Category Archives: counseling skills

June 16, 2010 · 9:21 am

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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June 15, 2010 · 5:54 am

Gain: Ethical boundaries relating to client gifts


[note: I found this document in my Ethics course files. I think I wrote this some time ago…but I don’t remember. It is possible that I received a WORD document with this in it from someone else. If so, I apologize for posting without acknowledging the source. Ah, the joys of aging.]

Professional counseling is founded on the assumption of the patient/practitioner relationship. The practitioner/expert provides a needed and appropriate service and the patient pays a reasonable fee—or their insurance company does for them. However, the extremely personal nature of counseling work often creates strong feelings between client and therapist and consequently the client may wish to bring a token gift signifying their thankfulness for a job well done.

Gifts beyond the token category provide therapists with “gain” and likely disrupt the fee/service relationship mentioned in the previous paragraph. While gain may not cause actual harm and may be unavoidable, the wise counselor remains aware of possible sources of gain and their consequences.

Consider the following examples and check whether you think they may be problematic:

  • A Board member of the counseling center offers one of the counselors tickets to a ball game
  • A Client offers his private counselor tickets to a ball game.
  • A student offers her teacher tickets to a ball game

Should the counselor in any of these scenarios accept the tickets? Does the cost of the gift or the wealth of the person giving a gift matter? Would it change your answer if the gift were a week’s stay at a beach house? Does it matter if the student is currently in a class with the teacher or not?

Gifts are a form of gain. Others may come in other forms of benefit for the counselor. If the counselee owns a publishing company, should the counselor accept an offer to have him or her publish his next book? If the counselor has a non-profit ministry, should he or she accept client gifts to that ministry? If a client offers to sit for a testimonial ad for the counselor’s new technique, should the counselor accept?

Gifts, though, represent expressions of thankfulness and thus a policy of rejecting all gifts may bring harm to the counseling relationship.

Wise Counselors explore with their clients any possibilities of gain and their potential consequences. Counselors consider how gains may harm the client or create an indebtedness that in the future clouds clinical judgment. For example, counselors do not accept gifts or fee sharing from treatment facilities in return for referrals. On the other hand, a cup of coffee brought to the session likely is just a cup of coffee, a friendly gesture. Christmas cookies are a small but personal thank you for a job well done. But, don’t assume that small gifts can not produce a quid pro quo (this for that) interaction. So, back to our first line in this paragraph. Take the time to explore the meaning of an offered gift and be willing to talk about it with clients.

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June 13, 2010 · 5:37 pm

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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June 4, 2010 · 1:47 pm

Being the warden


I was sent a new book to review (which I am not planning to do). Since it has to do with pastoral ministry to couples involved in a particular sexual crisis I thought I’d give it the 5 minute skim. In doing so I got a great image: The warden in the relationship. This is the person who was wronged in some terrible way and is now the warden who determines the accountability of the offending party.

When one has broken trust and is now trying to regain that trust, they must become entirely transparent. Their can be no hint of deceit, no unaccountability in any area of life. Not only must the person allow for accountability but they must show evidence they actually desire it and do not chafe at their limitations in life. But what of the other partner? The author says this:

It is not OK for one, considered to be the initial perpetrator, to live totally accountable in his life of genuine repentance, while the other partner never moves off being the warden of the relationship.

How does one fall into this position? The author says “just going with the flow of feelings about the injustice and harmfulness of things is all that is necessary to become the warden, and to never really forgive.” This, I must say, is in the larger context where he also says forgiveness does not require trusting the other or repatriating the other.

In much of Christian counseling, wardens get a raw deal. It is so obvious that they are demanding of a standard of perfectionism, judgmental, unwilling to be vulnerable, etc. It is easy to see this and to go after the hardness of heart that is evident in the warden while accepting the “repentance” of the offender at face value.

It is true that the warden must relinquish the position of judge if the relationship is going to survive long-term in any healthy manner. This does not mean the person stops taking stock of the offender’s actions and attitudes. Nor does it mean that they can forego self-examination.

Here’s my questions:

  1. How do you know the line between careful evaluation of the fact and warden mentality?
  2. What helps might be most helpful to let go of the warden mentality?
  3. How could the church be more supportive of the warden?

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June 1, 2010 · 8:40 am

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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May 28, 2010 · 8:38 am

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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May 26, 2010 · 2:50 pm

Intractable conflict in marriage


The latest American Psychologist (65:4, 2010) has an interesting article on the topic of intractable conflicts. These can be seen in families, communities or whole country disputes like found recently in Rwanda and the Congo.

The authors make this point at the outset of the article,

Conflict resolution should be easy. Conventional wisdom…has it that conflict arises when people feel their respective interests or needs are incompatible….A conflict that has become intractable should be especially easy to resolve….After all, a conflict with no ed in sight serves the interests of very few people, drains both parties’ resources, wastes energy, and diminishes human capital in service of a futile endeavor. Even a compromise solution that only partially addresses the salient needs and interests of the parties should be embraced when they realize that such a compromise represents a far better deal than pursuing a self-defeating pattern of behavior that offers them nothing but aversive outcomes with a highly uncertain prospect of goal attainment.  (p. 262)

True, but since when does logic ever beat conflict? It doesn’t and these authors know it.

As a conflict becomes a primary focus of each party’s thoughts, feelings, and actions, even factors that are irrelevant to the conflict become framed in a way that intensifies or maintains the conflict. It is as though the conflict acts like a gravity well into which the surrounding mental, behavioral, and social-structural landscape begins to slide. Once parties are trapped in such a well, escape requires tremendous will and energy and thus feels impossible. (ibid, my emphasis)

This is EXACTLY why marriage counseling is so difficult. Everything is read through the lens of “He is so controlling,” or “She won’t respect me.”

Why does this happen? On the surface, an intractable conflict might seem to be about land (e.g., Palestinians vs. Israelis) or about ideological solidarity (republicans vs. democrats) or about bald desire for power. In marriage conflict may appear to be about respect, money, or power. But these authors suggest that conflict becomes intractable because the larger system is supported by the conflict and would more or less collapse if peace were to overtake it. Attractors, they say help maintain a coherent view of the world, a way of promoting unequivocal action without hesitation. Truth be told. We like living in a black/white world where our actions are always clear to us and the bad guys are always bad. A word about power. In conflict, we use power to get what we want (via direct use or manipulation). But there are always power differences between parties. Someone always has more power. In couples, one spouse will always want more sex than the other. This isn’t a bad thing. It only becomes bad when either party refuses to accept the differences or show any capacity to be influenced by the other.

When peaceful resolutions take place, it is because a new system has been developed; a new set of values and definers of reality.

How do you implement such a change? You cannot go directly after the thing that maintains the conflict. In other words, don’t say, “You, wife, stop believing your husband doesn’t love you”; or “You, husband, start loving your wife by…” Built into the maintainers of conflict is a strain of resistance. “I know you just did something nice for me but you really are just trying to get on my good side so you can [fill in the blank], but I’m on to you!”

The authors say, and I agree, that, “Attempts to challenge directly the validity or practicality of an attractor for intractable conflict are therefore often doomed to fail and in fact are likely to intensify people’s beliefs and energize their response tendencies.” (p. 273)

Again, how do we deal with these longstanding conflicts? How do we stop seeing the problem as a simple equation (you stink and I’m great) to something more complex (we’re both broken and here’s what I can do to make things better)?

1. Force self to step back to see the complexity of the situation. This sometimes happens when something blows our mind (we act in a way we THOUGHT we never would). To do this we have to believe that the simple answer is easy but ALWAYS wrong and desire to have a more nuanced view of self and other

2. Go back to see previous unity. So, a couple might go back to remember their first love. What affinities did they once have? Can they recover them? Some couples can. From here, they may find the power to fix problems that seem just a wee bit smaller because of a more powerful unifying narrative that was forgotten.

3. Focus on who we want to be in the midst of trials and tribulations. What kind of person do I want to be (that God empowers me to be) come what may?

Notice that only #2 has to work towards maintaining the marriage and living in close quarters. One can develop a more complex and realistic view of the problem (#1) or focus on character development (#3) and still choose to end a violent or destructive relationship. Both also require that we value something greater than self-interest. From a Christian point of view, love must be the reason for all three options–a love given to us by God alone.

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May 19, 2010 · 5:51 am

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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May 18, 2010 · 11:22 am

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.

  1. Pay attention to your child’s (or friend’s) social networking and texts. Clues to their state of mind may well be evident.
  2. 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.
  3. 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.
  4. 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):

  1. Strong powerful experiences of pain
  2. Perception that the they cannot tolerate the pain
  3. Hopelessness and inability to see alternatives other than relief via suicide
  4. 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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May 12, 2010 · 12:24 pm

Professional communications by counselors: What do they reveal?


What we say and how we say it can tell someone quite a bit about our character. We counselors earn our keep with words. And yet, it is our words that may do the most harm to others. As a result, I encourage us to take stock of our words. What do they reveal about us? Oh, and don’t just consider the words you use in a session. How you talk to a colleague, about a colleague, to another professional may reveal your character more than you think. Consider the following communication issues:

1. Client put-downs. In agencies where counselors share clients with other professionals (e.g., psychiatrists, social workers, community workers, etc.), it is common for conversation to descend into put-downs. No doubt these professionals care about their clients. But if they are frustrated with the client, does it result in blaming the client? Making fun of their idiosyncracies? “He’s such a narcissist; She’s so Borderline”. These kind of comments reveal more about the speaker than the one spoken about.

2. Professional Lingo. Every guild has its lingo. Read a psychiatric or psychological evaluation and you will likely come across a number of words that only make sense if you are on the inside. The client probably wouldn’t really know what is being said about them with translation help. What do your progress notes communicate? Who are you writing for? How might our lingo hinder our work. I highly suggest that use the client as a standard to evaluate all our written communications. If the client couldn’t understand or could possibly be harmed by what we write, the think better of it.

3. Professional Territorialness. We communicate with other professionals about our clients. Does our communication reveal any condescending attitudes? Any unnecessary hierarchy? How do you talk about another professional to clients? To other colleagues? Do we withhold data for power reasons? For fear of mis-use by the other. If so, we have serious issues to address. Leaving them unaddressed will only injure the client.

4. Unprepared staffings. Staff communications regarding shared clients often include off-the-cuff comments about clients. These kind of statements can sound as if they are well supported by data. Sadly, we can offer up anecdotes about a client and they are weighted as heavily as objective test data. Can we support our comments and insights with data? Are there other data that might challenge our offered hypotheses?

5. General coarseness. I once had a supervisor who used the “F” word in every sentence (and in every form of speech possible). He relished the power he got from using that word. I’m not opposed to ever using curse words but they usually reveal more about the user than the situation. More recently, I’ve noticed how frequently we use genital imagery to talk about important character traits. “Do you have the stones to do that?” I heard this question asked in prime-time television. Why couldn’t they just talk about the trait of courage? I do think that language has a way of devolving in the heat of battle. Counselors work in the trenches and so it stands to reason that they might slip here some.

6. General grumbling. It is easy to slip into the habit of grumbling. I am tempted to revel (yes revel since I think I enjoy it some) in pointing out the failures of other people. I feel better when I can see their mistakes that I would never commit. We grumble against people, against institutions, against policies; against pretty much anything that irritates us.

Let us be diligent to explore what our communication reveals about our hearts and character and let us resolve, with God’s help, to love others even when they are not watching–and to model that love in our speech.

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