Category Archives: mental health

A is for Alone

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For most of my adult life, I have not much cared for being alone. I grew up in the country, away from other kids, no neighborhood gang to hang out with, no one but my little brother to play with, and while he is amazing to spend time with now, it was different when I was 8 and he was 3. I learned to entertain myself. I read books and wandered the woods around the house pretending to be Laura Ingalls Wilder or Sam from My Side of the Mountain, the kid who left home to go live in a hollowed out old tree stump in the Adirondacks at age 12 where he trained a falcon to hunt for him and taught himself to tan deer hide. But birds scared me, I had no idea how to skin a deer (nor did I want to), and the hollowed-out tree stumps on our property harbored far too many spiders and other bugs to make it habitable for me. But I learned in those long days of alone time that I could be good company for myself. That I had an imagination and could harness the power of my mind to entertain myself, to explore, and to learn new things.

Only as I grew up, did I begin to equate being alone with loneliness. We moved a lot as a family once I turned 12. I went to several high schools. I struggled to make friends. I lacked confidence. And then began the dawning awareness that I was, in fact, different in one fundamental way. I did not then have a word for what I was, but let’s just say I had some spidey sense that being attracted to other girls, sexually or romantically, wasn’t okay (it was, after all, the 1970s). I wasn’t okay according to our family’s religious beliefs; I wasn’t okay according to our culture; I wasn’t a typical girl in that I did not like typical girl things. I began to feel more and more alone, apart, separate. I began to hide who I really was. Which limited my pool of real friends and made me feel lonely AND alone.

I began the work, then, of trying to make sure I was never alone. Because in my mind, in the reality I had constructed, alone=loser. Not alone=not a loser. Many years of therapy and hard self-work later, I have finally unlearned that destructive lesson and gotten back to my child self, that confident girl who could entertain herself, be comfortable with her own company, relax into learning new things on her own, for herself, by herself. It wasn’t easy. I didn’t grow to love myself and my own company again overnight or even within a year. But I kept at it—I kept talking (and listening) to my therapists and teachers, trusting my own judgment, taking risks, being honest about myself with others.

In time, I learned that being alone was not a measure of how much I was loved nor a reflection of my worth. I learned what it means to have true friends, people who care and value me whether we are out for happy hour or thousands of miles apart from each other, people who I trust love me because I believe I am lovable. These lessons keep returning to me now, as I, a single divorced mother of two grown children, hunker down for the duration. Alone. But I am not lonely. I am loved. And so are you.

E is for Ethics (and also, a bit, for Exam)

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So, I wrote in yesterday’s blog that I had taken and passed my licensure exam. The state licensing exam is also the exam used for those counselors who want to be recognized as Nationally Certified Counselors. It measures competence in several areas: Research, Theories, Assessment, Ethics, and a few other categories. Overall, I did okay on the exam. I didn’t ace it, but I  did far better than the minimum requirements for licensure. Also, I totally rocked the Ethics section.

I love Ethics. Ethics, like counselor self-care, permeate every aspect of counseling. Ethics play such a critical role in counseling that the ACA (American Counseling Association) has its own handbook on ethics. Every branch of health practitioner has a code of ethics by which its members choose to abide. Nurses have a code of ethics, as do doctors and nursing assistants and pharmacists. All health care professionals in Washington state have an ethical code, including chemical dependency professionals, massage therapists, physical therapists, psychologists, and so on. Strong ethics provide safeguards and protect clients at their most vulnerable: when they are sick and/or seeking help.

The ACA Code of Ethics covers everything from whether or not to accept a gift from a client (if it cost less than $20 and to not accept the gift would cause the client more harm)  to how and when to refer a client to a different therapist (when the therapist has to leave her practice or if a client is just not making progress after many sessions).

Abiding by an ethical code isn’t just good for our clients. Counselors risk losing their licenses and livelihoods if they don’t adhere to robust ethical standards. Holding firm boundaries keeps us out of trouble. I subscribe to a Dept. of Health newsletter that lists the practitioners who have run afoul of the ethics board. This list is a good reminder of the possible costs of boundary crossing, no matter how well-intentioned.

We have ethical codes governing the use of electronic devices such as smart phones, laptops, tablets (must have passcodes if client information is stored there) and software:  videoconferencing, electronic health records, email, text and voice messages, social media, and the like (ethics dictate don’t engage with clients as “friends” on social media, and we must only use text and email messages for scheduling. Personally, I’ve mostly gotten offline since becoming a counselor).

Last spring, I attended a day long workshop on the ethics of marijuana in counseling. The surprisingly diverse range of topics included whether or not a counselor or therapist could ethically accept weed as a form of payment from a client who might be strapped for cash but has a job at a pot farm and is thus awash in weed (in states where marijuana is legal, of course, and NO, NOT OKAY for many reasons, primarily because legally, in Washington at least, one can only possess a certain amount of weed at a time, and a therapist would cost more weed than she could legally possess). Also, whether or not a group of therapists and counselors could sit around a campfire, pass around a bong while discussing cases (a resounding NO, but not for obvious reasons. Turns out, sharing weed is illegal in Washington State. Even sharing a joint or giving a friend an edible is illegal). Violating these laws means losing ones license. This was one of the liveliest and most well-attended workshops I’ve been to since I got into this field. Everyone had so many questions.

We have ethics around multicultural counseling (ethical counselors have multicultural awareness training), staying within our scope of practice (only provide services you are trained in), and self-disclosure (does sharing personal information with the client, help the client? What is the point of sharing the personal stuff? Personal gain or therapeutic?)

Most importantly, ethical counselors and therapists do not engage in personal relationships, sexual or otherwise with clients. The ACA Code of Ethics states a counselor must wait five years after a client has discontinued treatment before becoming personally involved with that client. Washington State law says two years. A counselor must be able to relate to a client without the client having any worries whatsoever about the counselor’s motives. The counselor is there strictly for the client, not for themselves (except as related to salary or fees). Personal and intimate relationships with a mental health provider become problematic as boundaries get blurry. Counselors should always avoid dual relationships, i.e. providing counseling to your neighbor’s husband or to your child’s teacher.

The counseling office is a sacred space and a strong code of ethics maintains the integrity of that space. We are not there to befriend our clients, but to assist them in becoming better friends to themselves. We are there to hold up a mirror and to simply reflect.

D is for Diagnosis

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I finally jumped through one of the final hoops I need to get full licensure. This morning I took, and passed, the state licensing exam. I could have done this as soon as I finished school at the end of 2017, but I did not. I put it off. So, here I am, ready to be done with supervision, primed to strike out on my own.

Anyway, one of the questions I’ve encountered on the practice exams goes something like this:  If your agency requires you diagnose a client, what are your alternatives? a) talk to your supervisor and tell her it’s against your ethics to diagnose someone b) talk to your colleagues and let them know you ethically can’t diagnose someone c) refuse to diagnose a client d) all of the above. The correct answer, apparently, is d) all of the above.  As a counselor, ethically I am not to diagnose anyone.

I’ve been trained to diagnose using the DSM, or Diagnostical and Statistical Manual, a compendium of mental health disorders cataloging the signs and symptoms of everything from adjustment disorder to xenophobia, anxiety to trichotillomania. It’s not an activity I take lightly. People seek help with mental health because they are looking for ways to feel better, to combat the distress they are experiencing. I want to empower clients to improve their lives. I don’t want to overwhelm them with a label that carries negative connotations, a diagnosis that scares them or strips them of their power and self-efficacy.

Giving someone a diagnosis is a double-edged sword—a client’s DSM diagnosis allows them to seek services utilizing their health insurance. No one has to go bankrupt to afford mental health care. If providers get paid, clients can keep coming back, and not just to counselors in private practice, but also to community mental health agencies such as the crisis center I wrote about yesterday. The money we receive from insurance companies enables us to serve a wide variety of folks, many without the means to pay privately for anything, let alone mental health care.

But a diagnosis is also a label, and a mental health diagnosis can follow someone for life, influencing not only how they think about themselves, but how others might perceive them. We’ve made a lot of progress in the past few years to destigmatize mental illness, and many more people are seeking counseling as a matter of course. Being in therapy doesn’t carry the stigma it used to. But still. Perceptions linger and diagnosing (and thus labeling) a college freshman as bipolar can have lifelong consequences. They can begin to see each themselves as more illness than person, begin to limit themselves or be limited by others, including overprotective parents and well-meaning professionals.

I don’t want to give anyone a label that will hold them back in life. I want to help clients find ways to learn, love, and live their best lives, to understand what’s happening with their mental health, and I want them to be able to keep coming back, even if they can’t afford it. So, I have to give them a diagnosis if they use insurance to pay for counseling.

But, a diagnosis should only be a means to an end, not the final word on who anyone truly is or a limit on what they can achieve or who they can become.

C is for What Constitutes a (mental health) Crisis?

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When I am not seeing clients in my private practice, I work as a clinician in a mental health crisis clinic run by a community mental health agency. I ended up at the crisis clinic by serendipitous accident. I had applied for an internship with said local agency, completely oblivious to the very existence of the crisis center. I imagined that during my internship, I would be meeting with clients one-on-one several hours a week for the year. Instead, I got to do something quite different.

How does someone end up in the crisis clinic? Community members who may be experiencing a mental health crisis can come to us, free of charge, for up to five days at a time. In those five days, we provide a safe environment, connections to community resources such as housing, CD (chemical dependence) treatment, case management for ongoing mental health support, medication management/stabilization, appointments with primary care providers and dentists, connections to youth services. A good number of our clients are without stable housing. Many spend most nights on the streets or at the drop-in center. Few have jobs. Most struggle with addiction, and I think it’s safe to say the vast majority experienced a major trauma in their lives: abuse, neglect, death of a parent or sibling or child, sex trafficking, even torture.

Most of our referrals come from the local hospital’s emergency department; many referrals come from our own agency’s counselors and case managers who work with hundreds of clients with mental health issues such as schizophrenia and bipolar disorder. Other referrals come from a variety of community agencies: housing, doctor’s offices, domestic violence shelters, the county crisis line, other mental health agencies in town.

But, what constitutes a mental health crisis? How does someone end up with us? When someone is feeling suicidal and unable to keep themselves safe, they may get a bed with us. If a person has made an unsuccessful attempt on their life that hasn’t required hospitalization, they could end up with us. We might get a young man who is experiencing his first psychotic break and his family has no idea how to help him. We may take in a young woman who recently lost custody of her children and is feeling despondent. Often, we have clients who are coming off of meth or detoxing from alcohol and are psychotic enough that they cannot be left alone yet not so gravely disabled that they require involuntary hospitalization. Others have previously diagnosed mental health issues that are not being well managed by medications. Some have urges to throw themselves into traffic or in front of a train but are oriented sufficiently to be coherent and logical and thus not detainable.

Interestingly, but probably not surprisingly, homelessness does not constitute a mental health crisis. We are not a program that bridges people to housing. Homelessness is so pervasive and intractable, we’d be holding folks for years if they were waiting to be housed. Occasionally, if someone is at risk of severe decompensation if they were to return to the streets, we’ll keep them for a few extra nights in order to transition them into a supervised living situation.

Nor do we provide respite. People can’t come to stay with us in order to heal from surgery or to get a break from their intolerable living situations. We are not a hostel, though one time we had a client in who had managed to use crisis centers like ours as way stations in his travels across the country. Desperate times call for desperate measures, and given the current housing and homelessness crises, folks get creative in order to feel safe, to be fed, to sleep in a bed. Many know what to say to get the ER social workers to call us. And why not? Doesn’t everyone deserve to feel safe? To sleep with a roof over their head? To have a hot meal and a hot shower?

A lack of housing may not constitute a crisis sufficient to warrant a bed in a crisis center, but I’m sure it would feel like a crisis if I were the one on the outside of that door. And that is exactly why I continue to work with folks in crisis long after my internship has ended. I am all too aware that life is a precarious balance.