A solid patient-therapist relationship is a crucible of wellness. And the path out of depression begins with a compatible therapist. of all other relationships you have, and so learning to resolve problems while maintaining connection provides . Clients often develop a close relationship with therapists but is it who is devoted to helping you figure out your problems, not the therapist's. In addition to being a dual relationship, sexual relationships with clients exploit. After months or years circling the same issues, we end up with what I call Another reason we remain stuck with clients going nowhere in therapy is that most in one couples therapy case I consulted on, the husband wasn't getting over his.
Counselors can have these reactions even if they have no personal history of childhood abuse. Counselors experiencing these symptoms may lose perspective and become either over- or underinvested in a client Briere, ; Pearlman and Saakvitne, Counselors who are underinvested may become numb to feelings that would otherwise cause anxiety, anger, or depression. A counselor may unintentionally, even unconsciously, dismiss, negate, or minimize a client's history of abuse.
This reaction represents an attempt to avoid and distance oneself from the uncomfortable issues raised by the abuse. He may respond to the client coldly and clinically. Those counselors who overinvest, on the other hand, become extremely involved with their clients, going beyond the appropriate boundaries of the relationship.
They may respond by becoming parental and doing problematic things such as lending their clients money, trying to solve their problems for them, or seeing them too frequently. They may also fail to confront clients when they behave inappropriately or destructively. When working with a client who was abused as a child, an overinvested counselor may have rescue fantasies or feel inappropriate anger directed at former therapists, child protective services CPS workers, and parents or caretakers.
In extreme cases, the relationship can cease to be beneficial as it becomes overly personal, with the attendant loss of objectivity that is necessary in a professional relationship Briere, Burnout As mentioned above, working with clients who have chronic mental health disorders, severe substance abuse disorders, or a history of childhood abuse and neglect can often lead to "burnout.
Burnout occurs when the pressures of work erode a counselor's spirit and outlook and begin to interfere with her personal life De Bellis, These secondary trauma responses have been called "compassion fatigue" Figley,referring to the toll that helping sometimes has on the helper.
Burnout affects many counselors and can shorten their effective professional life Grosch and Olsen, If the counselor sees a large number of clients many with trauma historiesdoes not get adequate support or supervision, does not closely monitor her reactions to clients, and does not maintain a healthy personal lifestyle, counseling work of this sort may put her at personal risk Courtois, This situation is even more serious in the current financially focused managed care atmosphere that requires health care workers to assume larger and more complex caseloads.
These complex cases often involve previously traumatized clients who present the counselor with many personal and treatment challenges Grosch and Olsen, Counselors can minimize the likelihood of burnout.
As much as possible, they should not work in isolation and should seek to treat a caseload of individuals with a variety of problems, not only those who have experienced childhood trauma. Discussing feelings and issues with others who are working with similar clients can decrease isolation through a process of shared responsibility Briere, Counselors also should try to keep a manageable caseload.
They should deliberately set aside time to rest and relax, keep personal and professional time as separate as possible, take regular vacations, develop and use a support network, and work with a supervisor who can offer support and guidance. Some treatment settings have established in-house support groups for counselors who work with abuse and trauma survivors. By sharing graphic descriptions of clients' experiences with a colleague, the counselor can gain the crucial support and perspective to be able to continue effective treatment.
Working as part of a treatment team can be a natural way to facilitate support and reduce stress. In some cases, counselors may want to seek personal help through therapy that will allow them to work more successfully with this population.
Among its other potential benefits, psychotherapy can help counselors come to terms with their own limitations. Counselors who are satisfied with their personal and professional lives are less likely to experience secondary trauma symptoms. Establishing the Treatment Frame and Special Issues Counselors should develop and maintain a treatment frame--those conditions necessary to support a professional relationship. Setting and maintaining boundaries is especially critical in treating survivors of childhood abuse and neglect.
Several parameters of the treatment frame are discussed below, as well as special issues that may arise. Because childhood abuse is a profound violation of personal boundaries, adult survivors of abuse or neglect may never have developed healthy and appropriate boundaries, either for themselves or in their expectations of others.
They often need a great deal of affection and approval, and counselors must make clear that they are not responsible for directly meeting all of those needs.
Boundaries help the counselor as well as the client because counselors tend to be nurturing healers, which may lead them to fall unwittingly into inappropriate roles in response to their clients' stories. For example, a counselor may react to strong countertransference feelings by trying to respond to a client's wishes and expectations.
The counselor should guide clients in doing difficult interpersonal tasks themselves, not only to strengthen the clients' ability to take responsibility for their lives but also to maintain important adult boundaries. The counselor must maintain a calm, optimistic interest in his clients, recognizing that getting overly involved will rob clients of the opportunity to identify and build upon their own inner resources. Other parameters of the counseling relationship, or treatment frame, set by many mental health professionals Briere, include Making regular appointment times, specified in advance Enforcing set starting and ending times for each session Declining to give out a home phone number or address Canceling sessions if the client arrives under the influence of alcohol or psychoactive drugs Not having contact outside the therapy session Having no sexual contact or interactions that could reasonably be interpreted as sexual Terminating counseling if threats are made or acts of violence are committed against the counselor Establishing and enforcing a clear policy in regard to payment These are general guidelines, and the specific arrangements between a counselor and client will vary according to a number of circumstances.
For example, a client may arrive under the influence of drugs or alcohol. Although the counselor will not conduct therapy, he should make sure the client doesn't leave the office and drive a motor vehicle.
Also, for some clients, telephone contact outside the therapy session is necessary and fosters a working alliance between client and counselor. Some clients may need ongoing support for dealing with difficulties with their children or suicidal feelings.
A rigid rule stating no contact outside of therapy may be harmful for very needy clients. Clients may feel abandoned if a telephone call is not returned, damaging the therapeutic alliance. In smaller communities, a counselor may expect to encounter clients in public places.
It is wise to discuss in advance with clients the confidentiality and boundary issues that could arise in these situations. Clients may prefer that the counselor not acknowledge them or may wish to be greeted with a simple hello. Addressing such issues in advance ensures that the client will understand the counselor's behaviors and will not feel ignored or abandoned. Building Trust Building trust has been described as the earliest developmental task and the foundation on which all others are built Erikson, Establishing trust is broadly accepted as fundamental to the development of a therapeutic relationship.
However, because adults who were abused or neglected by their parents have experienced betrayal in their most significant relationships, they often find it difficult to trust others. Clients who were not abused by persons close to them also experience problems with trust, but for those who have been betrayed by people on whom they were dependent, issues of confidentiality and privacy are especially critical.
Trust makes an individual vulnerable to criticism, abandonment, and rejection. Clients may therefore be mistrustful and suspicious of the counselor, making the development of a trusting relationship a potentially long and difficult task. Reflecting the transference discussed above, they may fear the counselor or see him as abusive, manipulative, or rejecting.
The counselor must not personalize these feelings but be consistent and reassuring, never taking trust for granted Courtois, As clients deal with childhood abuse and neglect issues, they may face a series of crises. These crises give the counselor opportunities to build trust.
In such situations, the counselor can remain consistent and available, helping to allay clients' fear of abandonment and rejection.
Many tenets of a good therapeutic relationship unconditional positive regard, a nonjudgmental attitude, and sincerity are also essential for establishing a foundation of trust. When the Client "Falls in Love" With the Counselor Because of the difficulties many abused clients have with intimacy, the new experience of having someone who listens and whom they can trust can sometimes lead them to believe that they are in love with the counselor.
Sadly, many survivors of abuse are so accustomed to negative feelings shame, fear, guilt, anger that positive feelings joy, trust, contentment, playfulness are unfamiliar to them. Such clients may not understand their own feelings, and they may not have the skills to differentiate them. In some cases, if a client has recently stopped abusing drugs or alcohol, romantic obsession or sexual fantasies can substitute for the substance addiction as a way of reducing tension.
Powerful romantic feelings may be directed toward the counselor, threatening the therapeutic relationship. The counselor may first become aware that a client is having strong transference issues by subtle changes in the client's demeanor or by more obvious signs, such as requests to see the counselor in a nonprofessional setting.
The counselor must, above all, avoid transgressing the boundaries of the relationship and continue to emphasize the guidelines discussed when the counselor established the treatment frame.
He should not consent to personal requests, even if they seem innocent e. Second, even if he only suspects a client of harboring sexual feelings for him, he should immediately bring the matter to the attention of a colleague. This consultation will serve not only to protect himself, should legal complications arise later, but can also help him work through the difficulty in the therapeutic relationship itself. If the counselor senses that a client is developing romantic feelings for her, she can try to discuss the matter openly by asking questions, such as "I sense that you are feeling very strongly about something today.
Is there something in particular you want to talk about? Clients should be encouraged to examine the feelings rather than act on them.
The tension of this interaction can lead to a "teachable moment" in which the client learns to better differentiate his feelings. The counselor should remind the client repeatedly of the purpose of their sessions, emphasizing what she and the client will and will not do as part of the relationship. Clients often substitute an attraction to the counselor for an attraction to the abused substance as a way to avoid dealing with unresolved feelings or emptiness.
Another, less confrontational way to deal with this type of situation is to maintain the boundaries of the client-counselor relationship but to use clients' feelings to help them discover solid but non-sexual relationships with people who listen.
The client can be assisted to differentiate feeling good from feeling sexual desire. The counselor can explain that the "attractive" aspects of their relationship, such as trust and feeling safe, are qualities that clients will want to look for in their personal relationships. Similar problems of inappropriate attachments and boundary issues can occur in group therapy, and counselors whether as group leaders or in separate individual counseling must be prepared to work with their clients on this dynamic.
Here, too, a treatment frame should be established at the outset that addresses interactions between group members and between the group leader and members. Clients should avoid letting any of these relationships become too personal and should be made to understand why, in this setting, developing sexual relationships would be counterproductive. Counselors, in turn, must understand and support the bonding that occurs when clients make disclosures in a safe and sympathetic environment--and the confusion group members may have about their feelings of dependence on or responsibility for other group members Valentine and Smith, in press.
These are therapeutic issues to be addressed in the group that can contribute to the clients' healing from the effects of abuse Briere, ; Courtois, The counselor's reaction to attempts at seduction Because of low self-esteem, incest survivors or other survivors of abuse may feel that the only way they deserve a relationship with another person is if they offer sexual involvement Courtois, If a victim of sexual abuse acts seductively toward the counselor, the counselor should understand that transference issues are in operation and that the victim is trying to sexualize the relationship.
Unfortunately, some counselors do become sexually involved with their clients, thus exploiting the counseling relationship and violating the trust the client has placed in them. Such behavior is unethical, unprofessional, and in some States, illegal. Counselors who become sexually involved with clients may be reenacting the role of victimizing caretaker.
Most treatment programs have policies prohibiting such behavior and will fire staff members who violate these policies. In addition, they are likely to register a complaint with the State licensing agency; professional associations will censure or expel members who have sexual contact with clients. In some States, sexual contact with clients is illegal, and counselors will be prosecuted.
Some in the treatment field believe that males should not treat female survivors of male sexual abuse. Although some women may feel safe only with a female counselor, many male counselors can provide effective treatment if they give adequate attention to abuse issues and their own reactions to clients.
Furthermore, sensitive handling of the case by a male who does not exploit the client can provide a new, positive male role model. Whenever possible, the client's preference regarding the counselor's gender should be respected; unfortunately, many facilities do not have adequate staffing to allow choice. In such situations, it is important to openly acknowledge the client's feelings and validate them as understandable reactions. This can reduce feelings of helplessness and help prevent the client from leaving treatment prematurely.
Dealing With Disruptive or Dangerous Behavior Clients in treatment for substance abuse may act rebelliously or violently, a situation that can be exacerbated by an undisclosed history of child abuse. Counselors working with this population have sometimes been victims of physical assault or other violence by clients.
It is the program's responsibility to be aware of and inform counselors of any client's history of violence which may be more common among adolescents in substance abuse treatment. Counselors should have a personal safety plan, and policies should be in place that require them to call law enforcement and press charges if they are threatened.
As well as taking steps to ensure their own safety, it is the responsibility of counselors to create and maintain a safe environment in which clients can explore and address issues. It is the client's responsibility to behave in ways that do not threaten others either physically or emotionally. Early in treatment--at the very outset, if it is a group setting--counselors should communicate and enforce ground rules about how clients can safely and appropriately deal with anger and other feelings of discomfort.
Knowing what is expected of them and the other group members contributes toward their experiencing the group as a safe place to share and be heard. Ground rules should include maintaining members' confidentiality and not sharing any information outside the group, no threats or acts of violence, no verbal abuse, no interrupting other members, and no disruptive behavior.
Counselors can help clients learn how to express their feelings constructively by validating their affect but not their expression if it is abusive or violent. Abuse survivors commonly are concerned about their safety--or their potential reactions to others--while reliving painful events. Counselors can help clients face these feelings by reinforcing the present safety of the counseling environment.
In a calm voice, the counselor should ask clients to explore rather than act out anger or disruptive behavior. The goal is to emphasize to disruptive clients that their feelings are acceptable as long as their behavior remains appropriate. Clients are allowed to have angry feelings--and verbally express them--but they are not allowed to hit anyone, to throw things, or be otherwise violent or disruptive. In this way, clients can be helped to separate their feelings from their actions.
Ten, fifteen, or more years later, that patient becomes a prominent, top in their field, attorney, surgeon, or other highly specialized professional. You discover that you need someone with those highly specialized qualifications. If the client is still a client even after all those years of no contact, is that a conflict of interest and a prohibited dual relationship? If it is an issue of power, who is in the position of power?
Is power in any relationship always static, or is it variable and subject to change based on the circumstances? Dual or Sequential Relationship When a therapist and client enter into a relationship that is outside of or in addition to the therapeutic relationship, it is generally referred to as a dual relationship.
Dual relationships are discouraged by most professional organizations. However, not all experts in the field believe that all dual relationships are necessarily harmful. It would depend on the context. However, when a therapist and long past patient enter into a relationship separate from the therapeutic one, is that actually a dual relationship? Would it be more accurate to call it a sequential or serial relationship? Is there a difference?
'Til Death Do Us Part: Does a Client Ever Stop Being a Client?
If one believes that our patients grow mature and sometimes surpass us in knowledge, wisdom, and power, then it is a significant difference. Of course, of all the dual or sequential relationships that are potentially possible with patients and former patients, when the issue of sex comes up, most all therapists of all disciplines react forcefully.
Having sex with a current patient or even a recently discharged patient is not only unethical—it is illegal. It is truly a betrayal of the trust the patient places in us. However, over time as in yearscan that change in some very special circumstances to allow exceptions to the rule? If a therapist and former patient meet some 10 or 15 years after the last therapeutic session and develop a personal relationship, get married, and have children, can we say that an ethical violation or a crime has been committed?
'Til Death Do Us Part: Does a Client Ever Stop Being a Client? - catchsomeair.us
Washington State is one exception. However, assuming the former client does not file any complaint, how enforceable would such laws be? For example, what if the former therapist and patient got married, were in a committed relationship, and had children? Would or should an ethics committee have the authority to interfere with a marriage or union among consenting adults? What about our belief in the right to free association?
What is the rationale for the prohibition against sex with patients? Many believe it is the power differential.
Behnke points out that many relationships have significant power differentials, including partnerships and marriages, and that we often do in fact put our own interests above those of clients when we charge fees, for example.
So, neither a power differential nor putting our own needs first is in and of itself unethical. Rather, Behnke says, it is because we have a fiduciary relationship that is compromised and creates additional risks that are not a necessary part of the therapeutic relationship, making psychotherapy impossible. But fiduciary relationships are not static and change with time and circumstances. Some would argue it is based on psychodynamic theory, and perhaps those who practice psychoanalytically have a higher standard.
But interestingly, there is nothing in psychodynamic theory or psychoanalysis that would state such. This would include taking patients on vacation and conducting analysis in hotel room beds. We tend to forget that that was a different time with different standards.
Therefore, perhaps, our reactions could possibly be a way of denying and reacting against the behaviors of a previous era we find frankly embarrassing and indefensible. Another possibility is that, whereas all of us require structure of some kind, some of us need more structure and clear inflexible rules more than others.
Some fear that if they bend the rules just a little, they may go down a slippery slope and cross all reasonable bounds.