Defining the differences between helping behavior and a helping relationship lies in the nature of the interactions between the parties. At one time or another everyone has provided support or advice to friends. A friendship is casual in nature with the tone of availability and support. Friendships are not bound by a code of ethics, but by an “understanding and desire to build the relationship” (Young, 2008). Usually advice is freely given, with little thought of the potential outcome, and the conversation is reciprocal. What may come easily for the friend with a sympathetic ear would not lend favorably in a professional helping relationship.
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A professional helping relationship in counseling or psychotherapy has a fairly consistent nature. Deciding how one wants to practice, either privately or part of an organization, and determining the focus of the practice as well as the type of population one wants to serve is only the first step of building this professional helping relationship. It has a purpose and can be entered into for different reasons.
The person seeking this relationship could be looking for help with a problem or specific issue needing further understanding, resolution, and closure, or it can be a relationship that begins with a referral from another provider. “Therapy represents a complex power relationship” (Anderson &Handelsman, 2009) and this helping relationship is formed with specific expectations. It is structured and consists of regularly scheduled meetings, prearranged by time and place. It is dynamic as defined by Anderson & Handelsman, (2009) “clients have the power to decide whether to come, yet both therapists and clients share decisions making about the therapeutic goals and some of the general strategies.” This relationship is bound by standards, practices and a Code of ethical responsibility.
Every client is not the same. Each one brings with them not only their own issues but their own heritage and cultural background that influence their belief system, values and ideas that may be foreign to the therapist. A challenge that the therapist may face is in understanding how they feel about dealing with a person with a belief system different from their own. “Effective helpers come to understand the personal cultures of clients” (Eagen, 2002) and therefore should spend some time searching their own personal beliefs and values. A counselor’s personal beliefs and value systems can influence the interactions that they have with their clients. Eagen (2002) speaks to this interaction and goes on to say that “understanding clients’ different approaches to developing and sustaining relationships is important” knowing where one stands in their personal beliefs and being sensitive to those differences helps the counselor enter the relationship without judgment to value and respect the individual.
Mark Young’s Learning the art of Helping listed characteristics of a therapeutic relationship. They are:
There is a liking or at least respect [of the client].
The purpose of the relationship is the client’s issues.
There is a sense of teamwork as both helper and client work toward a mutually agreed upon goal.
There is a contract specifying what will be disclosed outside of the relationship. Safety and trust are established.
There is an agreement about compensation for the helper.
There is an understanding that the relationship is confined to the counseling sessions and does not overlap into personal lives.
As a contractual relationship- the relationship can be terminated at anytime.
A counselor’s job is to listen to the client. To listen to not only what is being said, but by how it is said. Subtleties or changes in tone of voice, cadence, and body language all help the client to share their story. The therapist may find that the client is using emotional communication; or emotional language. This can contain both positive and negative feelings. Having an understanding that feelings are more than what is being said, “familiarity with feeling synonyms can enhance . . . perception of the client’s emotional state” (Knapp, 2007).
The use of empathy, allows the client to understand that the counselor is present and really focused on what is being said while validation and normalizing communicates to the client that they are in their own way unique, but not so unique that they are alone in whatever may be going on for them.
As the counselor listens, [they] must decide what responses may be helpful to the
client . . . and question, confront, or challenge the client in response. These are the
responses that make the counseling relationship unique, and these are the behaviors that build trust between the client and the counselor. (Glasser, 2004)
Empathy is a natural response to being with another person. “Emotional empathy is responding to another’s feelings” (Young, 2002). Empathy facilitates connections with a client because it shows that the therapist understands the person’s viewpoint. It is an important part of the therapeutic process and is seen as “a basic value that informs and drives all helping behavior” (Eagen, 2002). The use of empathy, allows the client to understand that the counselor is present and really focused on what is being said while validation and normalizing communicates to the client that they are in their own way unique, but not so unique that they are alone in whatever may be going on for them.
For example, a client comes into therapy stating that her son’s constant negative reactions to her requests are beginning to make her feel like a failure. An empathic response would be to reflect back to the client what has been said, because the counselor has listened to the experience and can reflect the emotion while describing the feeling, allowing the client to feel heard and understood.
One cannot think about using empathy effectively and not reflect on the work of Carl Rogers. Rogers used empathy to help a client feel understood; resulting in a feeling of empowerment and ability to solve their own issues as well a draw useful conclusions to their situation. His belief was that a therapeutic helper should meet a client with congruence, empathy and unconditional positive regard aligned with his therapeutic philosophy that “clients would move toward growth and positive outcomes if the helper provided the right environment” (Young, 2002). Kottler, (2007) described Rogers client centered therapy as a “power of nurturing relationships that offer respect, acceptance and warmth”.
The effective use of silence as a way of listening to a client allows presence
without intrusion. A form of non verbal communication attentive silence can be used when a client is given space to “reflect . . . and take time to think” (Young, 2008). Being able to hold the safe space and be quiet when the client is not speaking can present some challenges to a therapist. Being comfortable enough to allow the client to reflect, feel or view a problem or situation in a new way can all take place in moments of silence, and “when the client speaks again, a significant breakthrough in his thinking may occur” (Glasser, 2004).
As a professional, one needs to understand the nuances of their interaction with others as they determine how to help without hurting and support to those in need. Learning how to become an effective helping professional is a process of gaining knowledge from others and looking closely at self. Young (2008), offered advice on this stating a “reflective practitioner requires a commitment to personal awareness of your automatic reactions and prejudices and taking time to think on them”.
In deciding how one wants to practice, either privately or part of an organization, and determining the focus of the practice as well the type of population one wants to serve is only the first step. Building trust, a safe environment, and a professional demeanor is another. “In the role of therapist, . . . the therapy is about the client” (Knapp,2007). But it is the therapist’s responsibility to monitor the relationship and address issues as they arise through supervision and referral if they cannot be resolved.
Privacy and confidentiality with family or group
“Privacy is the client’s right to keep the counseling relationship a secret” (Cottone & Tarvydas, 2007). Therefore all aspects of the relationship fall under this definition. It is the counselor’s responsibility to ensure that all information shared is held strict confidence, and are guaranteed to be held in confidence unless the client approves the release of the information shared within the session. “Confidentiality is the obligation of the professional to respect the privacy of clients and the information they provide (Cottone & Tarvydas, 2007).
At the start of the professional relationship it should be made clear to client the limits of confidentiality. These specific situations include:
When presenting as a danger to self or others
Duty to warn another individual of an identifiable threat
Duty to protect said individual by some intervention or help
Any disclosed information about child or elder abuse or neglect
When questioned by parents or guardians when working with a minor
Consultation with other professionals or students of counseling
(Cottone & Tarvydas, 2007)
Breaking confidentiality outside of these limits can be devastating to a therapeutic relationship. “Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium” (APA, 2002), including files, internet or email correspondence and voice mail. Although therapists are human and subject to lapses of awareness and misguided judgments there is little room for such a grievous error.
For a practice that involves more than one individual as in the case for family or group therapy it is important that all people participating in the therapy understand “their roles and their relationships with all parties” (Fisher 2009). Since the therapeutic relationship is built on trust, a client that does not know the limits of the counselor’s sharing of information can be put in a potentially awkward or unsafe situation. It is the counselor’s job to explain roles clearly through the process of obtaining informed consent because all “clients have a right to know in advance . . . any limitation of privacy [and] confidentiality (Pope & Vasquez, 2007).
Standard 10.02 of the APA Ethics code defines Therapy Involving Couples or Families:
(a) When psychologists agree to provide services to several persons who
have a relationship (such as spouses, significant others, or parents and
children), they take reasonable steps to clarify at the outset (1) which of
the individuals are clients/patients and (2) the relationship the psychologist
will have with each person. This clarification includes the psychologist’s
role and the probable uses of the services provided or the information
(b) If it becomes apparent that psychologists may be called on to perform potentially conflicting roles (such as family therapist and then witness for one party in divorce proceedings), psychologists take reasonable steps to clarify and modify, or withdraw from, roles appropriately (APA, 2002).
Building trust, a safe environment, and a professional demeanor is important. By helping a client become comfortable and able to share what is on their mind, the therapist can avoid a power differential and can begin to establish a respectful and helping relationship. Regardless of where one chooses to practice, the foundational principles of that practice needs to be ethical.
Personal and professional growth
“Competence is the cornerstone of ethical practice; ethical behavior is contingent on intellectual and emotional competence” (Pope & Vasquez, 2007). A Practitioner should strive for constant personal and professional growth, but needs to be aware of personal limitations and stress while balancing multiple responsibilities and incorporate a system of self care.
Section 2.06 of the Code of Conduct speaks to competence and addresses personal problems and conflicts.
Refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work related activities in a competent manner.
Become aware of personal problems that may interfere with their performing work-related duties adequately, take appropriate measures such as obtaining perofessional consultation or assistance, and determine whether they should limit, suspend or terminate their work-related duties.
A simple formula to help achieve balance includes personal awareness, the counselor knowing the limits of his/her skills, participating in on going training, maintaining supervision to discuss ethical concerns and client progress, and know about current research and findings.
“Therapy represents a complex power relationship” (Anderson & Handelsman 2009). The counselor should be aware of his/her own system of judgments and as these and personal values are an important part of upholding ethical principles. He/she also needs to be aware of his/her client’s values remembering to be respectful and careful not to impose personal beliefs onto the client. The counselor holds all the responsibility to the client and all interactions need to remain within that framework.
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Maintaining a sense of balance and self care is vital to maintain an integrated and cohesive lifestyle. The therapist needs to determine obligations and life choices that are true to the self, looking deeply at beliefs, values and virtues held to know where one stands. Having the internal battle for good or bad, right or wrong is not conducive to good mental health. Decisions made impact not just the therapist and client, but families, spouses, partners and colleagues.
Ethical considerations and responsibilities
“Ethical awareness is a continuous active process” (Pope & Vasquez, 2007). As a practitioner strives for personal and professional growth they need to be aware of personal limitations, stress, and balancing multiple responsibilities.
To ensure that therapists, clinicians, and counselors uphold high professional standards the American Psychological Association (APA) developed the Ethical Principles of Psychologists and Code of Conduct (ethics code). Serving as a guide to dictate procedural applications and conduct within a therapeutic setting. “Ethics standards set forth enforceable rules [and the fact that] a given conduct is not specifically addresses by an ethical standard does not mean that it is necessarily either ethical or unethical” (APA, 2002).
The Code of Ethics is a document full of information and far too lengthy for full review here. It is not for the purpose of argument but for a deeper understanding of the subject that this writer will review ethical standards for confidentiality and privacy, and how a self care strategy can help a therapist avoid burnout and making mistakes.
The APA has identified moral principles as being the basis for ethical guidelines. They are Beneficence and Nonmaleficence, Fidelity and Responsibility, Integrity, Justice, and Veracity.
Beneficence and Nonmaleficence – Implies that the professional avoids doing harm, intentional or unintentional, remaining within the scope of practice, and informing clients of any risk.
Fidelity and Responsibility – Striving to establish trust with those with whom therapists work. Upholding professional standards of conduct clarify professional roles and obligations and accept appropriate responsibility for behavior.
Integrity – Seeking to promote accuracy, honesty, and truthfulness in the science, teaching and [practicing of psychology.
Justice – Fairness or equal treatment for all. Advocating for client services, and respecting cultural differences.
Respect for People’s Rights and Dignity – respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. Being aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making. Being loyal, terminating and referring a client when necessary.
Knowledge of the ethics codes need to go beyond just the writing on the page. “Ethical responsibility entails continuous awareness to prevent compromised performance” (Pope &Vazques, p.50) and therapists are expected to be knowledgeable and understand the guidelines that are in place. “A lack of awareness or misunderstanding of an Ethical Standard is not itself a defense to a charge of unethical conduct.” (APA, 2002).
In her article The Ethics of Being Ethical Patricia Stevens PhD (2000) University of Colorado-Denver explains “as we struggle to juggle aspects of our professional lives, we may choose to make life easier for ourselves by ignoring some of the basic ethical guidelines. . . [and] we develop multiple rationalizations to justify our behavior”. It is even easier to do when the therapist finds themselves under stress, distressed or pre-occupied with personal issues.
Asking for help, utilizing supervision and taking time to recharge is one way to help the counselor avoid breach of this very important ethical mandate. It is expected that the therapist has enough self awareness to recognize the fact that they are not performing up to capacity or are nearing burnout.
Boundaries can be defined two ways, permeable and flexible or impermeable and rigid. Although sometimes a mystery a therapists boundaries need to be flexible enough to adapt to the needs of the client while at the same time hold firm the expectations of the practice. Dimensions of personal boundaries are the responsibility of the therapist. One can follow ethical rules and mandates and still be flexible enough to be inclusive and culturally sensitive.
Pope and Vasquez’s Ethics in Psychotherapy and Counseling (2007) listed twenty justifications that for crossing professional boundaries. Seven of them are listed below and all of them start with the phrase it’s not unethicalâ€¦
If we have written an article, chapter or book about it.
As long as we can name others who do the same thing.
If we were under a lot of stress.
If no one has ever complained about it.
If the client asked us to do it.
If we could not (or did not) anticipate the unintended consequences of our acts.
If it would be almost impossible to do things any other way.
Counselors should be aware that “demonstrating behaviors like little to no self disclosing, not initiating social interaction with clients in a public setting, not entering into business arrangements with clients and not doing therapy with those whim you have relations” (Anderson & Handelsman, 2009), can help to keep boundaries in place. Questionable ethical practice in the areas of coercion, touch, gifts and sex are inappropriate and should not be tolerated.
In the spring of 2003 the American Counseling Association (ACA) assembled the Task Force on Impaired Counselors to “address the needs of impaired counselors and their clients” (ACA.org). The purpose of the task force was to design ways to help counselors that are impaired and get a better idea of the needs of the field.
Areas identified by the task force indicated that needs existed in the following areas:
Prevention and resilience education. Education efforts build on counselor strengths, helps counselors identify areas of vulnerability and provide strategies to promote wellness.
Resources, intervention and treatment including access to resources for impaired counselors and establishing best practice criteria for those who counsel and supervise impaired clinicians.
Advocacy within the ACA to address the needs of impaired counselors – through clarification of ethical guidelines providing access to services for impaired counselors before ethical concerns arise and addressing the stigma associated with seeking mental health treatment among counselors.
Glenn O Gabbard addressed patient-therapist boundary violations in his article Prevention of Boundary Violations: the roles of education, self-monitoring, and consultation (2008). Gabbard states his belief that education of the therapist and the public is useful to identify to the therapist and client to the “slippery slope concept one can reach with a subtle break in the therapeutic process.” He goes on to say the consultation can point out “blind spots in the therapist’s relationship with the client” with these two examples.
Anything you are doing with a patient should be something that can be freely shared with a consultant.
Anything you feel you must keep a secret from the consultant is exactly what you should be sharing.
Monitoring and self scrutiny are used to see that the counselor is balancing his/her life so that “emotional needs are met in the context of personal relationships in one’s private life . . . Gratification in doing the work cannot take place of an intimate relationship outside the therapeutic setting” (Gabbard, 2008).
There is value in learning how to develop positive self care strategies to use when feeling overwhelmed, stressed out, or emotionally, spiritually and financially drained. “As professional helpers, counselors have an obligation to model self care behaviors. . . and, when necessary, [seek] help from others” (McCarthy, 2008). Finding or developing a strategy that works may take some time but ultimately appears to be worth the effort.
Therapists do not enter the field with the intention of violating a client’s confidentiality or with intent to abuse or hurt in any way. But boundary violations, breaches in ethical responsibility and other incidents do happen. Gabbard, (2008) presents a model of asking oneself questions like “is what I am doing part of a carefully thought out treatment plan? Is anything I am doing potentially exploitative of the patient’s vulnerability? Is there anything I am doing that I could not share with a colleague?” Reflection on question like these may help to make a counselor aware of potential ethical or boundary violations.
“As counselors we must demonstrate the same level of commitment to self awareness, self care and balance for ourselves as we have for our clients” (ACA.org) ???
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