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REEL THERAPY Ethical and Professional Issues for Therapists.

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1 REEL THERAPY Ethical and Professional Issues for Therapists

2 Boundary  The “edge” of appropriate behavior  Designed to create an atmosphere of safety/predictability within which treatment can thrive  Professional boundaries: Absence of sexual contact, fee arrangements, length of sessions, asymmetry of self-disclosure etc.

3 Crossings and Violations Therapist allows boundary between therapist and client to be broken

4 Boundary Crossing  Lazarus and Zur: Boundary crossing is any deviation from traditional analytic and risk management practices (i.e. the strict, only in the office, emotionally distant forms of therapy)  Benign  Ultimate effect of the deviation of the usual behavior may be to advance the therapy in a constructive way that does not harm the patient

5 Boundary Violation  Using the client for the clinician’s benefit  Clearly harmful to or exploitable of the client  Examples: Therapist hugs client at end of each session, repeated disclosure of therapist’s personal problems, sexual contact

6 Keys  Timing/Stage of treatment  Treatment setting  Treatment type  Patient characteristics  Community, Culture  Content  Menninger: “When in doubt be human.”  Supervision

7 A middle aged male therapist is seeing a female client in her early 20’s for the first time. They hold hands the entire session. Crossing or violation?

8 1.10 Physical Contact Social workers should not engage in physical contact with clients when there is a possibility of psychological harm to the client as a result of the contact (such as cradling or caressing clients). Social workers who engage in appropriate physical contact with clients are responsible for setting clear, appropriate, and culturally sensitive boundaries that govern such physical contact.

9 Self-Disclosure Any behavior or verbalization that reveals personal information

10 Self-Disclosure: Therapeutic Benefits  Models/educates  Fosters therapeutic alliance  Validates reality  Normalizes  Provides hope  Sets norms of honesty/equality

11 Self-Disclosure: Risks  Reverse roles, client does not want to hurt clinician etc.  “Slippery Slope”: Boundary violations, such as sexual involvement  Perceive she is special to the therapist  Focus on clinician’s problems  Comfort clinician instead of receive attention  Feel ignored

12 Ava worked with a woman, Karen, who had been sexually abused by her father. After about a year of sessions, Karen was still blaming herself and did not feel comfortable going to a support group. Also, she was unable to disclose the details of the abuse to her husband, with whom she experienced intimacy issues. Ava decided to share that she had been sexually abused by her father and that is why she had developed this specialty. She also shared that she had difficulty moving from a place of shame and sense of responsibility for the abuse.

13 Karen seemed surprised, relieved, and a little disquieted to hear from Ava. She asked Ava a number of questions about how she worked through the shame and guilt, and conversations ensued that helped Karen shed some of these emotions. In response to Ava asking her how it affected her to have this information about her therapist, Karen said, “It makes me feel protective of you and worried about if I will say things that will be hard for you to hear, or give you flashbacks. Now I’m watching you to see if you are O.K.” (See slide 19 citation)

14 You are a therapist who just found out that you have breast cancer. How do you tell your clients that you are sick without making it their issue and staying focused on their treatment plan?

15 Martha has been working with a couple for over a year and she has developed a strong rapport with them. Martha is a lesbian and generally does not disclose that personal information to her clients. The couple is devoutly Mormon. On two or three occasions the couple has asked Martha about her husband and she lied about her relationship status or changed the direction of the conversation [continued].

16 She is concerned that the disclosure would offend the couple and/or harm the therapeutic relationship and is also concerned about being incongruent. She is sure the clients sense the incongruence.

17  Should Martha have responded differently?  What would you do?  Have you found yourself in a similar situation?

18 Self-Disclosure Guidelines  Be transparent tentatively and briefly, and look for feedback from client.  After any type of disclosure, keep turning the conversation back to client’s concerns and their story.  Be aware of where the disclosure might take you emotionally--so you can stay emotionally present and focused on the feelings and thoughts of the client.

19 Self-Disclosure Guidelines  Present dilemmas from your life and what it was like to grapple with them, rather than solutions.  Be aware of what level of disclosure is comfortable for you.  Be attentive to what transparency can mean in your particular work setting (and/or community).  Overall, keep thinking about your intent whenever you disclose. From Transparency and Self-Disclosure in Family Therapy: Dangers and Possibilities, Janine Roberts ( Published in Family Process, March 2005, Vol. 44, No. 1, pp. 45-63.

20 1.06 Conflicts of Interest (c) Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.)

21 3.05 Multiple Relationships (a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter another relationship in the future with the person or a person closely associated with or related to the person. [continued on next slide]

22 A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence or effectiveness…. (b) If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the ethics code.

23 A.2.a. Informed Consent Clients have the freedom to choose whether to enter into or remain in a counseling relationship and need adequate information about the counseling process and the counselor. Counselors have an obligation to review in writing and verbally with clients the rights and responsibilities of both the counselor and the client. Informed consent is an ongoing part of the counseling process, and counselors appropriately document discussions of informed consent throughout the counseling relationship.

24 A.5.c. Nonprofessional Interactions or Relationships (Other Than Sexual or Romantic Interactions or Relationships) Counselor-client nonprofessional relationships with clients, former clients, their romantic partners, or their family members should be avoided, except when the interaction is potentially beneficial to the client. (See A.5.d.)

25 A.5.d. Potentially Beneficial Interactions When a counselor-client nonprofessional interaction with a client or former client may be potentially beneficial to the client or former client, the counselor must document in case records, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit, and anticipated consequences for the client or former client and other individuals significantly involved with the client or former client. [continued on next slide]

26 A.5.d. Potentially Beneficial Interactions Such interactions should be initiated with appropriate client consent. Where unintentional harm occurs to the client or former client…the counselor must show evidence of an attempt to remedy such harm.

27 Examples of Potentially Beneficial Interactions (A.5.d.)  Attending a formal ceremony (e.g. wedding/commitment ceremony or graduation)  Purchasing a service or product provided by a client or former client (excepting unrestricted bartering)  Hospital visits to an ill family member  Mutual membership in a professional association, organization or community

28  Sexual or nonsexual  Current or former client  Cultivated by the counselor/client or brought about by circumstance

29  Not all boundary crossings are necessarily dual relationships: Out of Office: Making a home visit, going on a hike/walk, attending a wedding etc. Exchanging gifts, hugging, etc.  All dual relationships are boundary crossings (i.e. attending same church, bartering, taking same yoga class)  Incidental or accidental contact.

30 DR: Decision-Making Model  Is entering into the secondary relationship necessary, or should I avoid it?  Can the multiple relationship potentially cause harm to the client?  If harm seems unlikely or avoidable, would the additional relationship prove beneficial?  Is there a risk that the secondary relationship could disrupt the therapeutic relationship?  Can I evaluate this matter objectively? Motivations/Needs? Younggren and Gottlieb, Managing risk when contemplating multiple relationships, (Professional Psychology: Research and Practice 2004; 35, 255-260.)

31 Other Considerations  What is the client’s emotional vulnerability?  What is the degree of role overlap?  The “slippery slope”: minor boundary compromises could lead to more substantial boundary violations.  Imagine the worst case scenario.  Supervision. Supervision. Supervision.  Document.

32 Thoughts? “I was conducting therapy with a child and soon became aware that there was a mutual attraction between myself and the child’s mother. The strategies I had used and my rapport with the child had been positive. Nonetheless, I felt it necessary to refer to avoid a dual relationship (at the cost of the gains that had been made.)”

33 John has been seeing 14 year old Kevin for three months. A productive relationship seems to be developing. The focus of the therapy has been on helping Kevin work through the loss of his relationship with his biological father. He moved out a year ago and has had no contact with Kevin. Kevin reports being unhappy in school and appears to be mildly depressed. During a recent session, Kevin said that he might be enrolling in Bay Bridge Academy, a small private school. Upon hearing that, John felt his chest tighten. His 14-year-old daughter is a student at Bay Bridge and involvement in her school activities is a source of great pleasure and pride for him.

34 What Should John Do?  Possibly start with the physical sensation. What is it? Anxiety? Annoyance?  Sit and consider the opportunities and challenges. Differentiate his experience and needs from those of Kevin’s. John can collaborate with Kevin about how to deal with incidental contact (“Let’s talk about how you and I are going to make this work.”) As a result, Kevin may feel taken seriously. John may worry about the possibility of supervising extracurricular activities, including overnights. Kevin and John’s daughter may develop a social or dating relationship.

35  Consult with a colleague(s). Look at possibility of being too impaired to continue with Kevin.  Include Kevin and mother in decision-making process regarding referral.

36 CONSIDERATIONS WHEN CONTEMPLATING A FRIENDSHIP WITH A FORMER CLIENT  The length and nature of the counseling relationship (power differential)  Client diagnoses or issues  Circumstances and clarity of termination  The possibility that the client might want to return to counseling  Unresolved transference or countertransference issues  Whether any harm to client can be foreseen Herlihy & Remley. Legal and ethical challenges in counseling. In Locke, Myers, & Herr (Eds.),The handbook of counseling (pp. 69–90) (2001).

37  A former client makes a friend request or requests to follow you on twitter. How would you respond to these requests?  Would your response be any different if the client wants to connect on Linked In, a business social media site?  Do you have a policy in place that you share with clients regarding email, social media, etc?

38 “One of the most common failings of many psychotherapists is not having a regular peer consultant or consultation group from which to obtain feedback.” Brandt Caudill, Esq.

39 Cara, a mother of young twin boys, was hospitalized following a suicide attempt and diagnosed with DID. She and her husband were assigned to a therapist for marital therapy. Between sessions the therapist took long walks on hospital grounds with Cara. The husband eventually left the marriage after he discovered Cara had an affair prior to hospitalization. Soon afterward, after a four month stay, Cara was discharged.

40 Cara called the therapist a week later to discuss a personal problem. The therapist gave Cara her beeper number and they eventually talked on the phone daily. The therapist called DSS on Cara’s behalf when she said that she had no money to feed her sons. Later, uncomfortable with giving her money, the therapist shopped for groceries for Cara. Later it was help with rent, gas and electric bills and then lunch, tennis and an art class together. The relationship eventually became intimate.

41  Recently ended a 10 year relationship  Work provided her with her only emotional sustenance  Drinking alone at night  Family of origin issues  Never took an ethics course on boundaries

42 ACA Code of Ethics Section C Professional Responsibility Introduction In addition, counselors engage in self-care activities to maintain and promote their emotional, physical, mental and spiritual well- being to best meet their professional responsibilities.

43 Who (Self) Cares?  Assess your deep motives for becoming a therapist beyond “to help people”. How are these facilitating or hindering self-care?  What energizes or depletes you in your work?  How do you let go? Restore yourself? What keeps your spirit alive?  What gets in the way? What do you need to do differently?  Who do you talk to?

44 Develop a relationship with yourself that is so strong that the first person you ask what they think about something is yourself. Cheryl Richardson, Personal Coach

45 Save the Dates  Monday, November 11th: Portland 1.5 Hours CE (open to general public) TaborSpace 5441 SE Belmont Street Coping With Loss During The Holidays  Friday, January 31st: Portland 6 Hours CE “When In Doubt Be Human”: The Ethics of the Therapeutic Relationship

46 Save the Dates  Friday, February 7th: Corvallis 6 Hours CE “You’re Breaking Up With Me?”: The Ethics of Termination  Webinar, Date TBD 1.5 Hours CE Loss, Lincoln and Resiliency: What Do Abraham Lincoln and Research Say About A Griever’s Capacity to Cope

47 Michael Kahn, LPC, JD   704.962.8023 

48 Bibliography  Engstrom, Movie Clips for Creative Mental Health Education (Plainview, NY, Wellness Reproductions and Publishing 2004)  Kottler, On Being a Therapist (San Francisco, Jossey-Bass 2010)  Kottler and Carlson, Bad therapy: Master therapists share their worst failures (New York, Brunner-Routledge 2003)  Pope, Sonne and Greene, What Therapists Don’t Talk About and Why: Understanding Taboos That Hurt Us and Our Clients (Washington, DC, APA 2006)

49 Bibliography  Psychopathology Committee of the Group for the Advancement of Psychiatry, Reexamination of Therapist Self-Disclosure (Psychiatric Services 2001; 52:1489-1493)  Zur, Boundaries in Psychotherapy (Washington, DC, APA 2007)

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