man on smart phoneAs more information becomes available about Elliot Rodgers, the man who allegedly killed six people in California, the media continues to focus on what his therapist did or did not do right. Therapy can and does help people who struggle with challenges such as isolation and anger, but therapists face serious ethical challenges when faced with potentially dangerous clients.

The Importance of Confidentiality

Confidentiality is the bedrock of healthy and productive therapy. Many people have fleeting angry thoughts, and it’s common to speak in hyperbole, such as in the instance that a teenager tells her therapist that she wishes her mother were dead. Mandating that any violent thought or feeling be immediately reported, then, could be an overreaction that lands nonviolent people in trouble.

Some therapists are concerned that more stringent reporting requirements could undermine good therapy. People who desperately need help may opt not to seek therapy if they are worried that doing so will land them in jail or a psychiatric hospital. People who are currently in therapy may not be fully honest with their therapists if they sense that one wrong word will cause them to be reported to the authorities. Further, targeting people with mental health issues cannot fully solve the problem, since not all spree killers experience mental health issues. In fact, people with mental health issues are more likely to be crime victims than crime perpetrators.

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The Consequences of Reporting

Despite therapists’ best efforts to maintain confidentiality and offer extraordinary care, they have an ethical duty to protect general public and report clients who make clear and specific threats of violence. The decision to report isn’t always an easy one, though. State reporting requirements vary, and therapists must determine the appropriate person or authority to report the threat to.

The consequences to a client’s life of such a report can be powerful and long-lasting. Most police officers don’t get mental health training. Calling a client’s family or spouse is not always helpful, particularly if the family is unsupportive of the client’s attempts to get better in therapy. A client who is in serious distress may make police officers feel threatened. Several people who have had suicidal thoughts or tendencies have been shot by police in the last year.

Given the risks to which clients are exposed when their therapists report them, some therapists avoid reporting until they know a threat is imminent, and by then it may be too late. There’s only so much that law enforcement can do to stop a crime, and even the best therapist can’t talk someone out of a spree killing.

Improving Care for People with Anger Issues

Joshua Nash, a GoodTherapy.org anger Topic Expert, emphasizes that people who are at risk of harming others need better care and that mental health training could begin to improve outcomes for troubled therapy clients. He explained to GoodTherapy.org,

“If we continue to view these incidents as ‘anger management‘ concerns, we fail to see the underlying issues at play. All too often anger results from unexpressed emotions and the unacknowledged irrational beliefs that spawned them. Carrying around a core belief of one’s worthlessness and powerlessness can certainly serve as a powder keg for future explosions. A direction I would love to see the mental health field move towards is an increased focus on psychoeducation for all personnel that come into contact with high risk individuals. Learning to differentiate genuine peace and calm from a forced, affected ‘okayness’ might just prevent further tragedies from occurring.”

References:

  1. Experts fear proposed N.Y. gun law might hinder therapy. (2013, January 15). Retrieved from http://www.usatoday.com/story/news/nation/2013/01/15/ny-gun-law-therapy/1836323/
  2. Fact sheets. (n.d.). Retrieved from http://depts.washington.edu/mhreport/facts_violence.php
  3. Goldberg, J. (2014, May 25). Christian Alberto Sierra, Purcellville teenager threatening suicide, shot, killed by police. Retrieved from http://www.wjla.com/articles/2014/05/christian-alberto-sierra-purcellville-teenager-threatening-suicide-shot-killed-by-police-103465.html
  4. Palmer, B. (n.d.). Elliot Rodger was seeing multiple therapists. Why couldn’t they stop him? Retrieved from http://www.slate.com/articles/health_and_science/medical_examiner/2014/05/elliot_rodger_therapists_why_did_they_and_law_enforcement_fail_to_recognize.html

dr. phil tv therapistGoodTherapy.org is dedicated to ethical therapeutic practices, but the images people see in the media can color their perceptions of what therapy should and should not be. These portrayals might seem like mere entertainment, but they can intimidate some people about therapy, subtly discouraging people who need help from seeking it. Among those already in therapy, television portrayals of abusive or unethical therapy practices could cause clients to mistakenly believe that unethical, abusive practices are normal and healthy.

Hannibal

Hannibal tells the tale of a serial killer psychiatrist who eats his victims—a scary enough prospect. The questionable ethics don’t end there, though. Without receiving consent, Dr. Chilton and Dr. Lecter both use questionable hypnosis techniques to alter memories of the people who see them for therapy and change their behavior. Dr. Lecter continues to see Will Graham, a client who is investigating him for murder and who himself tried to have Dr. Lecter murdered. The show also portrays psychiatrists as all-knowing people who can exert significant control over people’s behavior. This is a particularly frightening portrayal in a television show where psychiatrists are murderous monsters.

Mad Men

In the first season of Mad Men, the anxious and insecure Betty Draper sees a psychiatrist to find a solution to recurrent numbness in her hands. The psychiatrist reveals details of Betty’s sessions to her husband, Don, without Betty’s consent. He uses her husband’s comments as his primary source of information about Mrs. Draper, completely ignoring Betty’s statements. In one session, Betty becomes concerned her psychiatrist is looking down her shirt.

Celebrity Rehab with Dr. Drew

Confidentiality is a hallmark of good therapy. People are more likely to reveal relevant pieces of life history and important feelings with their therapist when they know their privacy is protected. But Celebrity Rehab with Dr. Drew completely abandons this therapeutic norm by showing “therapy” sessions with celebrities. The ethical issues here are compounded by the fact that many of the people on Dr. Drew’s show seem troubled by the lack of privacy their celebrity status has yielded.

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Dr. Phil remains one of the most popular talk shows, but the series suffers from the same confidentiality challenges as Celebrity Rehab with Dr. Drew. Dr. Phil frequently yells at his guests and promotes a very specific set of values. Guests who disagree with Dr. Phil’s proclamations are lambasted and told they’re resistant to improving their own lives. Good therapy, by contrast, doesn’t force any particular value set onto someone in therapy, but instead builds upon his or her own values to help him or her create a more fulfilling life.

How I Met Your Mother

If therapy clients believed what they were told on TV, they might thinkdating your therapist is not only normal, but beneficial. In How I Met Your Mother, Robin dates her previous therapist. The pair justifies the relationship by arguing that she wasn’t in therapy very long, but such justifications have no place in the world of real therapy. A therapist is not an appropriate romantic partner, and therapists who engage in sexual relationships with their patients are taking advantage of a power imbalance.

Ethical therapy helps clients transform their lives without fostering dependence or demanding a client accept a predetermined set of values. To learn more about ethical therapy, check out this GoodTherapy.org guide to warning signs of bad therapy.

References:

  1. Code of ethics. (n.d.). Retrieved from https://www.aamft.org/imis15/content/legal_ethics/code_of_ethics.aspx
  2. Potential ethical violations. (n.d.). Retrieved from https://www.apa.org/topics/ethics/potential-violations.aspx

couple having problems“David, tell Randy you’re sorry.”

“Sorry.”

The mother takes 7-year-old David to another part of the playground. By the sound of the “saaaaawry,” I’m guessing that David was being obedient, but he didn’t really know what he did, didn’t feel like it was his fault, and wasn’t sorry at all.

As adults, we hear (or even give) apologies such as, “I’m sorry you felt hurt.” “If I did something that hurt you, I’m sorry.” “I apologize, but I was really distracted by something else.” “I’m sorry, but you should know that I really love you and you shouldn’t take it so personally. It’s just the way I am.” “I’m sorry, but you are really making too big a deal of this. It is just a little thing.” “I apologize, but give me a break.” “I’m sorry for the problem you had. My assistant is normally on top of things.” When we give such apologies, we can say, as 7-year-old David did, “But I apologized!” However, when the apology (as in the examples above) is an inauthentic or inadequate apology, it doesn’t heal, doesn’t resolve, doesn’t soothe, and the hurt remains unmoved.

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Authentic and effective apology is the very core of healing, clarifying, and restoring relationships, from interpersonal to organizational to cross-cultural ones. A real and well-thought-out apology can, like forgiveness, cut the cycle of anger, revenge, and hatred. However, making a genuine apology causes the giver to be extremely vulnerable. You are admitting directly to another that you did something that caused harm. This is very humbling! Doing so is also challenging because it’s like leaping off a cliff into the unknown. You are not in charge of how your apology will be received. Your efforts could be harshly rejected, your hopes for healing thrown back in your face.

A client spent some months working with his shame about having abused his younger sister. From a most humble place, he wrote her an apology in the hope that this could be a first step in restoring their relationship. Several weeks later, the letter was returned to him, with “Rejected. You will not be forgiven.” written across his words. He was devastated. Over time he began to look at what he could do rather than grieving for the loss of his relationship with his sister.

His sister couldn’t accept his apology, but he could demonstrate that he had learned and changed by volunteering at a women’s crisis center. He also could be proud that he had broken many generations of family history by not abusing his own daughters. These actions, which he was proud of, had shifted his inner wound from the shame of feeling unforgivable to the fact of being unforgiven. He could now move on.

I asked a few of my friends to remember a time when they needed to and did offer someone an apology. Usually, we rightly focus on the feelings and needs of the hurt person, but I wondered what the apologizer got from the process. This is what I heard: “I got to let go of at least some of my guilt.” “The apology was accepted. It repaired the relationship, and the friendship actually got better.” “In the process of getting to being able to apologize, I went through all my defenses and finally got to see something about myself that I didn’t like and face the truth about a familiar and hurtful pattern I had been denying or at least had been unaware of. This was hard work. Once I got it, the apology was easy.” “Honestly, I don’t know if I got anything at all. It was really like just getting it out of the way.” “It was unbelievably relieving for me.” “It took such courage. I try so hard to be ‘good,’ and it was painful but freeing to be able not only to see but to take responsibility for doing a bad thing.” “I learned that it’s really OK to make mistakes. What isn’t OK is not to apologize for them and learn from them.”

Apologies open big doors. As John Kador puts it, “Apology is the bravest gesture we can make to the unknown. … Apologies unmask all the hopes, desires, and uncertainties that make us human because, at the moment of genuine apology, we confront our humanity most fully. At the point of apology we strip off a mask and face our limitations. No wonder we hesitate” (Kador, pp. 43-44).

What is the value of apology to the one who has been wounded? Opportunity for restoring relationship, deescalating conflict, rebalancing power, recovering dignity, letting go and moving on, stopping a cycle of resentment and revenge, and increasing trust in the human capacity for goodness and truth. This is a strong litany. From the biggest perspective, “quarrels often escalate into serious conflicts on the fulcrum of apology. … Throughout human history, endless cycles of revenge and untold suffering have resulted from the denial of effective apology. It’s a tragedy because apology has the power to defuse almost all human conflicts” (Kador, p. 45).

In my book Right Use of Power: The Heart of Ethics and in my ethics programs, I talk about resolving difficulties as one of the most important and challenging skills to learn as leaders and human beings. I describe five things that most people need to hear in order to for an injured relationship to be restored. Not all of these things will be essential in all situations, but at least one—and probably more—will be needed. Here they are (Barstow, p. 160):

  1. Acknowledgement
  2. Understanding
  3. Regret
  4. Learning
  5. Repair

Making “a genuine apology or/and authentic expression of … regret” is the complete description of No. 3.

Effective Apologies

With a deep bow to Kador for his excellent book Effective Apology: Mending Fences, Building Bridges, and Restoring Trust, I want now to suggest how one can make an apology with greater wisdom and skill.

Kador also names five dimensions in making an effective apology (Kador, p. 124): recognition, responsibility, remorse, restitution, and repetition. Here’s more about each of these.

General Considerations

Accepting Apologies

The other side of offering an apology is accepting one. On the receiving side, you must discern whether the apology is genuine and whether it feels satisfactory. Accepting is just accepting. It doesn’t automatically include trusting or forgiving. Rebuilding trust happens over time. Forgiveness is a separate process.

When you do accept an apology, it is important to make an acknowledgment. Responses such as, “It was nothing,” or, “Don’t worry about it,” or, “You don’t need to apologize,” or, “It’s too late” have the effect of dismissing the intended communication. They trivialize a vulnerable moment. Before learning about the apology process, I had thought that when I said, “It was nothing,” I was being kind, generous, and forgiving. I now understand it to be disrespectful. When the apology is genuine, it is best to say, “I accept your apology.” The interaction needs to be complete and acknowledged. A friend’s “I’m sorry I’m late; I know that caused you some extra work” deserves my recognition of her humility and awareness of her negative impact. “Thank you, I accept your apology” as a response in this case works well.

Apology can move mountains. A half-hearted one can make things worse. A sincere and well-crafted apology can restore relationships.

therapist deep in thoughtIn my initial posting for GoodTherapy.org, I wrote about the fact self-testing for HIV is a reality in the United States. What this effectively does is change the access point for people to find out their HIV status. Prior to this, the only way to legally get tested was through a testing clinic (including health centers, testing vans, and Planned Parenthood) or through a medical provider. I say “legally” because people could buy self-tests online and have them shipped to their homes, but these were neither FDA-approved nor legal.

Since the approval, people can choose when and where they want to get tested. This has both clinical and legal implications for clinicians and clients. Future postings will explore many of the clinical issues, but as a starting point, it is important for clinicians to know some of the basics, especially the laws regarding transmission and disclosure.

Taking an HIV test does not change one’s status. It changes one’s knowledge about one’s status. The way current laws are written in most states, the concern is not as much with the former as it is with the latter. In more than 30 states, there are laws on the books regarding the transmission of HIV. These laws vary greatly, but broadly fall under two categories.

We often hear it said that “knowledge is power.” With regard to taking an HIV test, this has truth. As mentioned, the test does not change one’s status, just his or her relationship with the truth of status. However, as can be seen from the first category above, knowledge also has greater consequences. If someone has HIV and engages in sexual activity, but he or she does not know HIV status, the law may not hold the person accountable.

This sets up possible scenarios such as these: The person with HIV who does not know his or her status can have unprotected sex, spread HIV, and not be held liable, whereas the person who knows he or she has HIV, does not disclose this, uses protection, and does not spread HIV can be prosecuted. It is a flawed system that ultimately discourages doing the responsible thing (getting tested), and it is just one of many issues regarding HIV that are caught in a web of politics, prejudice, and fear. It is also a system that creates strong narratives of “victim” and “perpetrator,” holding the person who knows he or she has HIV wholly responsible while absolving the one who does not know his or her status. This victim/blame narrative is another common theme when dealing with HIV in clinical settings.

When working with clients, it is imperative that we continue to strive for higher levels of functioning than laws that blame the “perpetrator,” who, in many cases, also has been the “victim” (of cultural violence, for example). It is a deadly cycle, and one that we can help break with good foresight. From my training with the American Psychological Association’s HIV Office of Psychology Education (HOPE), we learned that the law, as intimidating as it is, is the lowest level from which we operate, often puts us in ethical binds, and we have to use our ethical dilemma models to act in the best ways we know to reduce harm and maximize benefit while documenting every step.

Back to the issue of HIV self-testing and implications for clinicians: Given that it is now possible that people can self-test (and more people will as advertising increases on places such as Facebook, MTV, and Comedy Central), it is important that clinicians become familiar with their state laws regarding transmission. This is especially the case for clinicians working with sexually active youth and young adults, and/or sexually active clients with addictions. A list of states and transmission laws, including what constitutes a felony, misdemeanor, or finable offense, can be found here.

Clinicians will also need to consider potential liability issues if he or she is the only person to whom the client has disclosed HIV status (say, in a situation where the person has self-tested and is not seeking treatment) and the person spreads HIV. Do we collude with the client and deny his or her HIV status in the absence of any other documentation? How do we document agreements with clients regarding disclosure?

As with all ethical dilemmas, there really is not clarity as to what is the right thing to do. What we can do is to make sure we have a reliable framework with which to address ethical dilemmas, colleagues with whom we can consult, and knowledge of the law in our state. Where laws exist, we should make sure the client is aware as well.

If people have questions or would like to explore any of this further, please feel free to reach out to me. We serve our profession and clients better when we are not caught off-guard, and this is one of those issues we should be considering.

Friends share a cup of coffee togetherOn more than one occasion, previous clients have asked if we could remain friends during or after our therapy sessions. While I could envision being friends with some of my previous clients if circumstances were different, I usually refrain from doing so and explain why I don’t encourage it.

As clients, it’s wonderful when your work with therapists has developed a strong sense of trust and safety over time. You have successfully been able to open up, gain more insight, and work through the primary issues for which you initially chose therapy. Perhaps you saw the evolution of talking about intimate details to a virtual stranger who then became what feels like a friendly confidant.

Good therapists with appropriate boundaries often do not view the evolution and closeness of the change in the therapeutic relationship with the potential for a friendship after therapy concludes, as some clients may. It is not that therapists wouldn’t like there to be a friendship in some instances. Nor does it mean they don’t care about or are indifferent toward their clients.

Therapists are usually not friends with their clients for two reasons:

  1. To maintain objectivity in the clients’ best interests
  2. To avoid conflicting dual relationships.

While some dual relationships are inevitable, ethically and legally therapists must evaluate and avoid dual relationships that harm or hinder the work with their clients. Therefore, other types of relationships that evolve during or after the therapeutic relationship are not normally encouraged. As an example scenario, let’s say you are hosting a dinner and wine tasting party at your home, and invite your therapist to meet your new significant other. Your therapist declines, and you feel angry. How will this affect your next session? Will it affect whether you decide to show up or not?

In another scenario, maybe you have successfully terminated your sessions, and somehow remained friends with your therapist. But what if another issue comes up for which you would like to resume therapy? The nature of the relationship would then be clouded and the boundaries unclear.

The therapeutic relationship is not a symmetrical relationship where there is mutual sharing on both sides. There is a natural imbalance. While a good therapist is a caring and empathetic person who you feel became a friend, he or she is also an authority figure to whom you are choosing to turn for professional help and support.

In friendships, there is normally a two-way dynamic in which both parties get to know each other and can mutually share vulnerable information about themselves over time. In the therapeutic relationship, the client primarily holds the role of sharing vulnerable information with the therapist. The therapist does not usually do so in turn, especially on the clients’ time. When personal issues come up for therapists, they will often seek consultation, supervision, and even their own therapy when needed.

The role of therapists is to serve their clients through listening, empathizing, mirroring, offering a different perspective, and assisting their clients gain more insight into their situations and their reactions. They help their clients with coping skills and equip them with tools to deal with their situations or relationships in a healthier manner. The therapist focuses attention on the primary issues a client is struggling with, rather than the other way around.

It is never the responsibility of the client to take care of the therapist or to solve an issue a therapist is struggling with in his or her personal life. This is one of the primary reasons developing a friendship with your therapist outside the appointed session time is not highly encouraged.

Most good therapists generally care about their clients tremendously and want to genuinely see them improve. In order to do so, they will keep the therapeutic boundaries clear and intact.

Empty waiting roomThe recent news that troubled country singer Mindy McCready took her own life has thrust the debate about the efficacy and ethics of “rehab” television shows and the people behind them, such as Dr. Drew and Dr. Phil, into the spotlight. McCready is the fifth cast member from Celebrity Rehab with Dr. Drew to die, prompting one well-known musician to take to Twitter to compare host Drew Pinsky to assisted-suicide icon Jack Kevorkian: “Same results,” Richard Marx wrote.

We wanted to know what our Topic Experts think, so we asked them the following questions: Is the criticism of Dr. Drew, Dr. Phil, and similar so-called experts-turned-media personalities warranted? Is it enough? After all, for many Americans, they are THE faces of therapy. Is that fair? Are they doing more harm than good? Is what they do simply exploitation, or is there more to it? With the popularity of reality TV on the rise, how can therapy professionals counteract any damage done by Dr. Drew, Dr. Phil, and others whose platforms extend into living rooms from coast to coast and beyond?

Here’s what they had to say:

What do you think about so-called “rehab TV”? Do you agree or disagree with our Topic Experts? Please share your thoughts in the comments section below.

GoodTherapy | 50 Signs of Good TherapyAs a companion piece to the 50 Warning Signs of Questionable Therapy article, it’s important to understand there are many signs of good therapy as well. After all, good therapy has been proven to help people from all walks of life, in thousands of different situations, and in countless ways.

Good therapy is all about helping the person seeking help to feel better, to make healthy decisions and set healthy boundaries, to move from a place of poor emotional health to good emotional health, to make connections with others, and to replace sadness, anxiety, anger, and frustration with happiness, peace, and hopefulness for the future.

Because the “Warning Signs” article is so focused on the therapist and the behaviors they engage in—or don’t engage in—we wanted the “50 Signs of Good Therapy” to put the focus on the person in therapy, which is exactly where it belongs.

While the “50 Warning Signs of Questionable Therapy” is structured in a list format, these 50 signs of good therapy are structured along thematic lines.

Themes include:

Below is a listing of the 50 signs of good therapy, placed in order by theme:

Training/Credentials, Experience, and Professionalism

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Most states and other municipalities require that therapists or counselors meet specific education and training requirements. Though these vary from location to location, all therapists must be educated, trained, and must follow basic professional codes of ethics and guidelines. The foundation for good therapy exists when:

1. Your therapist is trained appropriately and meets all local and/or state guidelines for providing therapy.

2. Your counselor seems competent and experienced enough to help you with your issues and does not appear overwhelmed by them. While it is possible you may see a counselor who does not have the training or experience to help you with your problems, they should always let you know if that is the case.

3. Your therapist explains the therapeutic process and how you can benefit from it, without guaranteeing your success or promising that “everything will be okay.” The bottom line is that no one can make such guarantees—neither the therapist, nor you.

4. Your counselor always maintains professional business practices by keeping the focus on you. They prepare ahead of time for your sessions by reviewing notes or action items from previous sessions. They keep your appointments; are generally on time; and demonstrate they are paying attention by not answering their phone, checking their email, or otherwise becoming distracted during your sessions.

5. Your therapist provides a diagnosis if necessary but remains steadfastly focused on helping you to manage any such diagnosis and get better. The diagnosis remains the backdrop for therapy, not the focus of it.

6. Your counselor understands and communicates to you that there are many effective approaches to therapy, and no one approach can meet the needs of every client. They model open-mindedness about other approaches to therapy.

7. Your counselor explains what psychotherapeutic technique they plan to use, welcomes and answers any questions you may have about a specific technique, and requests your comments for any technique that may be new or different for you.

8. Your counselor is active in the therapy community and regularly interacts with other professionals. It is this regular collaboration with other professionals that keeps your therapist current and able to provide the best therapy for you.

9. Your counselor provides insight and knowledge that you otherwise might not have seen. This insight clearly comes from experience and training.

10. Your therapist maintains a good balance between your thoughts and your feelings without neglecting or diminishing either one.

11. Your counselor always demonstrates a balanced and appropriate level of emotion during sessions. Because good counselors are empathic and genuinely care for their clients, sometimes they express emotion when learning about a client’s experience. For example, if the client has experienced the loss of a loved one, the counselor may show sadness. While some emotion is appropriate, an abundance of emotion is generally not okay. Good therapists maintain their focus on you and not their own emotions.

12. Your therapist helps you to work through highly vulnerable feelings or memories in a safe and therapeutic way that does not re-traumatize you. Because of your work together, they know when it is safe to deal with these feelings or memories and when it is not. They neither push you to “go there” nor do they prevent you from “going there.”

13. Your counselor has also experienced being in therapy. Many counselors choose this field because they’ve had positive therapy experiences themselves, and they want to do the same for others. For those who have not experienced therapy prior to entering a counselor education program, most curricula require counseling students to participate in therapy, even if briefly so. This allows therapists to understand therapy from the client’s perspective.

Informed Consent and Other Legal Issues

The term informed consent is common among therapists. It simply means that the client should be made aware of any and all benefits and risks of therapy or a particular treatment or technique so that he or she may make the best decision about proceeding with the therapy. Informed consent is often a legal requirement as well, and these next few signs of good therapy are specifically about informed consent and other legal issues. The foundation for good therapy exists when:

14. You receive a packet, commonly called intake forms or informed consent, to complete before or with your first appointment. This packet should explain how therapy with your counselor works, what your rights are as a client, the fee schedule, insurance information, privacy information, and more. Your therapist should also answer any questions about this packet to your full satisfaction.

15. Your counselor explains to you that therapy is always your choice. They should make you feel comfortable with the choice to discontinue therapy or to choose another therapist. Some people decide to leave therapy before the counselor thinks it is healthy to do so, and your therapist is obligated to express any concern if you opt to discontinue therapy before the therapy has been “completed.” However, this concern should not make you feel as if you don’t have the choice to leave.

16. Your counselor maintains your confidentiality at all times. While there are some occasions when it’s necessary for a counselor to break confidentiality, these are typically outlined very carefully in the state’s or other municipality’s legal and ethical guidelines for counselors. Though the guidelines vary depending on where you live, generally speaking, a counselor can divulge the contents of a therapy session or sessions if the client or another person appears to be in imminent danger, or if the court requires information for a legal proceeding. You may want to check your own local and state guidelines.

17. Your counselor maintains the confidentiality of other clients as well. While your counselor may tell you anecdotal stories of other people’s experiences with counseling if there is a therapeutic value to you, they should never reveal the identities of other clients or give you any information that would allow you to identify them.

18. Your therapist responds openly and honestly to any questions you may have about complaints filed with the licensing board. We recommend that you always check with the licensing board to make sure your therapist’s license is current and that there are no unresolved issues.

Communication and Client Focus

Effective communication and the relationship between you and your counselor are probably the most important and indicative factors in whether or not your therapy will be successful. While everyone has different communication styles, it is the counselor’s role to be clear throughout the counseling process. A key part of effective communication is the focus of the counselor—which should always be on you. The foundation for good therapy exists when:

19. Your counselor explains right up front how they can help you. They give you concrete examples of what they will do, what you will need to do, and how you will know the therapy is progressing.

20. Your counselor regularly checks your progress against your goals and helps you to understand where you are and where you may still need to go.

21. You feel a connection with your counselor that shows they really believe in you and in the goals you have set for your life.

22. Conversations with your counselor seem natural and balanced. They neither talk too much nor too little. They use terms and language you understand and explain any concepts that may be difficult or confusing.

23. Your counselor helps you to see your own role in your level of happiness and recognizes that, while some people in your life may influence you negatively, blame is a destructive force and cannot be part of healthy choices.

24. Your therapist balances the day-to-day needs of managing your symptoms using effective coping skills with the need to work through and resolve the underlying root causes of those symptoms. By focusing on both, they are better able to help you progress and move forward than by putting all therapeutic attention on one or the other.

25. Your counselor models the behavior they are trying to help you with. They are thoughtful with comments and responses. They remain calm and speak at a moderate volume and are not antagonistic or aggressive with you.

26. It is clear that your therapist’s sole purpose is to help you—without focusing on meeting their own needs, talking excessively about themselves, disclosing personal information that does not hold some therapeutic value for you, or enlisting your assistance with anything that is outside the purpose of helping you.

27. Your counselor recognizes they may not have all of the answers or be able to help you in some circumstances. They freely acknowledge any mistakes, welcome your honest feedback, and use these as learning experiences in order to better help you and understand your needs in the future.

Empathy and the Therapeutic Relationship

Empathy, or being able to “put yourself in somebody else’s shoes,” is a hallmark of good therapy. And therapists are often naturally empathic, as this is one of the common reasons they choose to be therapists in the first place. Demonstrating empathy within the therapeutic setting helps the client to feel safe, to feel understood, and ultimately to feel like they can make progress.

Empathy is what helps build a relationship with your therapist. And your relationship with the therapist is key to the success of therapy itself. Without a strong relationship, the therapist has little chance of genuinely helping the client work through difficulties, and the client has an equally low chance of progressing.

A number of the warning signs refer to a “dual relationship,” which is quite simply one where the client knows the counselor in another context or setting besides the counseling environment. This secondary relationship can cause confusion for the client, which is why it’s typically an ethical issue. Good therapists maintain a productive and professional relationship with you at all times. While the relationship with your therapist can seem quite close—after all, you are sharing your most private thoughts, sometimes over long periods of time—therapists are trained to manage this closeness and not cross the ethical line of becoming friends or romantic partners. The foundation for good therapy exists when:

28. Your counselor maintains a professional relationship with you at all times.Their demeanor could be friendly, but they never depict your relationship as a friendship.

29. Your therapist treats you as a “whole person,” an equal who is not defined by your issues, and does not make negative judgments about you. You feel genuine care and concern from your therapist. One of the hallmarks of good therapy is known as unconditional positive regard. This is an idea that is taught in counseling programs across the country; it maintains that the therapist should see clients in a positive light regardless of any behavior, lifestyle, or other issues.

30. Your therapist is respectful of your values and belief systems and does not exhibit an agenda founded on personal values or belief systems. They are sensitive to your culture and religion and use aspects of these as part of your therapy, when appropriate. If they lack knowledge about your beliefs, they ask questions in a respectful way to gain better insight.

31. Your therapist knows you well enough to understand any physical boundary issues you may have and does not “move into your space” or touch you without asking if it’s okay with you.

32. Your counselor empathizes with you at an appropriate level, such as a natural or fitting response or level of emotion to your life’s experiences, and not one that is either overdone or exaggerated, or flat and almost nonexistent.

Progress

Finally, your progress in therapy is the ultimate indicator of whether or not you are receiving good therapy. After all, regardless of how competent or skilled your therapist may be, you getting better is what really counts. Before we get into the final list, it is important to note that just because someone is not making progress doesn’t mean the therapist is bad or incompetent. Therapy by its very nature is highly subjective and influenced by the varying needs, readiness, and styles of both the client and the therapist. Sometimes a client may not be ready for therapy and sometimes the therapist and the client are not a good fit.

With regard to the changes listed below, it should be mentioned that they don’t usually happen all at once; instead, they often happen gradually and in different sequences. The foundation for good therapy exists when:

33. You feel better! You notice that you are happier, calmer, at ease more often, and more hopeful about the future.

34. You are resolving your own issues and not looking to your therapist or anyone else to fix things for you. A good therapist guides you to your own best solutions. They are not “rescuers” who are there to save you from the issues you are facing. Instead they help you achieve insight into your own thoughts, feelings, and experiences so that you can make the right choices for yourself and move toward a healthier emotional state.

35. You handle life’s ups and downs more easily and with more control over your emotions. You see the difficult times as part of life and are less likely to become overwhelmed by them.

36. You are more forgiving and accepting. You are seeing those around you, including those who may have hurt you, as humans who may have simply made mistakes just as you have.

37. You are more connected to yourself and your own emotions, to those around you, and to life in general. You look forward to living your life and not just moving through it.

38. You are beginning to see things differently. Your perspective on life and everything around you is changing, and you see solutions where you may have seen problems in the past.

39. You are making different choices and looking at your own needs more often. You recognize that you have choices you didn’t used to think you had.

40. You smile or laugh more; your whole demeanor is more positive and future-focused.

41. Other people are noticing differences in you, and they are beginning to react to you in different and more positive ways.

42. You are getting along better with the other people in your life—from your friends and family members, to your coworkers, to strangers you come across on a day-to-day basis.

43. You have more hope for a brighter future for yourself and for your loved ones.

44. You have some sort of plan or goal for what you want your life to be, and you’re working towards that goal.

45. You are setting healthy boundaries with the people in your life and actually building stronger relationships because of it.

46. You notice that you’re feeling better outside of the therapeutic setting and not just while you’re talking to your therapist.

47. You feel safe both emotionally and physically.

48. You feel important, competent, and significant in the lives of those around you. You know you have value to them and to yourself.

49. You feel stronger and better able to express your own needs and desires. You don’t feel victimized by the actions of others.

50. You are making your own healthier choices for your behavior, for your thoughts, and for your feelings.

Technology has advanced by leaps and bounds over the past several decades, affording clinicians the opportunity to provide services in more unique and far reaching way ways than ever before. However, these advancements have not come without risk. “Unfortunately, professional psychologists have also identified a number of disadvantages associated with the increased use of technology in psychological practice, including difficulties in managing electronic database and communication security, unauthorized access to client data, inappropriate disclosures of identifying information, and unethical interactions in the social-media context,” said Jason Van Allen of the Clinical Child Psychology Program at the University of Kansas. “To further complicate matters, regulatory, ethical, and legal standards in psychology are not advancing at the same rate as technological advances. This technological adoption and infrastructure mismatch is associated with a variety of potential challenges and concerns (e.g., psychologists operating without guidance from the professional organizations or with a consensus of the professional community).”

In order to identify how compromised ethical and regulatory guidelines have become with cyber-psychotherapy, Van Allen surveyed 28 psychologists and assessed their responses to virtual conditions using the Critical Incident Technique (CIT). “Overall, survey responses suggest a variety of technology-related concerns among practicing psychologists,” said Van Allen. “Responses were frequently associated with inappropriate access and/or dissemination of client data, and challenges with the use of social media.”

The American Psychological Association is aware of these concerns, but has yet to issue its own guidelines for ensuring client confidentiality and ethical adherence in a virtual world. “Overall, responsibility for ethical and professional integration of technology in practice lies with individuals,” said Van Allen. “Although psychology governance can do more (and is taking initial steps at this time) to provide guidance, psychologists would benefit from assessing the security of their electronic communications, from establishing social-media policies for themselves or their organizations, and from proactively weighing the risks and benefits each time they consider incorporating new technologies in their professional activities.”

Reference:
Van Allen, Jasono, and Michael C. Roberts. “Critical Incidents in the Marriage of Psychology and Technology: A Discussion of Potential Ethical Issues in Practice, Education, and Policy.” Professional Psychology: Research and Practice 42.6 (2011): 433-39. Print.

How I Met Your Mother's Robin sitting with boyfriendIf Hollywood is an indicator of our most common fantasies, modern Americans want to sleep with their therapists. I am horrified that so many television shows and movies depict romantic relationships between therapists and clients as though they were perfectly normal! The truth is, romance within a therapeutic relationship is as far from normal, acceptable, healthy, and sane as you can possibly get.

The writers of How I Met Your Mother currently have the character Robin dating her previous therapist. The relationship has been rationalized through a series of cutesy excuses: “Well, we only had a handful of therapy sessions … it hardly counted!” and, “Well, if we have a session where the previous client now becomes the therapist, it will all balance out!” ICK!  In no way, shape, or form is dating a current or previous therapist healthy, ethical, or socially acceptable.

In California, there is a legal clause that states that a personal relationship between a previous therapist and client may be pursued two years after the termination of services. However, research tells us that the power imbalance remains strong, even after time has passed, and that romance in this situation is usually still emotionally damaging to the one who was the client. Hormones, brain chemistry, and emotional issues often inadvertently conspire to lead us toward unhealthy romantic choices, which is why therapists are clearly instructed that “Professional Therapy Never Includes Sex” (this is the name of a pamphlet that every single therapist-in-training in California receives on several occasions). Although specifics vary from state to state, 19 states have sexual exploitation laws forbidding therapists from engaging in sexual contact with clients.

Even though in the movie 50/50, Joseph Gordon-Levitt appears to find care, comfort, and I-don’t-know-what-else in the arms of his intern therapist (I don’t know because I walked out of the movie), your therapist is neither your caretaker nor your best friend. Your therapist can help you develop the skills you need to go out and make friends and find someone to help you through the difficulties of life. But if your therapist tries to convince you that his or her role is to love and protect you, run away! That is NOT appropriate therapy! And if he or she makes any sexually suggestive advances (verbal or physical), you know you are not working with an ethical therapist.

Extensive worldwide research and anecdotal evidence dating back to the origins of formalized therapy indicate that romantic relationships between therapists and their clients, regardless of which role is the initiator, are criminally damaging to the client in the majority of situations. The client is typically left with extreme emotional disruption, feelings of emptiness, isolation and guilt, and a tragically impaired ability to trust.

Certainly the therapeutic relationship is a unique situation wherein two human beings share space in a room while playing particular roles that ask them to maintain strict discipline of their human instincts, but to share the greatest level of openness and honesty imaginable. When deconstructed, the therapeutic hour shows itself to be a very bizarre social construct that is quite challenging to enact in a productive and healthy way. When properly delivered, the benefits of appropriate psychotherapy can be powerfully life-changing. However, there are many ways to get off track throughout the process, which is why therapists need to be well-trained, licensed, ethically and emotionally stable, grounded in common sense, and masters of self-discipline and self-care.

The boundaries around the therapeutic relationship are essential to the success and integrity of our profession, and I find it inexcusable for our entertainment industry to treat the subject matter so lightly and irresponsibly. We know that the mass public derives their sense of “normal” and desirable from the information presented on the screens in front of them. If this were an isolated incident of poor judgment, I could write it off as such. But the theme has become so ubiquitous as to appear in highly rated productions reaching tens of millions impressionable minds worldwide.

I started enjoying the recently cancelled sitcom, Free Agents, until the female character’s therapist asked her out during a session and they started dating. What? After a few therapy sessions, in which he did nothing of therapeutic value, he declared her problem-free and decided to hit on her. My concern is that the writers of these shows may actually be typical, regular people who truly believe that relationships with therapists are normal. If this storyline is depicted in other regular people’s everyday media consumption, a very serious misconception about the purpose and practice of psychotherapy may occur.

Of course, romantic, sexual, and loving feelings can arise between two people who sit close together and speak of personal and intimate issues on a regular basis. A well-trained and ethical therapist will seek professional consultation if romantic or lustful feelings arise and will follow wise counsel as to the most ethical way to proceed. Often these feelings can be worked through and resolved without any negative effect on the therapy. If the feelings persist, the responsible and legitimate therapist will control his or her impulses and refer the client to another professional. With the help of an esteemed consultant, they can determine how best to implement the transition with the client.

The therapist portrayed by Gabriel Byrne in In Treatment struggled with sexual feelings toward a client in the first season of the series. I have not seen these episodes, but I know the series is highly revered and often seen by the general public as an accurate representation of therapy. It was very disheartening for me to hear that this character acted on his sexual impulses, even though he apparently understood the harm that physical intimacy could do to his client. I think these representations are misguided and ill-advised, as they imply that the psychotherapeutic setting is always imbued with sexual energy and tension.

It is not uncommon for strong feelings to arise in a psychotherapy client. For many schools of thought, this is actually an important part of the therapeutic process. However, if the feelings become strong enough to breach the integrity of the therapy, they must be addressed. In the healthiest of situations, the client would admit these feelings to the therapist—the best therapeutic alliances are built on trust and acceptance, communicating to the client that no judgment or disgust will befall them in that room, under any circumstances. If a client shares the feelings he or she is having, the issue can be discussed openly and often can be resolved, bringing greater insight and personal power to the client. If the feelings cannot be redirected and resolved, it is best to help the client find a new therapist to continue the growth work in a nonsexualized setting.

Looking at current blog posts, I see many people justifying their seductions, romances, and friendships with their therapists. Most of these bloggers are writing at the beginning of their relationships and seem not to believe that they may not get a Hollywood ending. I am very concerned that media representations of our profession are casting a skewed and uninformed light on this very complex issue. The general public is clearly buying into the idea that dating their therapists may be legitimate.

Perhaps we therapists can take this challenge as an opportunity for greater enlightenment and education with our clients. It will keep us on our toes (even more) so that we may identify and address misplaced emotional feelings that arise in therapy. This aspect of the profession is difficult enough without added pressures from the mass media. However, our awareness of the issue can serve to reinforce our ethical stance and prepare us for any type of challenge that may walk through our consultation door.

A recent article brings the severely distorted ethical and psychological life of the late Stuart Greenberg, renowned psychologist, back into the spotlight. Although it has been nearly four years since the suicide of the expert witness, many of those whose lives he affected remember the actions he took as if it were yesterday. For decades Greenberg held the futures of children in his hands as he testified to the psychological state of the parents who fought for their custody. He was directly responsible for information juries would use to determine guilt or innocence in sexual assault cases and gave specific details that would impact monetary rewards. Greenberg had a professional and social stronghold in the courts and knew that his testimony was never challenged and was deemed credible, in part due to his impeccable presence as a consummate performer. That was, until one determined mother, Cathy Graden, fought back. She sued after revealing that Greenberg had distorted reports and created misleading allegations, deeming her unfit to raise her four year old son and costing her custody. After years of litigation, the state Examining Board of Psychology eventually levied disciplinary charges against the psychologist, and prohibited him from conducting parenting evaluations for three years. (more…)

Kwan yin statueTo continue with the theme of the paramitas from last month, wherein we began with generosity, we will look at the practice of ethics or morality (Shila in Pali language), sometimes referred to as discipline.

Many of us have a negative response to the words morality and discipline (and possibly ethics), which can sound like something imposed, a should we never live up to. Some of us lose hope around these words, or like bad people, or self-righteous. In truth, discipline and morality are inner qualities that, when cultivated within a clear framework, bring a sense of peace and well being, from knowing we live a life of integrity and no-harm.

Cultivating Ethical Discipline offers the following benefits (and beyond):

In the Buddhist path of the paramitas, Shila has a specific structure. In most traditions, when a person becomes a Buddhist, they take five precepts as their vow of conduct. When we choose to practice the paramita of ethics/discipline, we use the precepts as the basis of our practice for developing these inner qualities.

We make an agreement with ourselves to do no harm to other beings, including refraining from killing insects. We agree not to steal, or take what isn’t freely given, including borrowing without asking. We agree not to lie, gossip, misinform, or otherwise harm with our speech. We agree to not harm through our sexual energy, including breaking our commitments or interfering with the commitments of others, participating in exploitation or fantasies that could harm others, and so forth. We agree not to drink to excess or take drugs, to keep from clouding our minds and obstructing clear-seeing.

These are ideals we strive for, not goals we punish ourselves for not attaining. As in training a puppy, beating ourselves into submission will not bring the desired results. Repeatedly offering ourselves clear, firm, and loving guidelines, until the new behavior becomes established, works much better. There are gradations in every field of human endeavor. I have managed to never murder a human I was angry with, but I still lose control when streams of ants flow through my kitchen, and I have resorted to ant-murder more than once. (My preferred approach now is to repel them with eucalyptus leaves scattered outside the house, but every so often they come in anyway and I break my vow again.)

I think most of us hold the intention, whether vaguely or explicitly, to live a good life, to refrain from harm, and behave well. The precepts give us a clear path for doing so, and a landmark we can refer to when we lose our way (which we all do, repeatedly, so be kind to yourself about it).

To integrate the precepts into our daily life, we can read the following aloud to ourselves each morning and see what arises throughout the day. People often think they know which precepts might trip them up, only to be surprised in practice. Keep an open, curious mind and see what arises.

Today I intend to:

There may be different precepts you would set for yourself, and maybe you will experiment with them. I encourage you to try these first, because they have worked for 2,600 years, and because most everything is covered: vowing to eat healthier food, have better relationships, do your practices regularly. It’s all here.

We may not know how to deal with a broken vow. Our parents may not have been consistent or clear in their rules and consequences for misbehavior, so we may only know how to beat ourselves up or feel guilty or bad if we do something that is out of integrity with who we want to be. There is a structure in Buddhism for working with moments or events when we fall short of our ideals. We all mess up from time to time, and we have to forgive ourselves and work through, or we will accumulate a burden of pain and guilt and shame that clouds our interactions and our experience of the world.

Making Amends
When, for example, we hurt someone with our speech or actions, we begin by allowing ourselves to fully feel the pain of causing pain. So often we turn away from this, or take refuge in guilt, rather than looking directly at what we have done, and why. If we can bear to see clearly the roots of our behaviors, and feel the results, it becomes easier to bring ourselves in line with what we generally intend, which is to do no harm?

Next, we do our best to mend the tear in our integrity, both with ourselves and with anyone we hurt. Our apologies need to be sincere and without expectation. If we require forgiveness or even acceptance of our apology, then the apology is attached to something other than our sincere regret. We can apologize from our hearts, freely, and allow the other person to do what they wish with that. It is not up to them to free us or grant us pardon. We are responsible for our own experience. This is our own work. Only we can complete it.

If there are other reparations to be made, we make them, without resentment or hesitation. If we break a window, we replace the glass. No story is needed about how bad we are for breaking it, or how mean they are for making us replace it. We trust our inherent morality to know what is right and we act accordingly.

We then vow to not behave in such a way again, and do our best to follow that pledge. We will, most likely, slip up anyway. So we return to the beginning of the process of amends and unravel it all over again. This is a lifelong process. Have patience.

Important Notice

GoodTherapy is not intended to be a substitute for professional advice, diagnosis, medical treatment, or therapy. Always seek the advice of your physician or qualified mental health provider with any questions you may have regarding any mental health symptom or medical condition. Never disregard professional psychological or medical advice nor delay in seeking professional advice or treatment because of something you have read on GoodTherapy.