encouraged to contribute to the knowl-
edge base of the profession and promote
a clearer understanding of the condi-
tions that lead to a healthy and more
just society. Counselors support the
efforts of researchers by participating
fully and willingly whenever possible.
Counselors minimize bias and respect
diversity in designing and implement-
ing research.

G.1. Research Responsibilities
G.1.a. Conducting Research

Counselors plan, design, conduct, and
report research in a manner that is con-
sistent with pertinent ethical principles,
federal and state laws, host institutional
regulations, and scientific standards
governing research.

G.1.b. Confidentiality in
Research

Counselors are responsible for under-
standing and adhering to state, federal,
agency, or institutional policies or appli-
cable guidelines regarding confidential-
ity in their research practices.

G.1.c. Independent Researchers
When counselors conduct independent
research and do not have access to an
institutional review board, they are
bound to the same ethical principles and

F.9. Evaluation and
Remediation

F.9.a. Evaluation of Students
Counselor educators clearly state to stu-
dents, prior to and throughout the train-
ing program, the levels of competency
expected, appraisal methods, and timing
of evaluations for both didactic and clini-
cal competencies. Counselor educators
provide students with ongoing feedback
regarding their performance throughout
the training program.

F.9.b. Limitations
Counselor educators, through ongoing
evaluation, are aware of and address
the inability of some students to achieve
counseling competencies. Counselor
educators do the following:

1. assist students in securing reme-
dial assistance when needed,

2. seek professional consultation
and document their decision to
dismiss or refer students for
assistance, and

3. ensure that students have recourse
in a timely manner to address
decisions requiring them to seek
assistance or to dismiss them and
provide students with due process
according to institutional policies
and procedures.

F.9.c. Counseling for Students
If students request counseling, or if
counseling services are suggested as
part of a remediation process, counselor
educators assist students in identifying
appropriate services.

F.10. Roles and Relationships
Between Counselor
Educators and Students

F.10.a. Sexual or Romantic
Relationships

Counselor educators are prohibited
from sexual or romantic interactions or
relationships with students currently
enrolled in a counseling or related pro-
gram and over whom they have power
and authority. This prohibition applies
to both in-person and electronic interac-
tions or relationships.

F.10.b. Sexual Harassment
Counselor educators do not condone or
subject students to sexual harassment.

F.10.c. Relationships With
Former Students

Counselor educators are aware of the
power differential in the relationship
between faculty and students. Faculty

members discuss with former students
potential risks when they consider
engaging in social, sexual, or other in-
timate relationships.

F.10.d. Nonacademic
Relationships

Counselor educators avoid nonacademic
relationships with students in which
there is a risk of potential harm to the
student or which may compromise the
training experience or grades assigned.
In addition, counselor educators do not
accept any form of professional services,
fees, commissions, reimbursement, or
remuneration from a site for student or
supervisor placement.

F.10.e. Counseling Services
Counselor educators do not serve
as counselors to students currently
enrolled in a counseling or related pro-
gram and over whom they have power
and authority.

F.10.f. Extending Educator–
Student Boundaries

Counselor educators are aware of the
power differential in the relationship
between faculty and students. If they
believe that a nonprofessional relation-
ship with a student may be potentially
beneficial to the student, they take pre-
cautions similar to those taken by
counselors when working with clients.
Examples of potentially beneficial in-
teractions or relationships include, but
are not limited to, attending a formal
ceremony; conducting hospital visits;
providing support during a stressful
event; or maintaining mutual mem-
bership in a professional association,
organization, or community. Coun-
selor educators discuss with students
the rationale for such interactions, the
potential benefits and drawbacks, and
the anticipated consequences for the
student. Educators clarify the specific
nature and limitations of the additional
role(s) they will have with the student
prior to engaging in a nonprofessional
relationship. Nonprofessional relation-
ships with students should be time
limited and/or context specific and
initiated with student consent.

F.11. Multicultural/Diversity
Competence in
Counselor Education
and Training Programs

F.11.a. Faculty Diversity
Counselor educators are committed
to recruiting and retaining a diverse
faculty.

• ACA Code of Ethics •

•  16  •

federal and state laws pertaining to the
review of their plan, design, conduct,
and reporting of research.

G.1.d. Deviation From
Standard Practice

Counselors seek consultation and ob-
serve stringent safeguards to protect
the rights of research participants when
research indicates that a deviation from
standard or acceptable practices may be
necessary.

G.1.e. Precautions to
Avoid Injury

Counselors who conduct research are
responsible for their participants’ wel-
fare throughout the research process
and should take reasonable precautions
to avoid causing emotional, physical, or
social harm to participants.

G.1.f. Principal Researcher
Responsibility

The ultimate responsibility for ethical
research practice lies with the principal
researcher. All others involved in the re-
search activities share ethical obligations
and responsibility for their own actions.

G.2. Rights of Research
Participants

G.2.a. Informed Consent in
Research

Individuals have the right to decline
requests to become research partici-
pants. In seeking consent, counselors
use language that
1. accurately explains the purpose

and procedures to be followed;
2. identifies any procedures that

are experimental or relatively
untried;

3. describes any attendant discom-
forts, risks, and potential power
differentials between researchers
and participants;

4. describes any benefits or changes
in individuals or organizations
that might reasonably be expected;

5. discloses appropriate alternative
procedures that would be advan-
tageous for participants;

6. offers to answer any inquiries
concerning the procedures;

7. describes any limitations on
confidentiality;

8. describes the format and potential
target audiences for the dissemi-
nation of research findings; and

9. instructs participants that they
are free to withdraw their con-
sent and discontinue participa-
tion in the project at any time,
without penalty.

G.2.b. Student/Supervisee
Participation

Researchers who involve students or
supervisees in research make clear to
them that the decision regarding par-
ticipation in research activities does
not affect their academic standing or
supervisory relationship. Students or
supervisees who choose not to partici-
pate in research are provided with an
appropriate alternative to fulfill their
academic or clinical requirements.

G.2.c. Client Participation
Counselors conducting research involv-
ing clients make clear in the informed
consent process that clients are free to
choose whether to participate in re-
search activities. Counselors take neces-
sary precautions to protect clients from
adverse consequences of declining or
withdrawing from participation.

G.2.d. Confidentiality of
Information

Information obtained about research
participants during the course of re-
search is confidential. Procedures are
implemented to protect confidentiality.

G.2.e. Persons Not
Capable of Giving
Informed Consent

When a research participant is not
capable of giving informed consent,
counselors provide an appropriate
explanation to, obtain agreement for
participation from, and obtain the ap-
propriate consent of a legally authorized
person.

G.2.f. Commitments to
Participants

Counselors take reasonable measures
to honor all commitments to research
participants.

G.2.g. Explanations After
Data Collection

After data are collected, counselors
provide participants with full clarifi-
cation of the nature of the study to re-
move any misconceptions participants
might have regarding the research.
Where scientific or human values
justify delaying or withholding infor-
mation, counselors take reasonable
measures to avoid causing harm.

G.2.h. Informing Sponsors
Counselors inform sponsors, insti-
tutions, and publication channels
regarding research procedures and
outcomes. Counselors ensure that
appropriate bodies and authorities
are given pertinent information and
acknowledgment.

G.2.i. Research Records
Custodian

As appropriate, researchers prepare and
disseminate to an identified colleague or
records custodian a plan for the transfer
of research data in the case of their inca-
pacitation, retirement, or death.

G.3. Managing and
Maintaining Boundaries

G.3.a. Extending Researcher–
Participant Boundaries

Researchers consider the risks and ben-
efits of extending current research rela-
tionships beyond conventional param-
eters. When a nonresearch interaction
between the researcher and the research
participant may be potentially ben-
eficial, the researcher must document,
prior to the interaction (when feasible),
the rationale for such an interaction, the
potential benefit, and anticipated con-
sequences for the research participant.
Such interactions should be initiated
with appropriate consent of the research
participant. Where unintentional harm
occurs to the research participant, the
researcher must show evidence of an
attempt to remedy such harm.

G.3.b. Relationships With
Research Participants

Sexual or romantic counselor–research
participant interactions or relationships
with current research participants are
prohibited. This prohibition applies to
both in-person and electronic interactions
or relationships.

G.3.c. Sexual Harassment and
Research Participants

Researchers do not condone or subject re-
search participants to sexual harassment.

G.4. Reporting Results
G.4.a. Accurate Results

Counselors plan, conduct, and report
research accurately. Counselors do not
engage in misleading or fraudulent re-
search, distort data, misrepresent data,
or deliberately bias their results. They
describe the extent to which results are
applicable for diverse populations.

G.4.b. Obligation to Report
Unfavorable Results

Counselors report the results of any
research of professional value. Results
that reflect unfavorably on institutions,
programs, services, prevailing opinions,
or vested interests are not withheld.

G.4.c. Reporting Errors
If counselors discover significant errors
in their published research, they take

• ACA Code of Ethics •

•  17  •

G.5.e. Agreement of
Contributors

Counselors who conduct joint research
with colleagues or students/supervi-
sors establish agreements in advance re-
garding allocation of tasks, publication
credit, and types of acknowledgment
that will be received.

G.5.f. Student Research
Manuscripts or professional presen-
tations in any medium that are sub-
stantially based on a student’s course
papers, projects, dissertations, or theses
are used only with the student’s permis-
sion and list the student as lead author.

G.5.g. Duplicate Submissions
Counselors submit manuscripts for con-
sideration to only one journal at a time.
Manuscripts that are published in whole
or in substantial part in one journal or
published work are not submitted for
publication to another publisher with-
out acknowledgment and permission
from the original publisher.

G.5.h. Professional Review
Counselors who review material sub-
mitted for publication, research, or
other scholarly purposes respect the
confidentiality and proprietary rights
of those who submitted it. Counselors
make publication decisions based on
valid and defensible standards. Coun-
selors review article submissions in a
timely manner and based on their scope
and competency in research methodolo-
gies. Counselors who serve as reviewers
at the request of editors or publishers
make every effort to only review ma-
terials that are within their scope of
competency and avoid personal biases.

Section H
Distance Counseling,

Technology, and
Social Media

Introduction
Counselors understand that the profes-
sion of counseling may no longer be
limited to in-person, face-to-face inter-
actions. Counselors actively attempt to
understand the evolving nature of the
profession with regard to distance coun-
seling, technology, and social media and
how such resources may be used to bet-
ter serve their clients. Counselors strive
to become knowledgeable about these
resources. Counselors understand the

reasonable steps to correct such errors
in a correction erratum or through other
appropriate publication means.

G.4.d. Identity of Participants
Counselors who supply data, aid in
the research of another person, report
research results, or make original data
available take due care to disguise the
identity of respective participants in
the absence of specific authorization
from the participants to do otherwise.
In situations where participants self-
identify their involvement in research
studies, researchers take active steps
to ensure that data are adapted/
changed to protect the identity and
welfare of all parties and that discus-
sion of results does not cause harm to
participants.

G.4.e. Replication Studies
Counselors are obligated to make
available sufficient original research
information to qualified professionals
who may wish to replicate or extend
the study.

G.5. Publications and
Presentations

G.5.a. Use of Case Examples
The use of participants’, clients’, stu-
dents’, or supervisees’ information
for the purpose of case examples in a
presentation or publication is permis-
sible only when (a) participants, clients,
students, or supervisees have reviewed
the material and agreed to its presenta-
tion or publication or (b) the informa-
tion has been sufficiently modified to
obscure identity.

G.5.b. Plagiarism
Counselors do not plagiarize; that is,
they do not present another person’s
work as their own.

G.5.c. Acknowledging
Previous Work

In publications and presentations,
counselors acknowledge and give rec-
ognition to previous work on the topic
by others or self.

G.5.d. Contributors
Counselors give credit through joint
authorship, acknowledgment, foot-
note statements, or other appropriate
means to those who have contributed
significantly to research or concept
development in accordance with such
contributions. The principal contribu-
tor is listed first, and minor technical
or professional contributions are ac-
knowledged in notes or introductory
statements.

additional concerns related to the use
of distance counseling, technology, and
social media and make every attempt
to protect confidentiality and meet any
legal and ethical requirements for the
use of such resources.

H.1. Knowledge and
Legal Considerations

H.1.a. Knowledge and
Competency

Counselors who engage in the use of
distance counseling, technology, and/
or social media develop knowledge and
skills regarding related technical, ethical,
and legal considerations (e.g., special
certifications, additional course work).

H.1.b. Laws and Statutes
Counselors who engage in the use of dis-
tance counseling, technology, and social
media within their counseling practice
understand that they may be subject to
laws and regulations of both the coun-
selor’s practicing location and the client’s
place of residence. Counselors ensure
that their clients are aware of pertinent
legal rights and limitations governing the
practice of counseling across state lines
or international boundaries.

H.2. Informed Consent
and Security

H.2.a. Informed Consent
and Disclosure

Clients have the freedom to choose
whether to use distance counseling,
social media, and/or technology within
the counseling process. In addition to
the usual and customary protocol of
informed consent between counselor
and client for face-to-face counseling,
the following issues, unique to the use of
distance counseling, technology, and/
or social media, are addressed in the
informed consent process:

• distance counseling credentials,
physical location of practice, and
contact information;

• risks and benefits of engaging in
the use of distance counseling,
technology, and/or social media;

• possibility of technology failure
and alternate methods of service
delivery;

• anticipated response time;
• emergency procedures to follow

when the counselor is not available;
• time zone differences;
• cultural and/or language differ-

ences that may affect delivery of
services;

• ACA Code of Ethics •

•  18  •

H.5.b. Client Rights
Counselors who offer distance counseling
services and/or maintain a professional
website provide electronic links to rel-
evant licensure and professional certifica-
tion boards to protect consumer and client
rights and address ethical concerns.

H.5.c. Electronic Links
Counselors regularly ensure that elec-
tronic links are working and are profes-
sionally appropriate.

H.5.d. Multicultural and
Disability Considerations

Counselors who maintain websites
provide accessibility to persons with
disabilities. They provide translation ca-
pabilities for clients who have a different
primary language, when feasible. Coun-
selors acknowledge the imperfect nature
of such translations and accessibilities.

H.6. Social Media
H.6.a. Virtual Professional

Presence
In cases where counselors wish to
maintain a professional and personal
presence for social media use, separate
professional and personal web pages
and profiles are created to clearly distin-
guish between the two kinds of virtual
presence.

H.6.b. Social Media as Part of
Informed Consent

Counselors clearly explain to their clients,
as part of the informed consent procedure,
the benefits, limitations, and boundaries
of the use of social media.

H.6.c. Client Virtual Presence
Counselors respect the privacy of
their clients’ presence on social media
unless given consent to view such
information.

H.6.d. Use of Public
Social Media

Counselors take precautions to avoid
disclosing confidential information
through public social media.

Section I
Resolving Ethical

Issues

Introduction
Professional counselors behave in an
ethical and legal manner. They are
aware that client welfare and trust in

• possible denial of insurance
benefits; and

• social media policy.

H.2.b. Confidentiality
Maintained by the
Counselor

Counselors acknowledge the limitations
of maintaining the confidentiality of
electronic records and transmissions.
They inform clients that individuals
might have authorized or unauthorized
access to such records or transmissions
(e.g., colleagues, supervisors, employ-
ees, information technologists).

H.2.c. Acknowledgment
of Limitations

Counselors inform clients about the
inherent limits of confidentiality when
using technology. Counselors urge
clients to be aware of authorized and/
or unauthorized access to information
disclosed using this medium in the
counseling process.

H.2.d. Security
Counselors use current encryption stan-
dards within their websites and/or tech-
nology-based communications that meet
applicable legal requirements. Counselors
take reasonable precautions to ensure the
confidentiality of information transmitted
through any electronic means.

H.3. Client Verification
Counselors who engage in the use of
distance counseling, technology, and/
or social media to interact with clients
take steps to verify the client’s identity
at the beginning and throughout the
therapeutic process. Verification can
include, but is not limited to, using
code words, numbers, graphics, or other
nondescript identifiers.

H.4. Distance Counseling
Relationship

H.4.a. Benefits and Limitations
Counselors inform clients of the benefits
and limitations of using technology ap-
plications in the provision of counseling
services. Such technologies include, but are
not limited to, computer hardware and/or
software, telephones and applications, so-
cial media and Internet-based applications
and other audio and/or video communi-
cation, or data storage devices or media.

H.4.b. Professional
Boundaries in Distance
Counseling

Counselors understand the necessity of
maintaining a professional relationship
with their clients. Counselors discuss

and establish professional boundaries
with clients regarding the appropriate
use and/or application of technology
and the limitations of its use within
the counseling relationship (e.g., lack
of confidentiality, times when not ap-
propriate to use).

H.4.c. Technology-Assisted
Services

When providing technology-assisted
services, counselors make reasonable
efforts to determine that clients are
intellectually, emotionally, physically,
linguistically, and functionally capable
of using the application and that the ap-
plication is appropriate for the needs of
the client. Counselors verify that clients
understand the purpose and operation
of technology applications and follow
up with clients to correct possible mis-
conceptions, discover appropriate use,
and assess subsequent steps.

H.4.d. Effectiveness of Services
When distance counseling services are
deemed ineffective by the counselor or
client, counselors consider delivering
services face-to-face. If the counselor is
not able to provide face-to-face services
(e.g., lives in another state), the coun-
selor assists the client in identifying
appropriate services.

H.4.e. Access
Counselors provide information to
clients regarding reasonable access to
pertinent applications when providing
technology-assisted services.

H.4.f. Communication
Differences in
Electronic Media

Counselors consider the differences be-
tween face-to-face and electronic com-
munication (nonverbal and verbal cues)
and how these may affect the counseling
process. Counselors educate clients on
how to prevent and address potential
misunderstandings arising from the
lack of visual cues and voice intonations
when communicating electronically.

H.5. Records and
Web Maintenance

H.5.a. Records
Counselors maintain electronic records
in accordance with relevant laws and
statutes. Counselors inform clients on
how records are maintained electroni-
cally. This includes, but is not limited
to, the type of encryption and security
assigned to the records, and if/for how
long archival storage of transaction
records is maintained.

• ACA Code of Ethics •

•  19  •

the profession depend on a high level of
professional conduct. They hold other
counselors to the same standards and
are willing to take appropriate action
to ensure that standards are upheld.
Counselors strive to resolve ethical
dilemmas with direct and open commu-
nication among all parties involved and
seek consultation with colleagues and
supervisors when necessary. Counselors
incorporate ethical practice into their
daily professional work and engage
in ongoing professional development
regarding current topics in ethical and
legal issues in counseling. Counselors
become familiar with the ACA Policy
and Procedures for Processing Com-
plaints of Ethical Violations1 and use
it as a reference for assisting in the
enforcement of the ACA Code of Ethics.

I.1. Standards and the Law
I.1.a. Knowledge

Counselors know and understand the
ACA Code of Ethics and other applicable
ethics codes from professional organiza-
tions or certification and licensure bod-
ies of which they are members. Lack of
knowledge or misunderstanding of an
ethical responsibility is not a defense
against a charge of unethical conduct.

I.1.b. Ethical Decision Making
When counselors are faced with an eth-
ical dilemma, they use and document,
as appropriate, an ethical decision-
making model that may include, but
is not limited to, consultation; consid-
eration of relevant ethical standards,
principles, and laws; generation of
potential courses of action; deliberation
of risks and benefits; and selection of
an objective decision based on the cir-
cumstances and welfare of all involved.

I.1.c. Conflicts Between Ethics
and Laws

If ethical responsibilities conflict with
the law, regulations, and/or other gov-

erning legal authority, counselors make
known their commitment to the ACA
Code of Ethics and take steps to resolve
the conflict. If the conflict cannot be re-
solved using this approach, counselors,
acting in the best interest of the client,
may adhere to the requirements of the
law, regulations, and/or other govern-
ing legal authority.

I.2. Suspected Violations
I.2.a. Informal Resolution

When counselors have reason to believe
that another counselor is violating or has
violated an ethical standard and substan-
tial harm has not occurred, they attempt
to first resolve the issue informally with
the other counselor if feasible, provided
such action does not violate confidential-
ity rights that may be involved.

I.2.b. Reporting Ethical
Violations

If an apparent violation has substantially
harmed or is likely to substantially harm
a person or organization and is not ap-
propriate for informal resolution or is not
resolved properly, counselors take fur-
ther action depending on the situation.
Such action may include referral to state
or national committees on professional
ethics, voluntary national certification
bodies, state licensing boards, or ap-
propriate institutional authorities. The
confidentiality rights of clients should be
considered in all actions. This standard
does not apply when counselors have
been retained to review the work of
another counselor whose professional
conduct is in question (e.g., consultation,
expert testimony).

I.2.c. Consultation
When uncertain about whether a
particular situation or course of ac-
tion may be in violation of the ACA
Code of Ethics, counselors consult with
other counselors who are knowledge-
able about ethics and the ACA Code

of Ethics, with colleagues, or with
appropriate authorities, such as the
ACA Ethics and Professional Stan-
dards Department.

I.2.d. Organizational Conflicts
If the demands of an organization with
which counselors are affiliated pose
a conflict with the ACA Code of Ethics,
counselors specify the nature of such
conflicts and express to their supervi-
sors or other responsible officials their
commitment to the ACA Code of Ethics
and, when possible, work through the
appropriate channels to address the
situation.

I.2.e. Unwarranted Complaints
Counselors do not initiate, participate
in, or encourage the filing of ethics com-
plaints that are retaliatory in nature or are
made with reckless disregard or willful
ignorance of facts that would disprove
the allegation.

I.2.f. Unfair Discrimination
Against Complainants
and Respondents

Counselors do not deny individuals
employment, advancement, admission
to academic or other programs, tenure,
or promotion based solely on their
having made or their being the subject
of an ethics complaint. This does not
preclude taking action based on the
outcome of such proceedings or con-
sidering other appropriate information.

I.3. Cooperation With
Ethics Committees
Counselors assist in the process of
enforcing the ACA Code of Ethics.
Counselors cooperate with investiga-
tions, proceedings, and requirements
of the ACA Ethics Committee or eth-
ics committees of other duly consti-
tuted associations or boards having
jurisdiction over those charged with
a violation.

1See the American Counseling Association web site at http://www.counseling.org/knowledge-center/ethics

• ACA Code of Ethics •

•  20  •

Glossary of Terms
Abandonment – the inappropriate ending or arbitrary ter-

mination of a counseling relationship that puts the client
at risk.

Advocacy – promotion of the well-being of individuals, groups,
and the counseling profession within systems and organiza-
tions. Advocacy seeks to remove barriers and obstacles that
inhibit access, growth, and development.

Assent – to demonstrate agreement when a person is oth-
erwise not capable or competent to give formal consent
(e.g., informed consent) to a counseling service or plan.

Assessment – the process of collecting in-depth information
about a person in order to develop a comprehensive plan
that will guide the collaborative counseling and service
provision process.

Bartering – accepting goods or services from clients in ex-
change for counseling services.

Client – an individual seeking or referred to the professional
services of a counselor.

Confidentiality – the ethical duty of counselors to protect a
client’s identity, identifying characteristics, and private
communications.

Consultation – a professional relationship that may include,
but is not limited to, seeking advice, information, and/
or testimony.

Counseling – a professional relationship that empowers
diverse individuals, families, and groups to accomplish
mental health, wellness, education, and career goals.

Counselor Educator – a professional counselor engaged
primarily in developing, implementing, and supervising
the educational preparation of professional counselors.

Counselor Supervisor – a professional counselor who en-
gages in a formal relationship with a practicing counselor
or counselor-in-training for the purpose of overseeing that
individual’s counseling work or clinical skill development.

Culture – membership in a socially constructed way of liv-
ing, which incorporates collective values, beliefs, norms,
boundaries, and lifestyles that are cocreated with others
who share similar worldviews comprising biological,
psychosocial, historical, psychological, and other factors.

Discrimination – the prejudicial treatment of an individual
or group based on their actual or perceived membership
in a particular group, class, or category.

Distance Counseling – The provision of counseling services
by means other than face-to-face meetings, usually with
the aid of technology.

Diversity – the similarities and differences that occur within
and across cultures, and the intersection of cultural and
social identities.

Documents – any written, digital, audio, visual, or artistic
recording of the work within the counseling relationship
between counselor and client.

Encryption – process of encoding information in such a way
that limits access to authorized users.

Examinee – a recipient of any professional counseling ser-
vice that includes educational, psychological, and career
appraisal, using qualitative or quantitative techniques.

Exploitation – actions and/or behaviors that take advantage
of another for one’s own benefit or gain.

Fee Splitting – the payment or acceptance of fees for client
referrals (e.g., percentage of fee paid for rent, referral fees).

Forensic Evaluation – the process of forming professional opin-
ions for court or other legal proceedings, based on professional
knowledge and expertise, and supported by appropriate data.

Gatekeeping – the initial and ongoing academic, skill, and
dispositional assessment of students’ competency for pro-
fessional practice, including remediation and termination
as appropriate.

Impairment – a significantly diminished capacity to perform
professional functions.

Incapacitation – an inability to perform professional functions.
Informed Consent – a process of information sharing as-

sociated with possible actions clients may choose to take,
aimed at assisting clients in acquiring a full appreciation
and understanding of the facts and implications of a given
action or actions.

Instrument – a tool, developed using accepted research
practices, that measures the presence and strength of a
specified construct or constructs.

Interdisciplinary Teams – teams of professionals serving
clients that may include individuals who may not share
counselors’ responsibilities regarding confidentiality.

Minors – generally, persons under the age of 18 years, un-
less otherwise designated by statute or regulation. In
some jurisdictions, minors may have the right to consent
to counseling without consent of the parent or guardian.

Multicultural/Diversity Competence – counselors’ cul-
tural and diversity awareness and knowledge about
self and others, and how this awareness and knowledge
are applied effectively in practice with clients and cli-
ent groups.

Multicultural/Diversity Counseling – counseling that recog-
nizes diversity and embraces approaches that support the
worth, dignity, potential, and uniqueness of individuals
within their historical, cultural, economic, political, and
psychosocial contexts.

Personal Virtual Relationship – engaging in a relationship
via technology and/or social media that blurs the profes-
sional boundary (e.g., friending on social networking
sites); using personal accounts as the connection point for
the virtual relationship.

Privacy – the right of an individual to keep oneself and one’s
personal information free from unauthorized disclosure.

Privilege – a legal term denoting the protection of confidential
information in a legal proceeding (e.g., subpoena, deposi-
tion, testimony).

Pro bono publico – contributing to society by devoting a por-
tion of professional activities for little or no financial return
(e.g., speaking to groups, sharing professional information,
offering reduced fees).

Professional Virtual Relationship – using technology and/
or social media in a professional manner and maintain-
ing appropriate professional boundaries; using business
accounts that cannot be linked back to personal accounts
as the connection point for the virtual relationship (e.g., a
business page versus a personal profile).

Records – all information or documents, in any medium, that
the counselor keeps about the client, excluding personal
and psychotherapy notes.

Records of an Artistic Nature – products created by the client
as part of the counseling process.

Records Custodian – a professional colleague who agrees to
serve as the caretaker of client records for another mental
health professional.

Self-Growth – a process of self-examination and challeng-
ing of a counselor ’s assumptions to enhance professional
effectiveness.

• ACA Code of Ethics •

•  21  •

Serious and Foreseeable – when a reasonable counselor
can anticipate significant and harmful possible conse-
quences.

Sexual Harassment – sexual solicitation, physical advances,
or verbal/nonverbal conduct that is sexual in nature; oc-
curs in connection with professional activities or roles;
is unwelcome, offensive, or creates a hostile workplace
or learning environment; and/or is sufficiently severe
or intense to be perceived as harassment by a reason-
able person.

Social Justice – the promotion of equity for all people and
groups for the purpose of ending oppression and injustice
affecting clients, students, counselors, families, communi-
ties, schools, workplaces, governments, and other social
and institutional systems.

Social Media – technology-based forms of communica-
tion of ideas, beliefs, personal histories, etc. (e.g., social
networking sites, blogs).

Student – an individual engaged in formal graduate-level
counselor education.

Supervisee – a professional counselor or counselor-in-train-
ing whose counseling work or clinical skill development

is being overseen in a formal supervisory relationship by
a qualified trained professional.

Supervision – a process in which one individual, usually a
senior member of a given profession designated as the
supervisor, engages in a collaborative relationship with
another individual or group, usually a junior member(s)
of a given profession designated as the supervisee(s) in
order to (a) promote the growth and development of the
supervisee(s), (b) protect the welfare of the clients seen by
the supervisee(s), and (c) evaluate the performance of the
supervisee(s).

Supervisor – counselors who are trained to oversee the profes-
sional clinical work of counselors and counselors-in-training.

Teaching – all activities engaged in as part of a formal edu-
cational program that is designed to lead to a graduate
degree in counseling.

Training – the instruction and practice of skills related
to the counseling profession. Training contributes to
the ongoing proficiency of students and professional
counselors.

Virtual Relationship – a non–face-to-face relationship (e.g.,
through social media).

Index
ACA Code of Ethics Preamble …………………… 3
ACA Code of Ethics Purpose …………………….. 3
Section A: The Counseling

Relationship …………………………………….. 4
Section A: Introduction ………………………….. 4
A.1. Client Welfare …………………………………. 4
A.1.a. Primary Responsibility ………………… 4
A.1.b. Records and Documentation ……….. 4
A.1.c. Counseling Plans …………………………. 4
A.1.d. Support Network Involvement …… 4
A.2. Informed Consent in the

Counseling Relationship ………………….. 4
A.2.a. Informed Consent ……………………….. 4
A.2.b. Types of Information Needed ……… 4
A.2.c. Developmental and

Cultural Sensitivity ………………………….. 4
A.2.d. Inability to Give Consent …………….. 4
A.2.e. Mandated Clients ………………………… 4
A.3. Clients Served by Others ……………….. 4
A.4. Avoiding Harm and

Imposing Values ……………………………….. 4
A.4.a. Avoiding Harm ……………………………. 4
A.4.b. Personal Values …………………………… 5
A.5. Prohibited Noncounseling Roles

and Relationships …………………………….. 5
A.5.a. Sexual and/or Romantic

Relationships Prohibited ………………….. 5
A.5.b. Previous Sexual and/or

Romantic Relationships ……………………. 5
A.5.c. Sexual and/or Romantic

Relationships With Former
Clients ………………………………………………. 5

A.5.d. Friends or Family Members ………… 5
A.5.e. Personal Virtual Relationships

With Current Clients ………………………… 5
A.6. Managing and Maintaining

Boundaries and Professional
Relationships…………………………………….. 5

A.6.a. Previous Relationships ………………… 5
A.6.b. Extending Counseling

Boundaries ………………………………………. 5
A.6.c. Documenting Boundary

Extensions ……………………………………….. 5
A.6.d. Role Changes in the

Professional Relationship …………………. 5
A.6.e. Nonprofessional Interactions or

Relationships (Other Than Sexual or
Romantic Interactions or
Relationships) ………………………………….. 5

A.7. Roles and Relationships at
Individual, Group, Institutional,
and Societal Levels ……………………………. 5

A.7.a. Advocacy …………………………………….. 5
A.7.b. Confidentiality and Advocacy …….. 5
A.8. Multiple Clients ……………………………… 6
A.9. Group Work ……………………………………. 6
A.9.a. Screening …………………………………….. 6
A.9.b. Protecting Clients ………………………… 6
A.10. Fees and Business Practices …………… 6
A.10.a. Self-Referral ………………………………. 6
A.10.b. Unacceptable Business

Practices …………………………………………… 6
A.10.c. Establishing Fees ……………………….. 6
A.10.d. Nonpayment of Fees …………………. 6
A.10.e. Bartering ……………………………………. 6
A.10.f. Receiving Gifts …………………………… 6
A.11. Termination and Referral ………………. 6
A.11.a. Competence Within

Termination and Referral …………………. 6
A.11.b. Values Within Termination

and Referral ……………………………………… 6
A.11.c. Appropriate Termination …………… 6
A.11.d. Appropriate Transfer of

Services ……………………………………………. 6
A.12. Abandonment and

Client Neglect ………………………………….. 6

Section B: Confidentiality and Privacy …. 6
Section B: Introduction ………………………….. 6
B.1. Respecting Client Rights ………………….. 6
B.1.a. Multicultural/Diversity

Considerations …………………………………. 6
B.1.b. Respect for Privacy ………………………. 6
B.1.c. Respect for Confidentiality …………… 7
B.1.d. Explanation of Limitations ………….. 7
B.2. Exceptions ……………………………………….. 7
B.2.a. Serious and Foreseeable Harm

and Legal Requirements ………………….. 7
B.2.b. Confidentiality Regarding

End-of-Life Decisions ………………………. 7
B.2.c. Contagious, Life-Threatening

Diseases …………………………………………… 7
B.2.d. Court-Ordered Disclosure ……………. 7
B.2.e. Minimal Disclosure ……………………… 7
B.3. Information Shared With Others ……… 7
B.3.a. Subordinates ………………………………… 7
B.3.b. Interdisciplinary Teams ……………….. 7
B.3.c. Confidential Settings ……………………. 7
B.3.d. Third-Party Payers ………………………. 7
B.3.e. Transmitting Confidential

Information ……………………………………… 7
B.3.f. Deceased Clients …………………………… 7
B.4. Groups and Families ………………………. 7
B.4.a. Group Work …………………………………. 7
B.4.b. Couples and Family Counseling ………7
B.5. Clients Lacking Capacity to

Give Informed Consent ……………………. 7
B.5.a. Responsibility to Clients ………………. 7
B.5.b. Responsibility to Parents and

Legal Guardians ………………………………. 7
B.5.c. Release of Confidential

Information ……………………………………… 7
B.6. Records and Documentation ……………. 7
B.6.a. Creating and Maintaining Records

and Documentation ………………………………7

• ACA Code of Ethics •

•  22  •

B.6.b. Confidentiality of Records
and Documentation …………………………. 8

B.6.c. Permission to Record ……………………. 8
B.6.d. Permission to Observe …………………. 8
B.6.e. Client Access ………………………………… 8
B.6.f. Assistance With Records ………………. 8
B.6.g. Disclosure or Transfer ………………….. 8
B.6.h. Storage and Disposal

After Termination …………………………….. 8
B.6.i. Reasonable Precautions ………………… 8
B.7. Case Consultation ……………………………. 8
B.7.a. Respect for Privacy ………………………. 8
B.7.b. Disclosure of Confidential

Information ……………………………………… 8
Section C: Professional Responsibility ……..8
Section C: Introduction …………………………… 8
C.1. Knowledge of and Compliance

With Standards ………………………………… 8
C.2. Professional Competence ……………….. 8
C.2.a. Boundaries of Competence ………….. 8
C.2.b. New Specialty Areas of Practice ….. 8
C.2.c. Qualified for Employment …………… 8
C.2.d. Monitor Effectiveness ………………….. 8
C.2.e. Consultations on Ethical

Obligations ……………………………………….. 9
C.2.f. Continuing Education ………………….. 9
C.2.g. Impairment …………………………………. 9
C.2.h. Counselor Incapacitation,

Death, Retirement, or Termination
of Practice ………………………………………… 9

C.3. Advertising and Soliciting Clients …… 9
C.3.a. Accurate Advertising …………………… 9
C.3.b. Testimonials ………………………………… 9
C.3.c. Statements by Others …………………… 9
C.3.d. Recruiting Through

Employment …………………………………….. 9
C.3.e. Products and Training

Advertisements ………………………………… 9
C.3.f. Promoting to Those Served ………….. 9
C.4. Professional Qualifications ……………… 9
C.4.a. Accurate Representation ……………… 9
C.4.b. Credentials ………………………………….. 9
C.4.c. Educational Degrees ……………………. 9
C.4.d. Implying Doctoral-Level

Competence …………………………………….. 9
C.4.e. Accreditation Status …………………….. 9
C.4.f. Professional Membership …………….. 9
C.5. Nondiscrimination …………………………. 9
C.6. Public Responsibility ……………………… 9
C.6.a. Sexual Harassment ………………………. 9
C.6.b. Reports to Third Parties ………………. 9
C.6.c. Media Presentations …………………….. 9
C.6.d. Exploitation of Others ……………….. 10
C.6.e. Contributing to the Public Good

(Pro Bono Publico) ……………………………. 10
C.7. Treatment Modalities …………………….. 10
C.7.a. Scientific Basis for Treatment ……… 10
C.7.b. Development and Innovation ……. 10
C.7.c. Harmful Practices ………………………. 10
C.8. Responsibility to Other

Professionals …………………………………… 10
C.8.a. Personal Public Statements ………… 10
Section D: Relationships With

Other Professionals ………………………. 10
Section D: Introduction ……………………….. 10
D.1. Relationships With Colleagues,

Employers, and Employees …………….. 10
D.1.a. Different Approaches ………………… 10
D.1.b. Forming Relationships ………………. 10
D.1.c. Interdisciplinary Teamwork ………. 10
D.1.d. Establishing Professional and

Ethical Obligations …………………………. 10
D.1.e. Confidentiality …………………………… 10

D.1.f. Personnel Selection and
Assignment ……………………………………. 10

D.1.g. Employer Policies ……………………… 10
D.1.h. Negative Conditions …………………. 10
D.1.i. Protection From Punitive Action
D.2. Provision of Consultation Services … 10
D.2.a. Consultant Competency ……………. 10
D.2.b. Informed Consent in

Formal Consultation ………………………. 10
Section E: Evaluation, Assessment,

and Interpretation …………………………. 11
Section E: Introduction ………………………… 11
E.1. General …………………………………………. 11
E.1.a. Assessment …………………………………. 11
E.1.b. Client Welfare …………………………….. 11
E.2. Competence to Use and

Interpret Assessment Instruments …… 11
E.2.a. Limits of Competence ………………… 11
E.2.b. Appropriate Use ………………………… 11
E.2.c. Decisions Based on Results ………… 11
E.3. Informed Consent in Assessment ….. 11
E.3.a. Explanation to Clients ………………… 11
E.3.b. Recipients of Results ………………….. 11
E.4. Release of Data to Qualified

Personnel ……………………………………….. 11
E.5. Diagnosis of Mental Disorders ………. 11
E.5.a. Proper Diagnosis ………………………… 11
E.5.b. Cultural Sensitivity ……………………. 11
E.5.c. Historical and Social Prejudices

in the Diagnosis of Pathology ………… 11
E.5.d. Refraining From Diagnosis ………… 11
E.6. Instrument Selection………………………. 11
E.6.a. Appropriateness of Instruments …. 11
E.6.b. Referral Information ………………….. 11
E.7. Conditions of Assessment

Administration ………………………………. 11
E.7.a. Administration Conditions ………… 11
E.7.b. Provision of Favorable

Conditions ……………………………………… 11
E.7.c. Technological Administration …….. 11
E.7.d. Unsupervised Assessments ……….. 12
E.8. Multicultural Issues/Diversity

in Assessment ………………………………… 12
E.9. Scoring and Interpretation

of Assessments ……………………………….. 12
E.9.a. Reporting …………………………………… 12
E.9.b. Instruments With Insufficient

Empirical Data ………………………………… 12
E.9.c. Assessment Services …………………… 12
E.10. Assessment Security …………………….. 12
E.11. Obsolete Assessment and

Outdated Results …………………………….. 12
E.12. Assessment Construction ……………. 12
E.13. Forensic Evaluation: Evaluation

for Legal Proceedings …………………….. 12
E.13.a. Primary Obligations …………………. 12
E.13.b. Consent for Evaluation …………….. 12
E.13.c. Client Evaluation

Prohibited ………………………………………. 12
E.13.d. Avoid Potentially Harmful

Relationships ………………………………….. 12
Section F: Supervision, Training,

and Teaching …………………………………. 12
Section F: Introduction …………………………. 12
F.1. Counselor Supervision and

Client Welfare …………………………………. 12
F.1.a. Client Welfare ……………………………… 12
F.1.b. Counselor Credentials ………………… 12
F.1.c. Informed Consent and

Client Rights ………………………………….. 13
F.2. Counselor Supervision

Competence …………………………………… 13
F.2.a. Supervisor Preparation ……………….. 13

F.2.b. Multicultural Issues/Diversity
in Supervision ………………………………… 13

F.2.c. Online Supervision ………………………. 13
F.3. Supervisory Relationship ……………….. 13
F.3.a. Extending Conventional

Supervisory Relationships ………………. 13
F.3.b. Sexual Relationships …………………… 13
F.3.c. Sexual Harassment ……………………… 13
F.3.d. Friends or Family Members ……….. 13
F.4. Supervisor Responsibilities …………….. 13
F.4.a. Informed Consent for

Supervision ……………………………………. 13
F.4.b. Emergencies and Absences …………. 13
F.4.c. Standards for Supervisees …………… 13
F.4.d. Termination of the Supervisory

Relationship …………………………………… 13
F.5. Student and Supervisee

Responsibilities ……………………………….. 13
F.5.a. Ethical Responsibilities ……………….. 13
F.5.b. Impairment ………………………………… 13
F.5.c. Professional Disclosure ……………….. 13
F.6. Counseling Supervision Evaluation,

Remediation, and Endorsement ……… 13
F.6.a. Evaluation ………………………………….. 13
F.6.b. Gatekeeping and Remediation ……. 13
F.6.c. Counseling for Supervisees …………. 14
F.6.d. Endorsements …………………………….. 14
F.7. Responsibilities of Counselor

Educators ………………………………………… 14
F.7.a. Counselor Educators …………………… 14
F.7.b. Counselor Educator Competence .. 14
F.7.c. Infusing Multicultural

Issues/Diversity …………………………….. 14
F.7.d. Integration of Study and Practice …. 14
F.7.e. Teaching Ethics …………………………… 14
F.7.f. Use of Case Examples …………………. 14
F.7.g. Student-to-Student Supervision

and Instruction ………………………………. 14
F.7.h. Innovative Theories and

Techniques ……………………………………… 14
F.7.i. Field Placements ………………………….. 14
F.8. Student Welfare …………………………….. 14
F.8.a. Program Information and

Orientation ……………………………………… 14
F.8.b. Student Career Advising …………….. 14
F.8.c. Self-Growth Experiences …………….. 14
F.8.d. Addressing Personal Concerns …… 14
F.9. Evaluation and Remediation ………….. 15
F.9.a. Evaluation of Students ……………….. 15
F.9.b. Limitations …………………………………. 15
F.9.c. Counseling for Students ……………… 15
F.10. Roles and Relationships

Between Counselor Educators
and Students …………………………………… 15

F.10.a. Sexual or Romantic
Relationships ………………………………….. 15

F.10.b. Sexual Harassment …………………… 15
F.10.c. Relationships With Former

Students …………………………………………. 15
F.10.d. Nonacademic Relationships ……… 15
F.10.e. Counseling Services ………………….. 15
F.10.f. Extending Educator–Student

Boundaries ……………………………………… 15
F.11. Multicultural/Diversity Competence

in Counselor Education and
Training Programs…………………………… 15

F.11.a. Faculty Diversity ………………………. 15
F.11.b. Student Diversity ……………………… 15
F.11.c. Multicultural/Diversity

Competence …………………………………… 15
Section G: Research and Publication ….. 15
Section G: Introduction ……………………….. 15
G.1. Research Responsibilities ……………… 15

• ACA Code of Ethics •

•  23  •

G.1.a. Conducting Research …………………. 15
G.1.b. Confidentiality in Research ……….. 15
G.1.c. Independent Researchers …………… 15
G.1.d. Deviation From Standard

Practice …………………………………………… 16
G.1.e. Precautions to Avoid Injury ……….. 16
G.1.f. Principal Researcher

Responsibility ………………………………… 16
G.2. Rights of Research Participants ……… 16
G.2.a. Informed Consent in Research …… 16
G.2.b. Student/Supervisee

Participation …………………………………… 16
G.2.c. Client Participation ……………………. 16
G.2.d. Confidentiality of Information ……. 16
G.2.e. Persons Not Capable of Giving

Informed Consent …………………………… 16
G.2.f. Commitments to Participants …….. 16
G.2.g. Explanations After Data

Collection ……………………………………….. 16
G.2.h. Informing Sponsors …………………… 16
G.2.i. Research Records Custodian ………. 16
G.3. Managing and Maintaining

Boundaries …………………………………….. 16
G.3.a. Extending Researcher–

Participant Boundaries …………………… 16
G.3.b. Relationships With Research

Participants ……………………………………. 16
G.3.c. Sexual Harassment and

Research Participants ……………………… 16
G.4. Reporting Results ………………………….. 16
G.4.a. Accurate Results ………………………… 16
G.4.b. Obligation to Report

Unfavorable Results ……………………….. 16
G.4.c. Reporting Errors ………………………… 16

G.4.d. Identity of Participants ……………… 17
G.4.e. Replication Studies ……………………. 17
G.5. Publications and Presentations ……… 17
G.5.a. Use of Case Examples ………………… 17
G.5.b. Plagiarism …………………………………. 17
G.5.c. Acknowledging Previous Work …… 17
G.5.d. Contributors ……………………………… 17
G.5.e. Agreement of Contributors ………… 17
G.5.f. Student Research ………………………… 17
G.5.g. Duplicate Submissions ………………. 17
G.5.h. Professional Review ………………….. 17
Section H: Distance Counseling,

Technology, and
Social Media …………………………………… 17

Section H: Introduction ………………………… 17
H.1. Knowlede and

Legal Considerations ……………………… 17
H.1.a. Knowledge and Competency …….. 17
H.1.b. Laws and Statutes ……………………… 17
H.2. Informed Consent and Security …….. 17
H.2.a. Informed Consent and Disclosure …. 17
H.2.b. Confidentiality Maintained by

the Counselor …………………………………. 18
H.2.c. Acknowledgment of

Limitations ……………………………………… 18
H.2.d. Security ……………………………………… 18
H.3. Client Verification ………………………… 18
H.4. Distance Counseling

Relationship …………………………………… 18
H.4.a. Benefits and Limitations …………….. 18
H.4.b. Professional Boundaries in

Distance Counseling ……………………….. 18
H.4.c. Technology-Assisted Services …….. 18
H.4.d. Effectiveness of Services …………….. 18

H.4.e. Access ………………………………………… 18
H.4.f. Communication Differences in

Electronic Media ……………………………… 18
H.5. Records and Web Maintenance ……… 18
H.5.a. Records ………………………………………. 18
H.5.b. Client Rights ………………………………. 18
H.5.c. Electronic Links …………………………. 18
H.5.d. Multicultural and Disability

Considerations ……………………………….. 18
H.6. Social Media………………………………….. 18
H.6.a. Virtual Professional Presence …….. 18
H.6.b. Social Media as Part of

Informed Consent …………………………… 18
H.6.c. Client Virtual Presence ………………. 18
H.6.d. Use of Public Social Media ………… 18
Section I: Resolving Ethical Issues ……… 18
Section I: Introduction ………………………….. 18
I.1. Standards and the Law …………………… 19
I.1.a. Knowledge ………………………………….. 19
I.1.b. Ethical Decision Making ……………… 19
I.1.c. Conflicts Between Ethics

and Laws ……………………………………….. 19
I.2. Suspected Violations ………………………. 19
I.2.a. Informal Resolution …………………….. 19
I.2.b. Reporting Ethical Violations ……….. 19
I.2.c. Consultation ………………………………… 19
I.2.d. Organizational Conflicts ……………… 19
I.2.e. Unwarranted Complaints
I.2.f. Unfair Discrimination Against

Complainants and
Respondents …………………………………… 19

I.3. Cooperation With Ethics
Committees ……………………………………. 19

Glossary of Terms ……………………………….. 20

Ethics Related Resources
From ACA!

• Free consultation on ethics for ACA Members
• Bestselling publications revised in accordance with the

2014 Code of Ethics, including ACA Ethical Standards
Casebook, Boundary Issues in Counseling, Ethics Desk
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• Podcast and six-part webinar series on the 2014 Code
• The latest information on ethics at counseling.org/ethics

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