Unethical Decisions and Moral Injury: Potential Hazards of Large Caseloads
Janice Barrocas-Decker, LPC, CRC, NCC
Kristina Henderson, PhD, LPC, CRC, CPCS
Originally appeared in LPCA Connection April 2023 Newsletter. PDF available here.
In 2016, a report on the National Projections of Supply and Demand for Selected Behavioral Health Practitioners projected an estimated shortage of more than 10,000 full-time mental health, substance abuse, and school counselors by 2025. (HRSA Workforce report, Nov. 2016) These projected counselor shortages did not anticipate the unforeseen impact of the COVID-19 pandemic.
In an October 2021 poll (NCMW, 2021), over 78% of mental health and substance use treatment organizations reported increased requests for services over the previous three months. The National Council for Mental Wellbeing also reported that 77% of counties in the United States are experiencing a severe shortage of mental health providers. Demand for mental health professionals is projected to increase during and after the COVID-19 pandemic.
Counselor shortages and increased demand often mean public sector counselors are required to serve large caseloads. Those large caseloads can have significant ethical and well-being implications for counselors in Georgia and across the nation.
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. Protecting client welfare may become unsustainable when unethical practice is a potential consequence for counselors with large caseloads. Counselors in the public sector may find themselves asking, when is a caseload so large that, in essence, by its sheer numbers, a counselor risks violating their code of professional ethics?
The ACA code of ethics is silent on appropriate caseload size and the ethical implications of handling an extensive caseload. In 2023, the CRCC code of ethics, for the first time, addressed client-to-professional ratio and length of service sufficiency as factors that impact follow- through and effectiveness of client services. (C.1.e)
Counselors have well-defined ethical obligations to individual clients, whereas caseload is not a term referenced in the code of professional ethics. Referring to clients as “cases” or collectively as a “caseload” depersonalizes the group. Individual clients have names, faces, and identities. On the other hand, caseloads consist of a nameless, faceless group of people. The ethical significance of replacing clients with caseloads deserves consideration, both in terms of the implications for policy and practice.
Furthermore, we must also consider that an organizational culture that normalizes large caseloads and depersonalization also may have far-reaching emotional consequences for counselors. Those 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, who enters the field to help people, repeatedly witnesses systemic failures and injustices that transgress their beliefs, moral injury may occur. Originally, moral injury described soldiers’ experience in active war zones. Moral injury in a military context refers to the lasting emotional damage caused when one’s actions or observed actions violate deeply held personal values and expectations. (Haight, W. 2017)
When a counselor witnesses harm or fails to prevent actions that violate their morals because they cannot deliver quality care to the number of clients they are assigned, their professional identity is shaken to the core. Counselors suffering from moral injury remaining on the job raises serious concerns for both counselor and client well-being.
There are no easy answers for this explosion of need intersecting with a shortage of trained counselors; however, the problem must be explored. Efforts must be made to address these issues and support mental health professionals in order to ensure the highest quality of care for those in need.
References:
American Counseling Association. (2014). ACA code of ethics. Retrieved from http://www.counseling.org/docs/ethics/2014-aca-code-of-ethics.pdf
Commission on Rehabilitation Counselor Certification. (2023) CRCC code of ethics. Retrieved from https://crccertification.com/wp-content/ uploads/2023/01/2023-Code-of-Ethics-1.pdf
Haight, W., Sugrue, E. P., & Calhoun, M. (2017). Moral injury among child protection professionals: Implications for the ethical treatment and retention of workers. Children and Youth Services Review, 82, 27–41.
National Projections of Supply and Demand for Selected Behavioral Health Practitioners: 2013-2025. (2016). Retrieved from: https://bhw.hrsa. gov/sites/default/files/bureau-health-workforce/data-research/behavioral- health-2013-2025.pdf
Janice Barrocas-Decker has dedicated her career to empowering clients to reach their goals and adjust to significant physical impairments, including vision loss. She has been an LPCA member for two years and is in the Atlanta District.
Dr. Kristina Henderson has a passion for preparing others to become leaders in the counseling field and for going beyond awareness to inclusion for persons with disabilities. She has been an LPCA member for over ten years and is in the Central District.