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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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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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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A Parent’s Private Pain


Most of my current counseling work is with adults. Didn’t used to be this way. When I started, I worked mostly with kids and then sometimes with their parents.

What do adults deal with? Some are dealing with personal problems, some are dealing with difficult marriages, work, and the like, some are dealing with parenting young children. All of them hope that counseling will be part of the solution: depression will lift; intimacy will increase, children will be more obedient.

But what of the parent of an adult child who seems to be going off course? Their beloved offspring refuses to address an addiction; rejects their faith; rejects values from faith or culture. Where do they find help and solace? Given the little power parents have over adult children no longer under their roof, these parents rarely choose counseling as an option. Seems too expensive for something that can’t change the situation.

Surely these parents hurt. Their assumptions or dreams seem dashed. They question what they did wrong. Others offer unsolicited advice as to what to do or why their child has departed from their family values. Surely these parents face confusing decisions. Do they cut off from the child? Cajole? Pretend nothing is wrong?

Where best might they turn?

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Criticizing Christian Counseling Models


Critical thinking and evaluation of what goes for “Christian” has always been a part of the Christian faith. This past Sunday my pastor preached on Colossians 2:13-19 and in the midst of the sermon he made this brief remark about Paul’s list of characteristics of those who have “false ideas about ‘righteousness’ and salvation”–in other words, those who use their critical evaluation skills to destroy others (rather than build up) or to build their own kingdoms.

Based on Paul’s list, he said these leaders tend to (a) be quick to pass judgment about the views of others, (b) equally quick to dismiss their opponents, (c) and likely to claim a vision or something special on which to base their own beliefs. He added that these leaders commonly hide their views under a veneer of humility.

In the counseling world, we have had many of these thought “leaders.” These are those who have a grain of truth as they point out the flaws in the views of others, who refuse to accept any critique of their own position and claim to have a purer view of the Bible (though never once really articulating it as a positive position).

But is there a place for critiquing others’ models? If so, how do you tell the difference between a false critique and a necessary critique? Try some of these questions:

  1. Are the critique overly personal? Does the writer give the benefit of the doubt or choose to read the one being critiqued in the worst possible light? If you finish a critique and it seems like the author was making fun of their opponent or making outlandish statements about the intentions or consequences of ideas–then they probably fail the test of constructive criticism and love for all.
  2. Does the one doing the critique identify where the author has spoken truthfully? If not, then the critique is not balanced.
  3. Does the critic offer an alternative after making statements of judgment? If not, then it is likely that the critic isn’t really looking for solutions but merely wants to be destructive.

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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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Buy scarves and support breast cancer research


Most breast cancer chemo patients lose their hair. Kim is not the exception. She’s done well in accessorizing her head with hats, wigs, halos (a ring of hair that would show under a hat or scarf), and other forms of head covering. They are so great I’ve lobbied for her to keep wearing some of them after her own hair returns.

But let me point those of you who wear scarves to one particular company: Good Wishes, which provides a free silken (very soft!) head wrap for any breast cancer patient. Kim’s came in the mail today and is absolutely

gorgeous. You can see lots of options on the site of “Its a wrap” scarves.

While they are not cheap, the company donates 20% of your purchase to the Triple Negative Breast Cancer Foundation which funds research. This is Kim’s kind of cancer.

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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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Filed under christian counseling, Cognitive biases, conflicts, counseling skills, Desires, marriage, Psychology, Relationships, Uncategorized