Check out this video of Julie Lowe showing off (in a good way!) her counseling office designed for counseling kids. Julie is at CCEF and an adjunct at Biblical Seminary. She is a Licensed Professional Counselor (LPC) and trained in play therapy. Here’s the link. [Link was broken, now fixed]
Category Archives: counseling science
Ethical blunders: Root causes?
Finishing up the Ethics course in the next week. There are two kinds of ethical errors in counseling: conscious violations of ethical practice and blunders.
Forrest Gump’s quotable line, “Stupid is as stupid does,” is ringing in my head as I write this post. We do stupid stuff–stupid as in without thinking. Most of our blunders are just that–things we never intended but did absent forethought. Example? Oh, I don’t know, like walking through a dark room while talking on a cell phone and resulting in a face plant over an unseen chair. That kind of thing…and the real reason why I’m hearing Gump in my head.
We all go through parts of our life in unthinking auto-pilot. Consider the equivalent in counseling: Starting a first session but forgetting to cover informed consent because you are focused on helping the person in front of you. Or, handing out personal contact information because the client asked nicely (but never considering ulterior motives). Or, calling back a spouse of one of your clients and discussing issues but failing to remember you do not have a release to speak to them. These are some of the unthinking blunders we may make.
Are there root causes to blunders? Try on some of these:
1. Naiveté. Taking the comments of others without considering context or motives. I am not suggesting that good counselors need to be suspicious. Rather, we need to be realistic, critical thinkers who employ wisdom. We need to consider motives, consequences, impact, etc. We need to think beyond the immediate moment.
2. Reactivity. Some of us are just more reactive or instinctive driven. This may be personality driven. However, it may also indicate that we are being driven by unexamined desires (e.g., “I want this person to like me”; “I want to defend myself from an accusation”).
3. Over-confidence. Sometimes our blunders come from overconfidence. We’ve all heard the evidence that talking on the cell phone while driving raises our risks of having an accident. But most of us do it anyway. Why? We don’t think or perceive ourselves as compromised. We consider ourselves better than the rest. Sometimes, blunders in counseling come from an unsupported confidence in self–I will act right because I am an ethical person. When we are overconfident we have placed our trust in something that may be good but not right in a particular situation.
4. Fear. Yes, fear. It can lock us up causing us to stop using our training and intellectual capacity. This is the counseling version of driving right into the thing you were trying to avoid. Fear paralyzes.
5. Group think. Group think happens when we stop asking questions and as a whole foreclose on other hypotheses. An agency may create this problem by how it manages staff meetings, supervision. As a group we may become comfortable with an ethical breach in such a way that it becomes normal–unseen.
Can you think of other root causes of unthinking ethical blunders?
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Ethics training without tears?
I once saw a title of a text, “Statistics without tears.” Few people are in tears in my Ethics class but most have looks of fear. Thus, my question. Is it possible to teach ethics to counselors without incurring fear?
Counselors, by nature, want to do what is right for their clients. They want to solve problems. They also want to avoid harming clients AND facing lawsuits or licensing board complaints. So, you can understand that my students take great interest in a course where we discuss standards of care and the bases for ethical practice.
I try to focus on the underlying values that guide counselor behavior. I try to remind students that suicide and lawsuits are extremely rare (as long as you aren’t trying to do things that are controversial or fail to consider the wise counsel of supervisors). But, bottom line, you have to discuss practical cases where errors matter–breaches of confidentiality, failure to warn or protect in the face of imminent harm, dual relationships, practicing outside of competency, etc. It is these vignettes that raise our fears.
I’ve tried to reduce student fears but in the end some fear is good. Fear that leads us to be careful, to ask for supervision, to double-check our motives may not be a bad thing. When fear paralyzes or leads to self-protection alone, then it is not helpful.
In the end, we must trust that God will not abandon us, even if we make mistakes. We must remember that humility will take us a long way and that every path we take has risk associated with it. Our job is to remain learners as we walk with others in their difficulty. As soon as we stop asking good questions about our clients or about our actions, we now enter risky practice.
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Minimal Brain Damage?
I’m thinking about brain injuries today. On Sunday one of my son’s teammates got carted off the diamond after falling on his head while trying to make a play. Though scary, it seems he did not sustain an injury other than a headache. At least that what the initial scans suggest. Then today I heard a story on NPR about brain injuries of soldiers experiencing a “concussive” event–those who survived roadside bombs. These soldiers may not have been pierced by shrapnel and may not have had their heads slam into something (two obvious causes of TBI) but may have experienced injury from the impulse of the blast of energy hitting their brain. Pro Publica explains the injury and has the larger story about the many soldiers who fail to be properly diagnosed and treated in military care centers.
It stands to reason why this would happen. Minor brain damage is hard to quantify. Brain scans may not pick up these minor changes. The person isn’t missing a limb which visually reminds others of injuries. Some of the symptoms are similar to other mental health problems and so providers may wonder whether injuries are physiological or psychological.
Some of you have been around long enough to remember MBD or minimal brain dysfunction. This was a term used in the 1960s for a wide variety of problems that now go under the name of ADHD. MBD was a way of signaling that something wasn’t right in the brain even though no one could actually pin point where the problem lay. At this point we may not have ways to identify damage to cells (rather than whole structures) and cell communication and so much use the term concussion or minor TBI (mTBI).
Worse than missing the diagnosis is not having great solutions to deal with the wide variety of symptoms. Our best solution for civilian sports related concussions is to avoid having a second, even minor, head bump. We do so by banning participation in sports for a couple of weeks. It is often these second or third bumps that do the worst of the damage. But I suspect that having a soldier sit in Iraq for a couple of weeks after being dazed by a blast will not be anyone’s desire.
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Filed under counseling science, Psychiatric Medications, Psychology
Maintaining progress in counseling with short sessions
Ever felt that a 10 minute session every day might be more beneficial than a 1 hour session once a week? While a short session cannot dig very deep, it can keep a person on track. One of the frustrating things about counseling is the fact that a client may leave with direction and clarity only to return 7 to 21 days later with confusion. What seems clear in the office becomes foggy in real life. It isn’t that much different from learning a language or algebraic formulations. You think you have it then you try to apply it to a novel situation and you realize you don’t have it quite down.
The phone call session should be short, directed at problem-solving, remembering a previously learned solution, or improving hope and motivation to continue some difficult task. Consider this for marital discord. So easily conflicted couples stay cold and distant between episodes of conflict. Short sessions may help them remember to soften each day and be more inviting of non-conflict interactions.
There is some support for this kind of interaction, though not in therapy literature. The support comes from addiction quitlines. Those who call in and gain support are more likely to remain abstinent than those who try to do it on their own. Sadly, insurance companies do not support this kind of interaction (they do not cover phone sessions). They should, it would likely save money in the long run.
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insomnia and suicidality
Counselors need to keep regular watch over the insomnia of their clients. Untreated or unresolved insomnia predicts poor recovery and lesser benefit from therapy. It ought not be treated as a secondary problem. But a recent abstract sent to me via email suggests that insomnia may also be a significant factor in suicidal ideation and action. Some researchers at Wake Forest followed 60 adults with both insomnia and major depression for 9 weeks. All received antidepressants but some received a sleep aid as well. Both were assessed by using the Hamilton Depression Scale and an insomnia severity scale.
Their findings suggest that insomnia is a factor in suicidal ideation independent of depression or lack of pleasure. Insomnia leads to more intense suicidal thoughts. Thus, counselors ought to redouble their efforts to ask about insomnia, to track it and to especially follow-up with questions about suicidal ideation or plans when complaints of insomnia increase.
Interested readers may find the abstract of the research here.
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Suicide assessment mistakes
Yesterday’s post was about suicide. Counselors sometimes fail to adequately evaluate suicidal ideation, plan, or intent in their counselees. Some years ago, I ran across a research study looking at the most common mistakes made by 215 masters level counselors when dealing with suicidal clients. I’ve lost the bibliographic data for the article and couldn’t find it easily in Psychlit…
Here are some of the mistakes (in no particular order):
- Superficial reassurance (“you have so much to live for”
- Avoidance of strong emotions (not allowing client to express strong despair–usually with first bullet point)
- Professionalism (cold and distant, possibly seen as uncaring in assessment)
- Inadequate assessment (failure to explore fully because of nervousness or fear of asking)
- Failure to identify precipitating causes (most suicides have both current and historical precipitating events. Counselors may identify historic event (e.g., divorce 4 years ago) but miss the current precipitant.)
- Passivity; failure to be empathic (25% took this stance)
- Insufficient directness. No contract to not harm, no next steps
- Overbearing advice. Counselee needs to be involved in the planning for safety
- Stereotyping response (“She’s just a borderline!”)
- Defensiveness (usually about whether hospitalization is necessary)
Every counselor worries about how they will perform when addressing the serious problem of suicide risk assessment. We do well to review (a) our natural inclinations when stressed (e.g., do we tighten up, become over-controlling, too professional?), (b) our standard of practice when confronted with despairing or suicidal clients, and (c) our assessment procedures with all clients. While there is no way to prevent the suicides of highly motivated people, we can increase our capacity to respond well to those the Lord sends our way.
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Helpful read on the warning signs of suicide
Sunday’s lead story in the Philadelphia Inquirer unfolds the tragic story of two high school girls who committed suicide by stepping in front of a speeding train last winter. The death of a child is always a tragedy. But death by suicide exponentially multiplies the pain. Could anyone see it coming? Could they have prevented it?
The story in the paper details the texts and social networking trail of tears leading up to their final actions. If this event happened when I was a child, the parents might have been left with a note or a journal to pour over looking for clues. But, in this case, there are texts and posts over a long span of time. Even worse, the girls made a number of final texts just before their deaths. It appears that loved ones searched frantically for them while “watching” cyberspace during their final act. I can only imagine that this “real time” aspect multiplies the trauma for the family.
Can we learn anything from this? Yes, I think so.
- Pay attention to your child’s (or friend’s) social networking and texts. Clues to their state of mind may well be evident.
- Act on concerns; take stock of their actions and attitudes. Per this case, it appears there were efforts to help them. Probably not enough. But let us not judge the family here. It is far too easy to become complacent. A child has strong feelings that they express over a period of time, thus making suicidal expressions normal. After the fact the signs seem so obvious. During the stress, it is hard to discern how bad it really is.
- Compounding suffering requires additional interventions, whether the child wants it or not. One girl’s father committed suicide, parents’ divorced requiring a move and change of school, a boyfriend was killed by a car. The more these kinds of experiences happen, the more attention the child needs by mentor or mental health workers.
- Even good schools won’t likely pick up on problems. Don’t assume school counselors have enough time to respond. It is not that they are incapable but the sheer number of students to follow makes their capacities limited.
Know that some people commit suicide and no one could have predicted it. Be wary of judging family members. They will live with enough guilt on their own. And yet, look for this recipe of pain and perceptions (summary of Jeff Black’s booklet):
- Strong powerful experiences of pain
- Perception that the they cannot tolerate the pain
- Hopelessness and inability to see alternatives other than relief via suicide
- Isolation
Other risk factors to consider: previous attempt? Suicidal ideation/plan? Hospitalization (even for non-psychiatric reasons)? Access to lethal means? Depressive anger coupled with impulsive history. These factors aren’t that helpful by themselves but looking over the total may provide *some* clues.
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Summer Counseling Courses
Want to learn more about counseling this summer? Are you in ministry and want to sharpen your skills? Already a licensed mental health provider and need CEUs*? Want to explore…
- How to counsel people diagnosed with Borderline Personality Disorder?
- How to help those diagnosed with a chronic condition?
- How to use the Old Testament better in counseling?
- How to better understand and evaluate the major models of counseling?
Just a reminder that this summer Biblical is offering 4 electives for students, alum and any auditors who might find the topics of interest. The first three of the four courses are only one credit and delivered in a weekend formats(Friday night and Saturday) with some pre-class reading/assignments. The fourth is a two credit course delivered in a completely on-line format.
For information about each of these course, the professors, the costs, and how to apply, click this link. It will take you to the Biblical website and a PDF of our flyer.
* Note: For those seeking CEUs, there are two ways you may be able to count them as fulfillment of your licensure requirements. Biblical Seminary is an accredited graduate institution and these courses are offered as graduate education in counseling and psychology. Most mental health licensure bodies accept graduate courses (shown on a transcript) as meeting the requirements for approved CE providers. You will need to check with your board to see if that applies to you. Second, we have applied for CE provider status for my class (Borderline Personality Disorder) from the State Board of Social Work, Marriage & Family Therapy, & Professional Counseling. If approved, we will be able to provide licensed attendees with 9 clock hours at the cost of ONLY $175.
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Seeing clients outside the office
Much of what we do in counseling or therapy is enculturated. Confidentiality, the 50 minute session, avoiding dual relationships…these things developed out of the culture of psychoanalysis. Now, that is not a criticism. I personally agree that good therapy requires privacy and the assurance of confidentiality. Who would talk about the deepest matters of the heart if they thought it would be broadcast to the world? And it isn’t as if this is a modern invention. Pastors have been practicing this since the early church.
One of those culture founded practices is seeing patients only in the office setting. Supposedly, this would maintain the “frame” of the counseling hour so as to avoid unnecessary outward intrusions. Further, it maintains one picture of the therapist. Having coffee with your therapist at the local diner would completely change that frame–and reduce confidentiality when your neighbor comes up and says, “Oh, I saw you go into the diner with Dr. Monroe. How do you know him?”
But there are some reasons why a counselor might intentionally see a client outside the office. Here are some reasons I have:
- Observation of a child in a school or home setting as part of an assessment
- Visiting a client in the hospital (either as a courtesy call or as part of a treatment continuity plan)
- Joint meeting with other providers (therapists, pastors, care team) at another location
- Part of a treatment plan (e.g., to practice walking over a bridge, get on an elevator, etc.
I have been asked to have coffee by current clients. I have been invited to house-warming parties. I have been asked to attend other celebrations. I’m more inclined to attend celebrations for kids or if the relationship is quite limited (wedding of a pre-marital client seen for 6 sessions only). I have taken clients outside my office for one reason or another (a brief walk, thrown a ball with a kid, etc.).
Whatever you choose to do. Be sure to evaluate the effect it will have on your relationship with the client. What potential pit-falls exist? Talk to them about it. Afterwards, continue to see if such actions introduce any relationship confusion. Be wary of informality. You don’t have to be stiff but informality breeds complacency and soon you are doing things you never dreamed of doing. Also be especially wary if the client has any history of abuse or boundary violations. Take care to protect those boundaries for their sake.
While psychological ethics are built on “Do no harm,” we know that the bible also supports this. Watch out for your weaker brother or sister!
Musings on Faith and Psychology 