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When therapists are wrong

Patty vs Leslie

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.)

 

 

Teens and Confidentiality in Counseling

Teens and Confidentiality in CounselingParental 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 clients and therapists don’t connect

Another therapist commented on this post about finding a new therapist and I thought it’d be great to bring it over to a new post and continue the discussion. Anna said:

I agree that being a good fit is important. I try my best to be a good therapist and I believe I am open to clients sharing anything with me. I believe in creating a non-judgmental environment. I even like when clients say they are mad at me or didn’t like something I said. It tells me we have that open relationship to talk about those things and sometimes those discussions lead to a greater understand of the situation. Yet, I sometimes get clients who don’t seem to connect with me, or maybe I don’t connect with them. These are the clients who don’t stay long. I’d love any suggestions on how to improve this (if it can be improved). I wonder if sometimes you just have to find the right therapist for you. I have an example without giving any specifics, I had a client recently who called asking for help with a certain issue. Whenever I brought the issue up, the client deflected. I tried working on other issues because I didn’t want to push too hard but the client kept going to “safe” topics. Needless to say, the client quit coming. Do you have any suggestions for this situation? Does it mean it isn’t a good fit or the client isn’t ready? Any suggestions are welcome.

smallcouch-insideI don’t think that any therapist can be the right counselor for every client because we are all so very, very different. I think sometimes a client who doesn’t get very far from us may not be ready to go far but also I think sometimes they just aren’t going to be able to do that work with us.

As to whether it’s because we’re not a good fit or because the client isn’t ready, sometimes I don’t think we’ll get to know. Sometimes it might be a little bit of both.

And that makes me think about counselor ego (not that Anna brought this up but it made me think about it).

Being a therapist is weird because we don’t really get any feedback. I mean, we do, we get feedback from our clients but given the nature of counselor/client relationships, we can’t really go with that. Sometimes a client will say, “I love working with you!” and it’s because we’re not being confrontational enough (like Anna says, sometimes our clients need to be mad at us and maybe NOT love working with us, at least not right in that moment). And we get to be witness to client success but any therapist worth her salt knows that client success belongs to the client.

Besides we can’t get our egos all wrapped up in any definition of success like a marriage saved or a job promotion secured or a child who learns how to behave because that’s a very limited view of success. Sometimes success looks like understanding a marriage is over or quitting a job or realizing that “good” behavior in one child doesn’t look like “good” behavior in another.

But back to the bad fit — this is one of those go with your gut things. If you feel like it’s time to push a client, then push. If you feel she isn’t ready, don’t push. I also think that in these cases where we’re not sure that we should seek out peer support. I don’t think any counselor — no matter how experienced — ought to be working in isolation. That means finding peers whose skills and knowledge overlap in some ways (so they can help give you perspective on kids if you work with kids) and don’t overlap in other ways (so they can help broaden your ability to work with all kinds of people).

If connection is an ongoing problem, if a counselor is feeling like her connection rate is down, then I’d say it might be time to look into some counseling ourselves. When we’re depleted or overwhelmed or preoccupied with other things, sometimes this can come through in our ability to be present with our clients. We might need help focusing on some self care or getting the attention we need (because to give loving attention we need to be getting loving attention).

If you are the client who isn’t connecting, I’d bring it up to the therapist if you feel comfortable or if you think the relationship is worth salvaging. Remember, it’s your relationship with your counselor that is the best predictor of your success in therapy so if you’re not feeling it, talk to her or go elsewhere. Just don’t give up on counseling because there are a zillion and one counselors out there, which means there is definitely the right one for you.

 

At this moment, in this place

clocktree-insideEarly in grad school one of my professors said that our job as counselors means being the healthiest person we can be at that moment in that place with our clients. He said, “You may be the healthiest person they interact with that week.”

I began thinking about this in other contexts. Like I began saying to myself, “Right now in this moment, in this place be the healthiest person you can be in this conversation with tech support.” Or “Right now at this moment, in this place the healthiest person you can be while you try to get your child to see reason about cleaning her room.”

I liked this because it felt do-able; I didn’t have to be the healthiest person I could be all of the time, because that felt overwhelming. I took it one bit at a time, one moment, one place at a time.

Change is hard and sometimes so daunting that we can’t see the way to do it. We vow to stop yelling at our kids then they drop the carton of eggs on your just mopped kitchen floor. Instead of giving up and yelling, we can try saying, “What would a non-yelling person do right now? In my healthiest most non-yelling version of my self, what would I do instead?” If we forget and yell anyway, we can give ourselves time to think back and write ourselves an imaginary do-over then we can do that better thing next time.

When we’re arguing with someone (a boss, a friend, a partner) and we feel ourselves becoming overwhelmed with anger or fear we can tell ourselves, “I can be the healthiest person I can be in this conversation and what do I imagine this healthiest person would say? Would that person argue back? Or would she choose not to engage? Would she try to change this person’s point of view or accept our differences? Would she allow herself to listen to this or would she walk away?”

What would our aspirationally healthy selves do and say if we gave them room to do and say it?

No guarantees in therapy

shutterstock_105731375Therapy is an investment of time and of money and it’d be nice if it came with guarantees but it doesn’t. There are just too many variables to make any promises about how therapy will work for any individual but there are some things you can do to get the most out of your time in the counselor’s office.

  1. Find the right counselor. Remember your progress comes down to the therapeutic relationship that you build with your therapist. If you want a more touchie-feelie counselor or a less touchie-feelie counselor then go find that person. Whether you want someone with lots of fiddle toys in a comfy overstuffed office or one who keeps everything streamlined and clinical, then go find that person. There are lots of different counselors in the world because there are lots of different people so when you call someone to check them out, don’t be afraid to ask them any weird question you feel you need to ask to feel comfortable.
  2. Leave the wrong counselor. If you’re working with someone and you just don’t feel comfortable or safe, switch. It’s ok. You’re the client and you get to decide what works for you.
  3. And if the counselor is almost right? Help them become all the way right. If you have an issue with your therapist and are afraid to bring it up, please give it a shot before you quit therapy. We therapists aren’t psychic so if we’re doing something that isn’t working for you we’d love for you to let us know. I know it’s scary but remember what I said, you’re the client and you get to decide what works for you. Besides it’s good practice for asserting your needs in the rest of your life.
  4. Show up. Sometimes we have to miss our therapy appointments because our cars don’t start or our kids spike fevers or our bosses move up our deadlines. That’s all true. And then sometimes we miss our therapy appointments because it’s just easier not to go. But therapy only works if we get ourselves into the office and into that chair to talk and listen so even when it’s hard — especially when it’s hard. And you know, you can tell your therapist how hard it was to get there that day; she’ll appreciate knowing.
  5. Stick to it. Speaking of how hard it is to come, please don’t drop out completely when therapy becomes tough. Sometimes we have to feel worse before we feel better. Growing is hard and sometimes it’s painful, which is why so many of us don’t do it. But you know what? It’s really worth it. I promise.
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