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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.)

 

 

Boundaries in counseling

brightcushions-insideLast week I said that I wanted to write about how the boundaries in counseling make the therapeutic relationship possible and so here I am! Writing about it!

The first time I really got the value of those boundaries was when I was driving away from a particularly tough session with a particularly tough client who also happened to be one of my very first clients. Without going into specifics that would compromise confidentiality, I will tell you that this was a client who seemed to have a black cloud of gloom and disaster following her. It always seemed like if a rotten thing could happen to her, it would. Some of this was of her own making but some of it was simply bad luck.

It made me miss being a case manager because as a case manager I’d have clear directives for her. We would be working a program together and I’d be bossing her around a little bit. I’d also have bus tickets and other program directors on speed dial to hook her up with other agencies (there’s an insider thing to case management that doesn’t seem to exist in community mental health agency work unless there’s a case management program there, too; like I can’t get a client free furniture but as a case manager in Portland I had access to those kinds of programs).

But I wasn’t her case manager (she had case managers), I was her counselor. And as her counselor I felt so helpless because I’d see her and she had so many challenges and I couldn’t do much but listen. I would meet with her and pay attention and help her make decisions and help her consider her options and help her process her emotions and I gave her all the unconditional positive regard I had at my disposal but it didn’t always feel like enough. I sure missed being able to hand over those bus tickets.

Unconditional positive regard is at the heart of counseling. When I am with a client, I am with them. I’m listening hard. I’m loving their humanity no matter what they’re saying. I’m seeing the human being that they are and I am accepting who they are even as I’m trying to help them to be their better selves.

So back to my tough session with my tough client.

I was driving away and I was thinking about something she’d said to me. We were talking about a pretty big barrier she was facing and I was itching to be the person in her life to be able to give her bus tickets and referrals and feeling pretty damn helpless to be just sitting there listening. I was having to work hard to not get lost in my feelings and instead stay there with her, present in her struggle, remembering that it was her struggle and not mine to fix. And she said, “This hour when we meet, it’s special to me because it’s the only time that’s all mine, all about me. It makes it so I can get through the rest of the week.”

That really brought home to me the value in “just” listening.

As I drove away I was thinking about how having nothing but my therapeutic self to give her — because counselors ethically can’t do the things case managers do. Ethically, counselors need to be very very very careful about handing out transportation or free furniture. Sure, we can give referrals to programs that do these things and there are times that stretching beyond ethical guidelines on gift giving is appropriate. But with this particular client, it was clear to me that any impetus I had to go beyond those limits would be about me and my fervent wish that her life be better and my feelings of helplessness in the face of her struggle.

I realized, too, that unlike the other helping people in her life (of which there were many), I was the only one who wasn’t asking her to do things. Well, that’s not entirely true — I did ask her to keep her appointments or at least call to cancel. And I did ask her talk to me. But these things happened more or less on her terms. She made the appointments at her convenience (within the bounds of my schedule). She talked about the things she most needed and wanted to talk about. We had a dialogue; I didn’t lecture and I didn’t make demands. She wrote her own treatment goals and we worked towards the things that mattered most to her with the context of her beliefs and values.

Because the boundaries of counseling dictated our relationship — that I not give her bus tickets, that I see her at this prescribed time in this prescribed way — I was able to fully be there with her.

If I had been her case manager I couldn’t have been with her as freely. Case management is all about moving someone through a case plan.  I also would have had to answer to the limits of our funding sources, which dictate which people a program can serve and how that program may serve them.

If I’d been her friend, I surely would have become fed up with the way her own decisions made her bad luck worse.

But as her counselor, I only had to be with her.

Our counseling relationship ended sooner than either of us would have liked due to some practicalities in her own situation but in the time we saw each other I did see real change in her attitude toward herself and towards her circumstances. Which is what cemented my faith in the value of the therapeutic relationship. Even if it doesn’t come with bus tickets.

Home-Based Counseling

manyhomes-insideWhen 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.

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