Pro bono counseling: How to make it work

By Bethany Bray

March 2021

The 2014 ACA Code of Ethics encourages counselors to “contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return.”

This is an important tenet of the counseling profession, and one that pulls at counselors’ empathy and call to social justice. However, counseling clients for a reduced fee or for free – pro bono – in a private practice setting comes with some caveats.

John Duggan, senior manager of continuing and professional education at the American Counseling Association, stresses that private practitioners who have any kind of third-party contract, such as agreements to accept clients from an employee assistance program, Medicaid or elsewhere, must take positive steps to avoid risk if they charge anything other than the same rate for service for 100% of their caseload. This is due to several reasons:

• Charging different rates for services reimbursed by federally funded programs opens the practitioner to risks of fraud accusations or investigations by the U.S. Centers for Medicare & Medicaid Services (CMS). In general, Medicaid and other third-party insurance plans prohibit practitioners from waiving copays.
• Insurance companies may be unwilling to honor a fee schedule if a practitioner charges different fees for the same contracted service to different clients.
• Offering remuneration to clients is unethical and potentially illegal (see Standard A.10.b. of the 2014 ACA Code of Ethics). While there are exceptions, waiving copays/fees and underbilling are potential HIPAA violations.

Lastly – and perhaps most importantly – Standard C.5. of the ethics code prohibits discrimination in professional counseling. Offering different fees to different clients could potentially make a counselor’s health care business vulnerable to accusations of discrimination or lawsuits, Duggan says.

The only private practice scenario that would be exempt from the above points is if a counselor does not have any existing third-party contracts and treats 100% self-pay clients, without insurance, he notes.

“It is ethically essential to prioritize our work that’s pro bono,” says Duggan, a licensed professional counselor and licensed clinical professional counselor. “However, the bottom line is that professional counselors who manage a health care business should also operate as ethical businesspeople. Always consider ethical, legal and compliance issues before reducing fees, copays/fees or underbilling.”

Duggan points out that there are many ways a counselor can do pro bono work that do not involve counseling clients on their practice caseload. Volunteer or reduced-fee work in the community – anything from public speaking or leading workshops to mental health response during disaster situations – can be a rewarding way for counselors to give back.

There are also organizations and agencies that facilitate the counseling of clients outside of a clinicians’ existing caseload. Duggan points to the Pro Bono Counseling Project (probonocounseling.org) as an example. The Maryland-based nonprofit pairs clients with limited incomes who are uninsured or underinsured with volunteer practitioners for free mental health care.

When it comes to navigating the nuances of pro bono work, Duggan suggests counselors refer to ACA’s numerous resources, most notably the 2014 ACA Code of Ethics (including standards C.1. and I.1.b.) and The Counselor and the Law: A Guide to Legal and Ethical Practice by Anne Marie “Nancy” Wheeler and Burt Bertram, particularly Chapter 3 (available at counseling.org/store). Practitioners may also want to consult an attorney for guidance.

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2014 ACA Code of Ethics, Standard C.6.e. “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, sharing professional information, offering reduced fees).”

• See the full ACA Code of Ethics at counseling.org/ethics
• ACA members who have further questions can schedule a practice or ethics consultation with ACA’s counseling specialists by emailing ethics@counseling.org. 

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Pro bono: Opportunities

• Remain cognizant of the potential for exploitation of clients, attend to their vulnerabilities, and consider their best interests in all professional decisions.
• Look for opportunities to serve your local community by providing some pro bono services that capitalize on your unique interests and skills (e.g., speaking, teaching, mentoring, leading support groups, volunteering at a local nonprofit clinic).
• Remember: Pro bono services are subject to the same rigorous ethical standards as all other counseling services. Practitioners offering clinical mental health services must also remain compliant with state and federal laws.

Source: John Duggan, senior manager of continuing and professional education at the American Counseling Association  

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Read more

Counselors who enter private practice often find themselves confronting the push and pull between their desire to provide empathic, client-focused care and the need to turn a profit. Counseling Today will take an in-depth look at this topic in the magazine’s April cover article, “Finding balance in counseling private practice.” 

The views expressed in Counseling Today are those of the authors and contributors and may not reflect the official policies or positions of the editors or the American Counseling Association.