Tag Archives: mental health

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

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

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?

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.

 

B is for Beliefs, or We Can Choose what We Believe

One of the primary strategies I use with clients is Cognitive Behavioral Therapy, or CBT. CBT posits that we too often believe our own thoughts. Think about it! Our minds generate bazillions of thoughts every day. And generally, we chose to believe what we think. And most of the time, what we believe is not even true. We make decisions based on faulty beliefs. And then we’re surprised when trouble ensues.

CBT Triangle

CBT works like this (more or less):

  • Something happens (this is called an Activating Event)
  • I have a thought about the Event (I tell myself something)
  • I have a feeling based on my thought and what I believe
  • I do something based on my feeling (behavior)

Here’s the deal. We don’t have to believe our thoughts. Ninety-nine percent of the time what we believe isn’t actually true. Now, that doesn’t mean that our feelings are real. They are, but we can change the way we feel if we can change our beliefs.

Here’s an example (and one that I continually struggle with):

The Activating Event: Some jerk cuts me off in traffic, just doesn’t even look and pulls right out in front of me. And then, THEN, has the audacity to drive five miles an hour under the speed limit all the way into town!

My Thoughts: What a jerk! You idiot! Don’t you know how to drive? Don’t you know I have places to go and things to do? You must be high. Or stupid.  Every driver in this town drives like they’re high.

My Belief based on my thought: Every driver is high or stupid and every driver drives as if they are stoned. Every driver is in my way and has nowhere important to go, at least not as important as what I have to go to.

My Feeling based on my Belief: Anger. Rage. An inflated sense of self-importance.

My Action: Flip them off. Gun my engine and veer dangerously around them. Tailgate.

The Result: Best case scenario, I arrive at my destination in a foul mood, grumpy and bitter, muttering about people’s terrible driving habits. Worst case scenario: I get a ticket for tailgating or, worse yet, end up rear ending someone because I can’t brake in time.

OR, I could choose to NOT believe my thoughts. Because, really. I don’t know what is going on with the person driving the vehicle in front of me. Instead of getting mad, I can pause and bring some awareness to the moment. “Pam, you do not know what is happening for that other driver. Breathe. Have some compassion. You’re okay. Breathe.”

My Feeling now? Low level agitation, dissipating into calm acceptance. Maybe they’re just learning to drive. Maybe they just did not see me. Maybe they’re tired. I can accept the humanity they just demonstrated and I can let it go (oh, trust me, I get to this point only sometimes, but I am improving with practice).

My Action: I slow down, ease my foot off the gas, and take a deep breath. Turn up the radio. Tap my fingers on the steering wheel and choose to be grateful I was paying attention to the road.

The Result:  I arrive at my destination much less grumpy, much less agitated. My day is not ruined by one driver who did not see me. I save myself time and money.

I dare you to choose NOT to believe your thoughts. What is it costing you to cling tightly to faulty beliefs?

A is for Anxiety, Allow, Authenticy

Welcome to my most recent attempt at the annual A – to – Z blog a day. I’ve not done this for a couple of years and might be a bit out of practice since I’ve devoted the past couple of years to becoming a counselor rather than writing, but hey, it’s high time the two halves of my life introduced themselves, because I can’t be one without the other. I can’t be a counselor without writing and I really want to add writing to my counseling career, and what better way to start?

At first, I thought I’d write A is for Anxiety. Turns out I’ve done that several times already, so I pondered what else might be applicable. As I considered my options, I realized that Anxiety is a perfect place to start and from there it’s a hop skip and a jump to those other A words: Awareness, Authenticity, and Allow. It so happens that I have many clients who are living with anxiety.  Anxiety permeates every aspect of our lives these days whether we are students, workers, parents, or children. Everyone seems to be facing down this demon.  Over the past year, as I’ve talked to dozens of individuals and couples, I have come to visualize anxiety as the tension between what we want to be and where we are currently, this distressing in-between place.  And because we feel trapped and uncomfortable in our anxiety, we try to suppress our discomfort when instead, in order to work with our anxiety, we need to first Allow it to be. And then we need to Ask it what it wants.

I did not come up with this strategy on my own—I learned it from one of my counselors who told me I need to invite my feelings “in for tea” so I could “get to know them.”  What I have learned from this exercise is that if we can allow ourselves to face our fears, we can stop running and listen to what they are trying to tell us. To be aware in our lives, which allows us to be fully present, and in being fully present we can become authentic, our real true selves because we have faced our worst fears and found ourselves more powerful for our bravery.

Try it. I dare you. Interview your Anxiety. Ask it to sit next to you on the couch. Hell, give it a name, introduce yourself, and ask it what it wants. What needs to change in order for you to lessen the tension between what you are and what you want to be? Allow yourself to become! (thanks Michelle Obama)