Two VERY DIFFERENT bosses
When you look at the ethical guidelines for therapists a whole lot of them are in place to address the power imbalance between therapist and client. In the minds of our clients, the things we therapists do or say hold greater weight than the same thoughts that, say, your hairdresser or mechanic might offer. (Except when it comes to how to do your hair or fix your car.) When we share our reflections about your life choices and relationships then we need to be aware that our clients will likely take those thoughts very seriously, which is why it can be painful and even dangerous to have a therapist get things really wrong with you.
I remember the second therapist I ever saw when I was a freshman or sophomore in college and was in love with a boy who didn’t love me back. (That’s what brought me to therapy although it turns out — no surprise — I had a lot more going on than just that.) Anyway, the therapist just loved all my stories about my super interesting boyfriend and would agree with me, “He does sound amazing! And in a band, too, wow!” which was not what I needed to hear. Now I understand that likely he was just trying to join with me (this thing where therapists go along with you to help build rapport) but at the time I thought, “Well, it’s hopeless. My boyfriend is too amazing for me to ever get over him and even my therapist loves him” and I quit going to therapy. What would have been better is if I’d come back and said, “Hey, I’m sick of hearing about how great you think my stupid boyfriend is” and then we could have had a discussion about it.
Because therapists get stuff wrong. It happens. We’re not perfect and even the best therapist is not necessarily the best fit for any given client. We will get things wrong and it’s up to you, dear clients and potential clients, to help us get it right.
Sometimes we get things wrong because we don’t ask for enough information and sometimes this is because we don’t even know we need it. You say, “Hey, my boss!” and the therapist is sitting there merrily picturing Leslie Knope and really you’re talking about your boss who is more like Glenn Close in Damages only the therapist has already decided she knows what’s going on and so things just get confused.
That happens. Although eventually situations like that work themselves out if the therapist is a good listener and asks good questions.
What’s trickier is when the therapist is wrong only you don’t know she’s wrong because it’s nothing as clear cut as facts. Instead she’s operating with a set of biases that you don’t know about. Like say she is against beach vacations and thinks everyone should go hiking in Hocking Hills and you don’t know this so when she’s discouraging you from planning your vacation to Bethany Beach you think there really is something wrong with your ideas. You wonder, “Is this what’s wrong with me? That I always go to the beach?” and it’s confusing. Because sometimes it’s true — your ingrained thoughts or beliefs are part of the problem — but sometimes it’s not. Sometimes it’s just a matter of different priorities and opinions.
So what do you do?
First of all, if you feel like your therapist is being biased, tell her. Have a discussion about it. Heck, have a debate. Good therapists know their biases (we all have them) and will be willing to engage with you. She will be able to say, “Here is my bias” but she’ll also be willing to say, “My issue with the beach is not because I’m against beaches, it’s because you’ve told me that you are allergic to sand in previous discussions and I want to challenge your assumption that you should go to the beach anyway.”
Or the discussion might help you discover that your boss thinks Glenn Close in Damages makes a GREAT boss and that you should suck it up and let her murder people and violate legal ethics and blackmail everyone because your therapist places a high value on career achievement and that’s just her philosophical starting point. In which case you can decide for yourself if that’s the kind of therapist that you want to have.
Very often you and your therapist won’t agree about things and a lot of the times, that won’t matter because our ethical guidelines state:
Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. Counselors respect the diversity of clients, trainees, and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature.
(this is from the 2014 American Counseling Association Code of Ethics)
In other words, even if your counselor would personally love to work for Glenn Close, she ought to be able to appreciate that you would rather work for Leslie Knope. But if you’re not sure, ask her. Have that discussion. Find out what’s going on there if you feel like she’s misunderstanding your point of view or steering you away from your goals. Because even though we are therapists and sit in the big comfy chair (or at least the chair with good lumbar support because this job is hard on your back) that does not mean we know everything or that we’re the boss of you. Sometimes we’re wrong. Call us out when we are; good therapists will appreciate the discussion.
(For the record, I prefer a Hocking Hills vacation as long as there’s air conditioning and obviously I would prefer to work for Leslie Knope because I like waffles a lot more than I like murder and blackmail.)
Parental involvement is a key ingredient in kid client success in therapy. What this looks like will depend on your child and his/her treatment plan, your practical ability to be involved (are you a noncustodial parent? Is your child receiving services at school?) and the therapist. But at the very least, you and your child’s therapist should be communicating regularly.
Depending on the child, the parents and the treatment goals, I include parents in the following ways:
- Parents attend sessions with their child (this is common with young children and with children who are struggling with attachment);
- Parents come in for the first or last few minutes of session;
- Meeting with parents separately before or after the child’s session;
- Scheduling separate sessions with parents when needed and appropriate;
- Arranging for phone calls to check in.
I like kid feedback for how parents should be involved, particularly with teenagers who are navigating the developmentally appropriate need to separate along with the necessary support from parents. Sometimes this means helping the teen figure out how they want to talk to parents about something and then inviting parents to session to help mediate a discussion.
I go over confidentiality with parents and teens in session with the understanding that we will all respect the teen’s privacy in the counseling relationship but that the adults will keep her safety paramount in decision-making around what to share. When kids are struggling in a gray area, I always encourage them to invite parents to the discussion but I won’t go over their heads and tell secrets unless I’m concerned for their safety.
Here’s the Ohio ACLU publication about minors and their rights. The part about counseling (this is a PDF file) starts at page 40: Your Health and the Law: A Guide for Teens.
From the file:
A minor who is at least 14 years old can request outpatient care without notifying a parent as long as the treatment does not include medication. However, such care is limited to six sessions or 30 days, whichever comes first. After that, the care must stop or the parents must be informed and must consent in order for treatment to continue. During the first six sessions or 30 days, the parents will not be informed of the treatment unless the teen consents or the care provider feels the minor is likely to harm someone. Still, before the parents can be informed, the care provider must first tell the teen that the parents will be notified.
I have not had a teen call and ask for counseling on her own but I have had other loving adults (relatives or family friends) call me to find out if they can bring the teen to counseling without parental consent. I always explain how the law works and explain that except in cases where parental involvement would be dangerous to the child, it’s really best to have parents be a part of counseling.
There are guidelines around counseling teens and maintaining confidentiality. As a counselor practicing in Ohio, my ethical guidelines come from Ohio’s Counselor, Social Worker, and Marriage and Family Therapist board and my professional organization, the American Counseling Association. Both these entities recognize that teen confidentiality is a gray area. The ACA and their sister organizations for social workers and other therapists regularly publish articles and papers on the topic.
Here’s a handful for you to check out:
As you can see, there are not definitive answers because these topics are complex and so very individual. How I might, for example, handle it if a client tells me s/he is sexually active will depend on many things including but not limited to:
- Why the teen is in counseling in the first place;
- With whom they are being sexually active (is it consensual? Is it legal?);
- How old the teen is (there’s a big difference between a 13 year old and a 17 year old);
- The family’s values around sexual activity;
- The circumstances surrounding the sexual activity (are there pressing concerns about safety?).
My first priority is always first and foremost safety but I recognize my ideas about safety may be different than the families. For example, say I learn that a 17-year old after careful consideration and planning decides to access birth control and have sex with her long-term partner. Perhaps she comes from a strict, conservative family whose religious beliefs condemn premarital sex. I am unlikely to break confidentiality under those circumstances.
I say this to encourage parents to talk to their teen’s counselor to make sure that they understand each other. If you want a counselor who would break confidentiality then I’m not the right person to work with your teen. It’s best we all know this ahead of time.
That said, I do not ever encourage teens to lie and I do not side with them against parents.
Finally, when confronted with a sticky situation I seek supervision, meaning I go to my peers and my mentors to get feedback when I’m not sure. While maintaining confidentiality about the individual and the family, I ask for help and document these efforts accordingly. It’s dangerous for any therapist to operate in a vacuum and I am fortunate to have great counselors available to me to answer questions and help me examine ethical practice as it applies to the complicated reality that is counseling kids and teens.
When I first started my internship most of my clients were home-based, which means I go into their homes to work with them. We’ve since had to shut down our home-based program (funding issues — although we still do some home-based work through our school program) so now I only have two clients to visit each week.
I love home-based work. It’s an honor to be invited into a client’s life in that literal way and it also gives me a much more full picture of what’s going on and what’s most important to her. I also really like that it allows people who have many barriers to counseling get the help that they need and deserve. All the home-based clients I have are mothers and all have transportation and childcare problems that make it impossible for them to get to my office. So I come to them — perfect!
But home-based counseling can be complicated. The boundaries are different. Our ethical guidelines state that we can’t accept gifts from a client but can we accept a glass of water on a hot summer day? Is it ok if a client shows up to session in her pajamas? And what about all the things we learn about how to sit and where to sit and how to arrange our office chairs to promote sharing? Where does all of that go when you’re meeting in a client’s hotel room and sitting on the edge of her bed? I had questions about it and I wanted to talk to people more experienced than I am so I pitched an article to Counseling Today, which is the trade magazine for the American Counseling Association. The result, Home is where the client is, is in the September issue but you can read it online.