When Ethics Meet Reality: The Hazards of Organizational Needs Clashing With Ethical Obligations

Abstract: According to the National Institutes of Health, in 2021, an estimated 57.8 million adults 18 or older in the United States were living with a mental illness. That number is almost five million more than the year before. The United States is facing a severe shortage of mental health and rehabilitation counselors at a time when they are needed most. This presentation investigates the potential ethical considerations and harm for clients and clinicians in the United States who are faced with significant provider shortages.

A 2016 report on the projections of supply and demand for behavioral health practitioners estimated a shortage of more than 10,000 full-time mental health, substance abuse, and school counselors by 2025 (HRSA Workforce report, Nov. 2016), while the Bureau of Labor Statistics estimates almost 10,000 openings per year for rehabilitation counselors. In addition, the National Council for Mental Wellbeing reported that over 78% of mental health and substance use treatment organizations described increased requests for services (NCMW, 2021). The NCMW also reported that 77% of counties in the United States are experiencing a severe shortage of mental health providers, with stressors from the pandemic affecting both practitioners and clients.

Mental health systems overwhelmed with an increase in demand for services have resulted in large caseloads for counselors across the nation and across disciplines. This trend has significant ethical (Hartley & Cartwright, 2016; Shaw & Lane, 2008) and wellbeing implications for counselors, those they serve, and the larger healthcare systems within which they operate.

Research shows high caseloads impact counselor effectiveness, client satisfaction, and counselor burnout rates. Unethical decisions and moral injury are potential hazards of large counselor caseloads, a situation exacerbated by the rate of professional burnout in physicians estimated to affect up to 50% of U.S. physicians pre-pandemic. (Mollica, Fernando, & Augusterfer, 2021)

To fully grasp this impact, one must understand the codes of professional ethics governing counselors. The American Counseling Association (ACA, 2014) code of ethics and the Commission on Rehabilitation Counselor Certification (CRCC, 2023) code of ethics both refer to the counselor's responsibility to protect client welfare and avoid harm. Both the CRCC and ACA codes of ethics require counselors to speak up and take necessary action when workplace policies are inconsistent with the Code, potentially disruptive, damaging to clients, or limit the effectiveness of services provided. If constructive action within the organization does not allow ethical conduct, counselors are expected to voluntarily resign.

Organizational culture that normalizes large caseloads also may have far-reaching emotional consequences for counselors. Counselors may see clients harmed by the counselor's own inability to act or maintain the contact needed to promote client safety and health. When a counselor repeatedly witnesses systemic failures that transgress their beliefs, moral injury may occur. Originally, moral injury described soldiers' experience in active war zones and referred to the lasting emotional damage caused when one's actions or observed actions violate deeply held personal values and expectations (Litz, et al., 2009). The understanding of moral injury has expanded beyond the battlefield and is now explored in healthcare professions (Čartolovni, Stolt, Scott, & Suhonen, 2021) and education (Haight, 2017). Counselors suffering from moral injury while remaining on the job raise serious concerns for both counselor and client well-being.

If large caseloads persist, mental health systems need to take action to assess the clinical impact of this trend. Previously unexpressed and unexamined assumptions about staffing levels built into current evidence-based practice may need to be reassessed. Additional research data are needed to assess whether high caseloads are, in fact, becoming outcome determinants. This presentation will: discuss the current and expected shortage of counselors, consider the relevant ethical codes and concerns, and examine the potential hazards for clients and providers.