Midterm Exam Study Notes PDF

Theoretical Approaches to Counselling & Psychotherapy Week 2 - September 9, 2024 Introduction to Therapeutic Approaches Personal integration as a framework for the professional education of counselors. When students are presented with a single theory and are expected to subscribe to it alone, their...

Theoretical Approaches to Counselling & Psychotherapy Week 2 - September 9, 2024 Introduction to Therapeutic Approaches Personal integration as a framework for the professional education of counselors. When students are presented with a single theory and are expected to subscribe to it alone, their effectiveness will be limited when working with a diverse range of clients in the future. An undisciplined mixture of approaches, however, can be an excuse for failing to develop a sound rationale for systematically adhering to certain concepts and to the techniques that are extensions of them. It is easy to pick and choose fragments from the various therapies because they support our biases and preconceptions. Each therapeutic approach has useful dimensions for understanding human behavior. No theory is either "right" or "wrong"; each theory offers a unique contribution to understanding human behavior and has implications for counseling practice. Accepting the validity of one theory does not necessarily imply rejecting other approaches. There is a clear place for theoretical pluralism, especially in a society that is becoming increasingly diverse. More approaches have been developing methods that involve collaboration between therapist and client, making the therapeutic venture a shared responsibility. This collaborative relationship, coupled with teaching clients ways to use what they learn in therapy in their everyday lives, empowers clients to take an active stance in their world. It is imperative that clients be active, not only in their counseling sessions but in daily life as well. Homework, collaboratively designed by clients and therapists, can be a vehicle for assisting clients in putting into action what they are learning in therapy. A related assumption is that we can exercise increasing freedom to create our own future. Accepting personal responsibility does not imply that we can be anything we want to be. Social, environmental, cultural, and biological realities oftentimes limit our freedom of choice. Being able to choose must be considered in the sociopolitical contexts that exert pressure or create constraints; oppression is a reality that can restrict our ability to choose our future. We are also influenced by our social environment, and much of our behavior is a product of learning and conditioning. That being said, I believe an increased awareness of these contextual forces enables us to address these realities. It is crucial to learn how to cope with the external and internal forces that influence our decisions and behavior. We should challenge the assumption that therapy is exclusively aimed at "curing" psychological "ailments." Such focus on the medical model restricts therapeutic practice because it stresses deficits rather than strengths. Psychotherapy is a process of engagement between two people, both of whom are bound to change through the therapeutic venture. At its best, this is a collaborative process that involves both the therapist and the client in co-constructing solutions regarding life's tasks. Therapists are not in business to change clients, to give them quick advice, or to solve their problems for them. Instead, counselors facilitate healing through a process of genuine dialogue with their clients. The kind of person a therapist is remains the most critical factor affecting the client and promoting change. If practitioners possess wide knowledge, both theoretical and practical, yet lack human qualities of compassion, caring, good faith, honesty, presence, realness, and sensitivity, they are more like technicians. It is essential that counselors explore their own values, attitudes, and beliefs in depth and work to increase their own awareness. With respect to mastering the techniques of counseling and applying them appropriately and effectively, it is my belief that you are your own best technique. Your engagement with clients is useful in moving the therapeutic process along. It is impossible to separate the techniques you use from your personality and the relationship you have with your clients. Administering techniques to clients without regard for the relationship variables is ineffective. Counseling entails far more than becoming a skilled technician. It implies that you are able to establish and maintain a good working relationship with your clients, that you can draw on your own experiences and reactions, and that you can identify techniques suited to the needs of your clients. As a counselor, you need to remain open to your own personal development and to address any significant personal problems. The most powerful ways for you to teach your clients is by the behavior you model and by the ways you connect with them. Your personal characteristics are of primary importance in becoming a counselor, but it is not sufficient to be merely a good person with good intentions. To be effective, you also must have supervised experiences in counseling and sound knowledge of counseling theory and techniques. It is essential to be well grounded in the various theories of personality and to learn how they are related to theories of counseling. Differences between you and your client may require modification of certain aspects of the theories. Some practitioners make the mistake of relying on one type of intervention (supportive, confrontational, information giving) for most clients with whom they work. In reality, different clients may respond better to one type of intervention than to another. Even during the course of an individual's therapy, different interventions may be needed at various times. In developing an integrative perspective, it is essential to think holistically. To understand human functioning, it is imperative to account for the physical, emotional, mental, social, cultural, political, and spiritual dimensions. If any one of these facets of human experience is neglected, a theory is limited in explaining how we think, feel, and act. Overview of Contemporary Counseling Models Psychodynamic approaches: Psychoanalytic therapy is based largely on insight, unconscious motivation, and reconstruction of the personality. ○ The psychoanalytic model appears first because it has had a major influence on all of the formal systems of psychotherapy. Some of the therapeutic models are extensions of psychoanalysis, others are modifications of analytic concepts and procedures, and still others emerged as a reaction against psychoanalysis. Many theories of psychotherapy have borrowed and integrated principles and techniques from psychoanalytic approaches. Adlerian therapy differs from psychoanalytic theory in many respects, but it can broadly be considered an analytic perspective. ○ Adlerians focus on meaning, goals, purposeful behavior, conscious action, belonging, and social interest. Although Adlerian theory accounts for present behavior by studying childhood experiences, it does not focus on unconscious dynamics. Experiential and relationship-oriented therapies: Includes the existential approach, the person-centered approach, and Gestalt therapy The existential approach stresses a concern for what it means to be fully human. It suggests certain themes that are part of the human condition, such as freedom and responsibility, anxiety, guilt, awareness of being finite, creating meaning in the world, and shaping one's future by making active choices. ○ This approach is not a unified school of therapy with a clear theory and a systematic set of techniques. Rather, it is a philosophy of counseling that stresses the divergent methods of understanding the subjective world of the person. The person-centered approach, which is rooted in a humanistic philosophy, places emphasis on the basic attitudes of the therapist. It maintains that the quality of the client-therapist relationship is the prime determinant of the outcomes of the therapeutic process. ○ Philosophically, this approach assumes that clients have the capacity for self-direction without active intervention and direction on the therapist's part.  Another experiential approach is Gestalt therapy, which offers a range of experiments to help clients gain awareness of what they are experiencing in the here and now that is, the present. ○ In contrast to person-centered therapists, Gestalt therapists tend to take an active role as they follow the leads provided by their clients. These approaches tend to emphasize emotion as a route to bringing about change, and in a sense, they can be considered emotion-focused therapies. Cognitive behavioral approaches: Sometimes known as the action-oriented therapies because they all emphasize translating insights into behavioral action. These approaches include: ○ Choice theory / reality therapy ○ Behavior therapy ○ Rational emotive behavior therapy ○ Cognitive therapy Reality therapy focuses on clients' current behavior and stresses developing clear plans for new behaviors. Like reality therapy, behavior therapy puts a premium on doing and on taking steps to make concrete changes. A current trend in behavior therapy is toward paying increased attention to cognitive factors as an important determinant of behavior. Rational emotive behavior therapy and cognitive therapy highlight the necessity of learning how to challenge inaccurate beliefs and automatic thoughts that lead to behavioral problems. These cognitive behavioral approaches are used to help people modify their inaccurate and self-defeating assumptions and to develop new patterns of acting. These general approach encompasses the systems and postmodern perspectives: Feminist therapy and family therapy are systems approaches, but they also share postmodern notions. The systems orientation stresses the importance of understanding individuals in the context of the surroundings that influence their development. To bring about individual change, it is essential to pay attention to how the individual's personality has been affected by gender-role socialization, culture, family, and other systems. The postmodern approaches include social constructionism, solution-focused brief therapy, narrative therapy, and motivational interviewing. These newer approaches challenge the basic assumptions of traditional approaches by assuming that there is no single truth and that reality is socially constructed through human interaction. Both  postmodern and systemic theories focus on how people produce their own lives in the context of systems, interactions, social conditioning, and discourse. Practitioners need to pay attention to what their clients are thinking, feeling, and doing, and a complete therapy system must address all three of these facets. Some of the therapies included here highlight the role that cognitive factors play in counseling. Others place emphasis on the experiential aspects of counseling and the role of feelings. Still others emphasize putting plans into action and learning by doing. Combining all of these dimensions provides the basis for a comprehensive therapy framework. Psychodynamic Approaches Psychoanalytic therapy Founder: Sigmund Freud A theory of personality development, a philosophy of human nature, and a method of psychotherapy that focuses on unconscious factors that motivate behavior. Attention is given to the events of the first six years of life as determinants of the later development of personality. Adlerian therapy Founder: Alfred Adler Key Figure: Rudolf Dreikurs Following Adler, Dreikurs is credited with popularizing this approach in the United States. This is a growth model that stresses assuming responsibility, creating one's own destiny, and finding meaning and goals to create a purposeful life. Key concepts are used in most other current therapies. Experiential and Relationship-Oriented Therapies Existential therapy Key Figures: Viktor Frankl, Rollo May, and Irvin Yalom Reacting against the tendency to view therapy as a system of well-defined techniques, this model stresses building therapy on the basic conditions of human existence, such as choice, the freedom and responsibility to shape one's life, and self-determination. It focuses on the quality of the person-to-person therapeutic relationship. Person-centered therapy Founder: Carl Rogers. Key Figure: Natalie Rogers. This approach was developed during the 1940s as a nondirective reaction against psychoanalysis. Based on a subjective view of human experiencing, it places faith in and gives responsibility to the client in dealing with problems and concerns. Gestalt therapy Founders: Fritz and Laura Perls Key Figures: Miriam and Erving Polster An experiential therapy stressing awareness and integration; it grew as a reaction against analytic therapy. It integrates the functioning of body and mind and places emphasis on the therapeutic relationship. Introduction to the Counsellor One of the most important instruments you have to work with as a counselor is yourself as a person. In preparing for counseling, you will acquire knowledge about the theories of personality and psychotherapy, learn assessment and intervention techniques, and discover the dynamics of human behavior. Such knowledge and skills are essential, but by themselves they are not sufficient for establishing and maintaining effective therapeutic relationships. To every therapy session we bring our human qualities and the experiences that have influenced us. This human dimension is one of the most powerful influences on the therapeutic process. Ample research supports the conclusion that psychotherapy is an irreducibly human encounter. The Counselor as a Therapeutic Person If we hide behind the safety of our professional role, our clients are likely to keep themselves hidden from us. If we strive for technical expertise alone, and leave our own reactions and self out of our work, we are likely to be ineffective counselors. Our own genuineness can have a significant effect on our relationship with our clients. If we are willing to look at our lives and make the changes we want, we can model that process by the way we reveal ourselves and respond to our clients. If we are inauthentic, we will have difficulty establishing a working alliance with our clients. If we model authenticity by engaging in appropriate self-disclosure, our clients will tend to be honest with us as well. Abundant research indicates the centrality of the person of the therapist as a primary factor in successful therapy. The person of the psychotherapist is inextricably intertwined with the outcome of psychotherapy. Clients place more value on the personality and character of the therapist than on the specific techniques used. Indeed, evidence-based psychotherapy relationships are critical to the psychotherapy endeavor. Personal and interpersonal components are essential to effective psychotherapy, whereas techniques have relatively little effect on therapeutic outcome. Both the therapy relationship and the therapy methods used influence the outcomes of treatment. It is essential that the methods used support the therapeutic relationship being established with the client. An effective psychotherapist is one who employs specific methods, who offers strong relationships, and who customizes both treatment methods and relationship stances to the individual person and condition. Personal Characteristics of an Effective Counsellor Personal characteristics of effective counselors: Effective therapists have an identity ○ They know who they are, what they are capable of becoming, what they want out of life, and what is essential. Effective therapists respect and appreciate themselves ○ They can give and receive help and love out of their own sense of self-worth and strength. They feel adequate with others and allow others to feel powerful with them. Effective therapists are open to change ○ They exhibit a willingness and courage to leave the security of the known if they are not satisfied with the way they are. They make decisions about how they would like to change, and they work toward becoming the person they want to become. Effective therapists make choices that are life oriented  ○ They are aware of early decisions they made about themselves, others, and the world. They are not the victims of these early decisions, and they are willing to revise them if necessary. They are committed to living fully rather than settling for mere existence. Effective therapists are authentic, sincere, and honest ○ They do not hide behind rigid roles or facades. Who they are in their personal life and in their professional work is congruent. Effective therapists have a sense of humor ○ They are able to put the events of life in perspective. They have not forgotten how to laugh, especially at their own foibles and contradictions. Effective therapists may make mistakes and are willing to admit them ○ They do not dismiss their errors lightly, yet they do not choose to dwell on misery. Effective therapists generally live in the present ○ They are not riveted to the past, nor are they fixated on the future. They are able to experience and be present with others in the "now." Effective therapists appreciate the influence of culture ○ They are aware of the ways in which their own culture affects them, and they respect the diversity of values espoused by other cultures. They are sensitive to the unique differences arising out of social class, race, sexual orientation, and gender. Effective therapists have a sincere interest in the welfare of others ○ This concern is based on respect, care, trust, and a real valuing of others. Effective therapists possess good interpersonal skills ○ They are capable of entering the world of others without getting lost in this world, and they strive to create collaborative relationships with others. They readily entertain another person's perspective and can work together toward consensual goals. Effective therapists become deeply involved in their work and derive meaning from it ○ They can accept the rewards flowing from their work, yet they are not slaves to their work. Effective therapists are passionate ○ They have the courage to pursue their dreams and passions, and they radiate a sense of energy.  Effective therapists are able to maintain healthy boundaries ○ Although they strive to be fully present for their clients, they don't carry the problems of their clients around with them during leisure hours. They know how to say no, which enables them to maintain balance in their lives. Do not think of these personal characteristics from an all-or-nothing perspective; rather, consider them on a continuum. A given trait may be highly characteristic of you, at one extreme, or it may be very uncharacteristic of you, at the other extreme. Summary on what makes a good counselor: Self-awareness and self-reflection on: ○ Biases ○ Values ○ Limitations ○ Self-efficacy Defined sense of self Genuineness Flexibility and openness Interpersonal skills Empathy and concern for others Self-care and vitality Personal Therapy for the Counselor The vast majority of mental health professionals have experienced personal therapy. Personal therapy contributes to the therapist's professional work in three ways: 1) As part of the therapist's training, personal therapy offers a model of therapeutic practice in which the trainee observes a more experienced therapist at work and learns experientially what is helpful or not helpful 2) A beneficial experience in personal therapy can further enhance a therapist's interpersonal skills, which are essential to skillfully practicing therapy  3) Successful personal therapy can contribute to a therapist's ability to deal with the ongoing stresses associated with clinical work. Practitioners learn from their personal therapy experiences pertain to interpersonal relationships and the dynamics of psychotherapy. Some of these lessons learned are the centrality of warmth, empathy, and the personal relationship; having a sense of what it is like to be a therapy client; valuing patience and tolerance; and appreciating the importance of learning how to deal with transference and countertransference. By participating in personal therapy, counselors can prevent their potential future countertransference from harming clients. Through our work as therapists, we can expect to confront our own unexplored personal blocks such as loneliness, power, death, and intimate relationships. This does not mean that we need to be free of conflicts before we can counsel others, but we need to be aware of what these conflicts are and how they are likely to affect us as persons and as counselors. For example, if we have great difficulty dealing with anger or conflict, we may not be able to assist clients who are dealing with anger or with conflictual relationships. Personal therapy can be instrumental in healing the healer. As counselors, we cannot take our clients any farther than we have gone ourselves. If we are not committed personally to the value of examining our own life, how can we inspire clients to examine their lives? By experiencing our own psychotherapy, we gain an experiential frame of reference with which to view ourselves. This provides a basis for understanding and having compassion for our clients, and we can draw on our own memories of reaching impasses in our therapy, of both wanting to go farther and at the same time resisting change. As we increase our self- awareness through our own therapy, we gain increased appreciation for the courage our clients display in their therapeutic journey. Participating in a process of self-exploration can reduce the chances of assuming an attitude of arrogance or of being convinced that we are totally healed. The Role of Values in Counseling Our values are core beliefs that influence how we act, in both our personal and our professional lives. Personal values influence how we view counseling and the manner in which we interact with clients, including the way we conduct client assessments, our views of the goals of counseling, the interventions we choose, the topics we select for discussion in a counseling session, how we evaluate progress, and how we interpret clients' life situations. The counselor's role is to create a climate in which clients can examine their thoughts, feelings, and actions and to empower them to arrive at their own solutions to problems they face. The counselor's task is to assist individuals in finding answers that are most congruent with their own values. It is not beneficial to give clients your answers to their questions about life. You may not agree with certain of your clients' values, but you need to respect their right to hold divergent values from yours. This is especially true when counseling clients who have a different cultural background and perhaps do not share your own core cultural values. Your role is to provide a safe, accepting, and inviting environment in which clients can explore the congruence between their values and their behavior. If clients acknowledge that what they are doing is not getting them what they want, it is appropriate to assist them in developing new ways of thinking and behaving to help them move closer to their goals. This is done with full respect for their right to decide which values they will use as a framework for living. Individuals seeking counseling need to clarify their own values and goals, make informed decisions, choose a course of action, and assume responsibility and accountability for the decisions they make. Managing your personal values so they do not contaminate the counseling process is referred to as bracketing. Counselors are expected to set aside (or bracket) their personal beliefs and values when working with a wide range of clients. Your core values may differ in many ways from the core values of your clients, and they will bring you a host of problems framed by their own worldview. Some clients may have felt rejected by others or have suffered from discrimination, and they should not be exposed to further discrimination by counselors who refuse to render services to them because of differing values. Value imposition refers to counselors directly attempting to define a client's values, attitudes, beliefs, and behaviors. The American Counseling Association (ACA) has taken a clear position on this, stating that the counselor's personal values should neither interfere with the counseling process nor be imposed on a client. Although this ethical mandate is clear, counselors often experience difficulty in successfully navigating value conflicts in a way that preserves client autonomy and the counseling relationship. Personal Values. Counselors are aware of and avoid imposing their own values, attitudes, beliefs, and behaviors. Clients are in a vulnerable position and require understanding and support from a counselor rather than judgment. It can be burdensome for clients to be saddled with your disclosure of not being able to get beyond value differences. Clients may interpret this as a personal rejection and suffer harm as a result. Counseling is about working with clients within the framework of their value system. If you experience difficulties over conflicting personal values with clients, the ethical course of action is to seek supervision or consultation and learn ways to effectively manage these differences. Merely disagreeing with a client's value system is not ethical grounds for a referral. It is unethical for a counselor to refer a client based on a lack of agreement on values. Consider a referral only when you clearly lack the necessary knowledge and skills to deal with the issues presented by the client. The counseling process is not about your personal values; it is about the values and needs of your clients. Your task is to help clients explore and clarify their beliefs and apply their values to solving their problems. Can Counselors Who Self-Identify as Religious Provide Value-Free Counseling to LGBTQ+ Clients? The concept of human diversity encompasses all forms of oppression, discrimination, and prejudice, including those directed toward people on the basis of their age, gender, socioeconomic status, religious affiliation, disability, or sexual orientation. Counselors or counselors-in-training must begin by challenging their own personal prejudices, biases, fears, attitudes, assumptions, and stereotypes regarding sexual orientation if they expect to understand the ways in which prejudice, discrimination, and multiple forms of oppression are manifested in society toward LGBTQ+ people. Counselors and counselor trainees have an ethical responsibility to acquire and use professional knowledge and skills in serving the diverse range of clients that they are likely to encounter in their practice. Counselors must be invested in the process of a client's decision making rather than in directing the client toward outcomes the counselor judges to be appropriate. Addressing Religious and Spiritual Values in Counseling The American Psychological Association (APA) affirms that religion is a key consideration within diversity (Principle E), and states that attending to a client's religious and spiritual values and beliefs can positively influence outcomes of the therapy process. Asking questions about a client's religious or spiritual background at the beginning of therapy demonstrates to the client that religious and spiritual values can be an asset in therapy. If counselors do not inquire about a client's spiritual or religious values and concerns during assessment, the client may be hesitant to bring up these topics in counseling sessions. Religious and spiritual values can foster increased social belonging, connection, and support. Counselors can use this important cultural lens in case conceptualization, developing treatment goals, and selecting appropriate interventions. Incorporating religious and spiritual values when clients wanted to include this as a part of the therapy process significantly improve treatment outcomes. However, they caution therapists to avoid making assumptions based on religious identification and to recognize that considerable variation exists in the needs, wants, and expectations of clients. Some guidelines to follow when working with cultural-diverse clients: Consider religion and spirituality as a potentially significant aspect of the client's identity. Explore the client's history, values, and commitment to religion and spirituality as part of the intake session and the informed consent process. Incorporate the client's religious and spiritual values and worldview in psychotherapy as requested and when clinically indicated. Follow the client's lead when incorporating these beliefs and practices.  When a client's treatment goals include not only symptoms remission but also spiritual development, integrating the client's religious and spiritual values in therapy is a treatment of choice. Customize treatment when working with clients whose religious and spiritual values are an influential force in their daily life. It is important to assess clients' preferences and accommodate treatment accordingly. Practice respect and cultural humility when discussing clients' religious worldviews and practices. For many clients, spirituality or religion are core aspects of their sense of self, worldview, and value system. Religious or spiritual concerns may be relevant to the reasons some clients seek therapy, either as areas of conflict for them or as sources of strength and support that can enhance the therapy process. If clients do not see religion and spirituality as being relevant factors in their life, it is not appropriate for counselors to take the lead and bring these matters into the therapy process. The Role of Values in Developing Therapeutic Goals Almost all theories are in agreement that it is largely the client's responsibility to decide upon goals, collaborating with the therapist as therapy proceeds. Counselors have general goals, which are reflected in their behavior during the therapy session, in their observations of the client's behavior, and in the interventions they make. The general goals of counselors must be congruent with the personal goals of the client. Setting goals is inextricably related to values. The client and the counselor need to explore what they hope to obtain from the counseling relationship, whether they can work with each other, and whether their goals are compatible. Even more important, it is essential that the counselor be able to understand, respect, and work within the framework of the client's world rather than forcing the client to fit into the therapist's scheme of values. Therapy must begin with an exploration of the client's expectations and goals. Clients initially tend to have vague ideas of what they expect from therapy. In some cases, clients have no goals; they are in the therapist's office simply because they were sent for counseling by their parents, probation officer, or teacher. The initial interview can be used most productively to focus on the client's goals or lack of them. When a person seeks a counseling relationship with you, it is important to cooperatively discover what this person is expecting from the relationship. If you try to figure out in advance how to proceed with your clients, you may be depriving them of the opportunity to become active partners in their own therapy. It is important to keep this focus in mind so the client's agenda is addressed rather than an agenda of your own. Becoming an Effective Multicultural Counselor Therapists must be able to actively engage and effectively work with diverse client populations. Becoming a diversity-competent counselor is not a destination to be reached; rather, it is a lifelong learning process that includes formal training, self-reflection, and questioning what is occurring in cross-cultural therapeutic partnerships. Counselors entering cross-cultural helping relationships need to develop a variety of techniques and skills consistent with the life experiences and cultural values of their clients. Becoming a competent multicultural practitioner involves cultural awareness, cultural knowledge, and cultural skills. Clients are more likely to engage in treatment, remain in therapy, and experience positive outcomes when treatments are tailored to match the characteristics of their clients. Part of the process of becoming an effective multicultural counselor involves learning how to recognize diversity issues and shape your counseling practice to fit the client's worldview. Counselors have an ethical obligation to understand these cultural differences and to assist clients in making decisions that are congruent with their worldview, not to live by the therapist's values. When therapists neglect how their worldviews and cultural values influence the ways they practice, or when they fail to understand the role that culture plays in their clients' lives; therapists are limiting their ability to make appropriate and useful interventions. Acquiring Competencies in Multicultural Counseling Diversity-competent practitioners understand their own cultural conditioning, the cultural values of their clients, and the sociopolitical system of which they are a part. Acquiring this understanding begins with counselors' awareness of the cultural origins of any values, biases, and attitudes they may hold. Counselors from all cultural groups must examine their expectations, attitudes, biases, and assumptions about the counseling process and about people from diverse groups. Recognizing our biases and prejudices takes courage because most of us do not want to acknowledge that we have cultural biases. Everyone has biases, but being unaware of the biased attitudes we hold is an obstacle to client care. A major part of becoming a diversity-competent counselor involves challenging the idea that the values we hold are automatically true for others. Conceptual framework for competencies and standards in multicultural counseling that address three areas: 1) Beliefs and attitudes  Counselors are aware of their positive and negative emotional reactions toward people from other racial and ethnic groups that may prove detrimental to establishing collaborative helping relationships. They seek to examine and understand the world from the vantage point of their clients. They respect clients' religious and spiritual beliefs and values. They are comfortable with differences between themselves and others in terms of race, ethnicity, culture, and beliefs Rather than maintaining that their cultural heritage is superior, they are able to accept and value cultural diversity. They realize that traditional theories and techniques may not be appropriate for all clients or for all problems Culturally skilled counselors monitor their functioning through consultation, supervision, and further training or education. 2) Knowledge Diversity-competent practitioners actively attempt to understand the worldview of their clients. ○ They know their own racial and cultural heritage and understand how it affects them personally and professionally. ○ They understand the dynamics of oppression, racism, discrimination, and stereotyping and are in a position to detect their own racist attitudes, beliefs, and feelings. ○ They understand the worldview of their clients, and they learn about their clients' cultural background ○ They do not impose their values and expectations on their clients from differing cultural backgrounds and avoid stereotyping clients. These practitioners are aware of the institutional barriers that prevent minorities from utilizing the mental health services available in their communities. ○ They possess knowledge about the historical background, traditions, and values of the client populations with whom they work including minority family structures, hierarchies, values, and beliefs. They are knowledgeable about community characteristics and resources and can help clients make use of indigenous support systems. In areas where they are lacking in knowledge, they seek resources to assist them. 3) Skills  Diversity-competent practitioners have acquired skills in working with culturally diverse populations. Multicultural counseling is enhanced when practitioners use methods and strategies and define goals consistent with the life experiences and cultural values of their clients. Such practitioners modify and adapt their interventions to accommodate cultural differences. Incorporating Culture in Counseling Practice It is unrealistic to expect a counselor to know everything about the cultural background of a client, but some understanding of the client's cultural and ethnic background is necessary. For counseling to be effective, therapists must take into account the worldview and background of every client. Failing to do this seriously restricts the potential impact of the therapeutic endeavor. Counseling is by its very nature diverse in a multicultural society, so it is easy to see that there are no ideal therapeutic approaches. Instead, different theories have distinct features that have appeal for different cultural groups. Some theoretical approaches have limitations when applied to certain populations. Practitioners who truly respect their clients will be aware of clients' hesitations and will not be too quick to misinterpret this behavior. Instead, they will patiently attempt to enter the world of their clients as much as they can. Practical Guidelines in Addressing Culture Practical guidelines include: Learn more about how your own cultural background has influenced your thinking and behaving. Take steps to increase your understanding of other cultures. Identify your basic assumptions, especially as they apply to diversity in culture, ethnicity. race, gender, class, age, spirituality, religion, and sexual orientation. Think about how your assumptions are likely to affect your professional practice. Examine where you obtained your knowledge about culture. Remain open to ongoing learning of how the various dimensions of culture may affect therapeutic work. Realize that this skill does not develop quickly or without effort. Be willing to identify and examine your own personal worldview and any prejudices you may hold about other racial/ethnic groups.  Learn to pay attention to the common ground that exists among people of diverse backgrounds. Be flexible in applying the methods you use with clients. Don't be wedded to a specific technique if it is not appropriate for a given client. Remember that practicing from a multicultural perspective can make your job easier and can be rewarding for both you and your clients. Expressing cultural humility and tracking clients' satisfaction with cultural responsiveness markedly improves client engagement, retention, and treatment outcome. Issues Faced by Beginning Therapists Dealing with anxiety Most beginning counselors have ambivalent feelings when meeting their first clients. A certain level of anxiety demonstrates that you are aware of the uncertainties of the future with your clients and of your abilities to really be there for them. A willingness to recognize and deal with these anxieties, as opposed to denying them, is a positive sign. One way is to openly discuss our self-doubts with a supervisor and peers. The possibilities are rich for meaningful exchanges and for gaining support from fellow interns who probably have many of the same concerns and anxieties. Being yourself and self-disclosure If we are able to be ourselves in our therapeutic work, and appropriately disclose our reactions in counseling sessions, we increase the chances of being authentic. It is this level of genuineness and presence that enables us to connect with our clients and to establish an effective therapeutic relationship with them It is possible to err by going to extremes in two different directions. ○ At one end are counselors who lose themselves in their fixed role and hide behind a professional facade. These counselors are so caught up in maintaining stereotyped role expectations that little of their personal self shows through. Counselors who adopt this behavior will likely remain anonymous to clients, and clients may perceive them as hiding behind a professional role. ○ At the other end of the spectrum is engaging in too much self-disclosure. Some counselors make the mistake of inappropriately burdening their clients with their spontaneous impressions about their clients. In determining the appropriateness of self-disclosure, consider what to reveal, when to reveal, and how much to reveal. It may be useful to mention something about ourselves from  time to time, but we must be aware of our motivations for making ourselves known in this way. Assess the readiness of a client to hear these disclosures as well as the impact doing so might have on the client. Remain observant during any self-disclosure to get a sense of how the client is being affected by it. The skill of immediacy involves revealing what we are thinking or feeling in the here and now with the client, but be careful to avoid pronouncing judgments about the client. When done in a timely way, sharing persistent reactions can facilitate therapeutic progress and improve the quality of our relationship with the client. Avoiding perfectionism Perhaps one of the most common self-defeating beliefs with which we burden ourselves is that we must never make a mistake. If our energies are tied up presenting an image of perfection, this will affect our ability to be present for our clients. Students willing to risk making mistakes in supervised learning situations and willing to reveal their self-doubts will find a direction that leads to growth. Being honest about your limitations It takes honesty to admit that you cannot work successfully with every client. It is important to learn when and how to make a referral for clients when your limitations prevent you from helping them. However, there is a delicate balance between learning your realistic limits and challenging what you sometimes think of as being "limits." Understanding silence Silent moments during a therapeutic session may seem like silent hours to a beginning therapist, yet this silence can have many meanings. The silence may be refreshing, or the silence may be overwhelming. Perhaps the interaction has been on a surface level, and both people have some fear or hesitancy about getting to a deeper level. When silence occurs, acknowledge and explore with your client the meaning of the silence. Dealing with demands from clients Clients may want to see you more often or for a longer period than you can provide. They may want to see you socially. Some clients may expect you to continually demonstrate how much you care or demand that you tell them what to do and how to solve a problem One way of heading off these demands is to make your expectations and boundaries clear during the initial counseling sessions or in the disclosure statement. Dealing with clients who lack commitment Involuntary clients may be required by a court order to obtain therapy, and you may be challenged in your attempt to establish a working relationship with them. It is possible to do effective work with mandated clients, but practitioners must begin by openly discussing the nature of the relationship. Counselors who omit preparation and do not address clients' thoughts and feelings about coming to counseling are likely to encounter resistance. It is critical that therapists not promise what they cannot or will not deliver. It is good practice to make clear the limits of confidentiality as well as any other factors that may affect the course of therapy. In working with involuntary clients, it is especially important to prepare them for the process; doing so can go a long way toward increasing their cooperation and involvement. Tolerating ambiguity Many beginning therapists experience the anxiety of not seeing immediate results Realize that oftentimes clients may seemingly "get worse" before they show therapeutic gains. Also, realize that the fruitful effects of the joint efforts of the therapist and the client may manifest themselves after the conclusion of therapy. Becoming aware of your countertransference Countertransference, defined broadly, includes any of our projections that influence the way we perceive and react to a client. This phenomenon occurs when we are triggered into emotional reactivity, when we respond defensively, or when we lose our ability to be present in a relationship because our own issues become involved. Recognizing the manifestations of our countertransference reactions is an essential step in becoming competent counselors. Unless we are aware of our own conflicts, needs, assets, and liabilities, we can use the therapy hour more for our own purposes than for being available to our clients Beginning counselors need to learn how to "let clients go" and not carry around their problems until the next session. If we become lost in clients' struggles and confusion, we cease being effective agents in helping them find solutions to their problems. If we accept responsibility for our clients' decisions, we are blocking rather than fostering their growth.  The emotionally intense relationships we develop with clients can be expected to tap into our own unresolved problem areas. Our clients' stories and pain are bound to have an impact on us. We will be affected by their stories and can express compassion and empathy. Our personal therapy can be instrumental in enabling us to recognize and manage our countertransference reactions. Developing a sense of humor It is important to recognize that laughter or humor does not mean that work is not being accomplished. There are times, of course, when laughter is used to cover up anxiety or to escape from the experience of facing threatening material. The therapist needs to distinguish between humor that distracts and humor that enhances the situation. Sharing responsibility with the client One mistake is to assume full responsibility for the direction and outcomes of therapy. This will lead to taking from your clients their rightful responsibility of making their own decisions. It could also increase the likelihood of your early burnout. Another mistake is for you to refuse to accept the responsibility for making accurate assessments and designing appropriate treatment plans for your clients. How responsibility will be shared should be addressed early in the course of counseling. It is your responsibility to discuss specific matters such as length and overall duration of the sessions, confidentiality, general goals, and methods used to achieve goals. It is not your role to assume responsibility for directing your clients' lives. Collaboratively designing contracts and homework assignments with your clients can be instrumental in your clients' increasingly finding direction within themselves. Declining to give advice Therapists help clients discover their own solutions and recognize their own freedom to act. Even if we, as therapists, were able to resolve clients' struggles for them, we would be fostering their dependence on us. They would continually need to seek our counsel for every new twist in their difficulties. Our task is to help clients make independent choices and accept the consequences of their choices. The habitual practice of giving advice does not work toward this end. Defining your role as a counsellor The central function of counseling is to help clients recognize their own strengths, discover what is preventing them from using their resources, and clarify what kind of life they want to live. Counselors provide support and warmth, yet care enough to challenge clients so that they will be able to take the actions necessary to bring about significant change. Maintaining Your Vitality as a Person and as a Professional It is of paramount importance that we take care of ourselves, for how can we take care of others if we are not taking care of ourselves. Become attuned to the subtle signs of burnout rather than waiting for a full-blown condition of emotional and physical exhaustion to set in. Self-monitoring is a crucial first step in self-care. If you make an honest inventory of how well you are taking care of yourself in specific domains, you will have a framework for deciding what you may want to change. As counseling professionals, we tend to be caring people who are good at taking care of others, but often we do not treat ourselves with the same level of care. If we neglect to care for ourselves, our clients will not be getting the best of us. If we are physically drained and psychologically depleted, we will not have much to give to those with whom we work. We cannot provide nourishment to our clients if we are not nourishing ourselves. To be able to commit to making a difference in the lives of clients, we must work to maintain our vitality. Discovering ways to consistently practice self-care is best viewed as an ongoing preventive activity. Ideally, our self-care should mirror the care we provide for others. Self-care is not a luxury; it is an ethical mandate. Therapeutic lifestyle changes (TLCs) offer significant therapeutic advantages such as enhancing health and well-being, and research and clinical evidence support the value of this practice. Some suggestions based on Walsh's list of therapeutic lifestyle changes follow for you to consider as specific ways to take care of yourself. Therapeutic lifestyle changes (TLCs) that promote wellness for individuals: Physical activity and exercise Nutrition and diet Time in nature Relationships Recreation Religious or spiritual involvement Service to others Common Factors Theory Factors other than the therapeutic approach / techniques are as or more important to the efficacy of treatment (ie: necessary and sufficient for change). These factors include: Therapeutic alliance Collaboratively set goal of treatment Therapist’s attitude toward the treatment and the client Client’s expectations Therapist feedback Client’s attribution of outcomes Some evidence suggests that the therapist-client relationship, or therapeutic alliance, is one of the primary forces of change Ethical Considerations in Psychotherapy Week 3 - September 16, 2024 Introduction Mandatory ethics involves a level of ethical functioning at the minimum level of professional practice. In contrast, aspirational ethics focuses on doing what is in the best interests of clients. Functioning at the aspirational level involves the highest standards of thinking and conduct. Aspirational practice requires counselors to do more than simply meet the letter of the ethics code. It entails understanding the spirit of the code and the principles on which the code is based. Fear-based ethics does not constitute sound ethical practice. Ethics is more than a list of things to avoid for fear of punishment Positive ethics is an approach taken by practitioners who want to do their best for clients rather than simply meet minimum ethical and legal standards to stay out of trouble. Transference is the redirection of feelings about a specific person onto someone else (in therapy, this refers to a client’s projection of their feelings about someone else onto their therapist). Countertransference is the redirection of a therapist’s feelings toward the client. What is Ethics Generally ethics is: A set of moral principles or values Guiding philosophy Principles guiding an individual or group Ethics is also the branch of philosophy that investigates both the content of moral judgments (ie: what is right and what is wrong) and their nature (ie: whether such judgments should be considered objective or subjective). Objective judgement is a universal opinion. For example, in the context of psychotherapy, you should not have an intimate relationship with a client Subjective judgement in opinion based. In the context of psychotherapy, should you accept a gift from a client? Everyone has different opinions Ethics can also be the principles of morally right conduct accepted by a person or a group or considered appropriate to a specific field. In psychological research, for example, proper ethics requires that participants be treated fairly and without harm and that investigators report results and findings honestly. Putting Clients' Needs Before Your Own As counselors we cannot always keep our personal needs completely separate from our relationships with clients. Ethically, it is essential that we become aware of our own needs, areas of unfinished business, potential personal problems, and especially our sources of countertransference. We need to realize how such factors could interfere with effectively and ethically serving our clients. Our professional relationships with our clients exist for their benefit. It takes considerable professional maturity to make an honest appraisal of how your behavior affects your clients. It is not unethical for us to meet our personal needs through our professional work, but it is essential that these needs be kept in perspective. An ethical problem exists when we meet our needs, in either obvious or subtle ways, at the expense of our clients' needs. It is crucial that we avoid exploiting or harming clients. As helping professionals, we must actively work toward expanding our self-awareness and learn to recognize our areas of prejudice and vulnerability. If we are aware of our personal problems and are willing to work through them, there is less chance that we will project them onto clients. If certain problem areas surface and old conflicts become reactivated, we have an ethical obligation to do whatever it takes to avoid harming our clients. Ethical Decision Making Professionals are expected to exercise prudent judgment when it comes to interpreting and applying ethical principles to specific situations. Although you are responsible for making ethical decisions, you do not have to do so alone. Consult with colleagues, keep yourself informed about laws affecting your practice, keep up to date in your specialty field, stay abreast of developments in ethical practice, reflect on the impact your values have on your practice, and be willing to engage in honest self-examination. You should also be aware of the consequences of practicing in ways that are not sanctioned by organizations of which you are a member or the state in which you are licensed to practice. The Role of Ethics Codes as a Catalyst for Improving Practice Professional codes of ethics serve a number of purposes. They educate counseling practitioners and the general public about the responsibilities of the profession. They provide a basis for accountability, and they protect clients from unethical practices. Ethics codes provide a basis for reflecting on and improving your professional practice. Being an ethical practitioner involves far more than following a list of rules. If we are too concerned with being sued, it is unlikely that we will be very creative or effective in our work. It makes sense to be aware of the legal aspects of practice and to know and practice risk-management strategies, but we should not lose sight of what is best for our clients. One of the best ways to prevent being sued for malpractice is to demonstrate respect for clients, keep client welfare as a central concern, and practice within the framework of professional codes. Ethics codes are best used as guidelines to formulate sound reasoning and serve practitioners in making the best judgments possible. The Right of Informed Consent Informed consent is an ethical and legal requirement that is an integral part of the therapeutic process. It also establishes a basic foundation for creating a working alliance and a collaborative partnership between the client and the therapist. Informed consent involves the right of clients to be informed about their therapy and to make autonomous decisions pertaining to it. Providing clients with information they need to make informed choices tends to promote the active cooperation of clients in their counseling plan. By educating your clients about their rights and responsibilities, you are both empowering them and building a trusting relationship with them. Some aspects of the informed consent process include the general goals of counseling, the responsibilities of the counselor toward the client, the responsibilities of clients, limitations of and exceptions to confidentiality, legal and ethical parameters that could define the relationship, the qualifications and background of the practitioner, the fees involved, the services the client can expect, and the approximate length of the therapeutic process. Other areas might include the benefits of counseling, the risks involved, and the possibility that the client's case will be discussed with the therapist's colleagues or supervisors. As a part of the informed consent process, it is wise to discuss the potential privacy problems of using a wide range of technology and to take preventive measures to protect both you and your clients. Educating the client begins with the initial counseling session, and this process will continue for the duration of counseling. The challenge of fulfilling the spirit of informed consent is to strike a balance between giving clients too much information and giving them too little. For example, it is too late to tell minors that you intend to consult with their parents after they have disclosed that they are considering an abortion. Young clients have a right to know about the limitations of confidentiality before they make such highly personal disclosures. Clients can be overwhelmed, however, if counselors go into too much detail initially about the interventions they are likely to make. It takes both intuition and skill for practitioners to strike a balance. Dimensions of Confidentiality Confidentiality and privileged communication are two related but somewhat different concepts. Both of these concepts are rooted in a client's right to privacy. Confidentiality is an ethical concept, and in most states it is the legal duty of therapists not to disclose information about a client. Privileged communication is a legal concept that protects clients from having their confidential communications revealed in court without their permission. These laws ensure that disclosures clients make in therapy will be protected from exposure by therapists in legal proceedings. Generally speaking, the legal concept of privileged communication does not apply to group counseling, couples counseling, family therapy, child and adolescent therapy, or whenever there are more than two people in the room. Confidentiality is central to developing a trusting and productive client-therapist relationship. Because no genuine therapy can occur unless clients trust in the privacy of their revelations to their therapists, professionals have the responsibility to define the degree of confidentiality that can be promised. Counselors have an ethical and legal responsibility to discuss the nature and purpose of confidentiality with their clients early in the counseling process. In addition, clients have a right to know that their therapist may be discussing certain details of the relationship with a supervisor or a colleague. Exceptions to Confidentiality and Privileged Communication In determining when to breach confidentiality, therapists must consider the requirements of the law, the institution in which they work, and the clientele they serve. Because these circumstances are frequently not clearly defined by accepted ethics codes, counselors must exercise professional judgment. Whenever counselors are not clear about their obligations regarding confidentiality or privileged communication, it is critical to seek consultation and to document these discussions. There is a legal requirement to break confidentiality in cases involving child abuse, abuse of the elderly, abuse of dependent adults, and danger to self or others. All mental health practitioners and interns need to be aware of their duty to report in these situations and to know the limitations of confidentiality. Here are some other circumstances in which information must legally be reported by counselors: When the therapist believes a client under the age of 16 is the victim of incest, rape, child abuse, or some other crime When the therapist determines that the client needs hospitalization When information is made an issue in a court action When clients request that their records be released to them or to a third party In general, the counselor's primary obligation is to protect client disclosures as a vital part of the therapeutic relationship. Informing clients about the limits of confidentiality does not necessarily inhibit successful counseling. Ethical Issues From a Multicultural Perspective Ethical practice requires that we take the client's cultural context into account in counseling practice. There is abundant evidence that supports the need to consider the culture of our clients and our cultural competence in our professional work, and not doing so can harm clients. Is Counseling Culture-Bound? Historically, therapists have relied on Western therapeutic models to guide their practice and to conceptualize problems that clients present in mental health settings. Western models of counseling have some limitations when applied to special populations and cultural groups such as Asian and Pacific Islanders, Latinx, Native Americans, and African Americans. Some of these approaches may not be applicable to clients from different racial, ethnic, and cultural backgrounds. Methods often need to be modified when working with clients from diverse cultural backgrounds. To the extent that counselors are focused on the values of the dominant culture and insensitive to variations among groups and individuals, they are at risk for practicing unethically. Counselors need to understand and accept clients who have a different set of assumptions about life, and they need to be alert to the possibility of imposing their own worldview. In working with clients from different cultural backgrounds and life experiences, it is important that counselors resist making value judgments for them. It is essential to be mindful of diversity and social justice issues if we are to practice ethically and effectively. Focusing on Both Individual and Environmental Factors Counselors who operate from a multicultural framework also have certain assumptions and a focus that guides their practice. They view individuals in the context of the family and the culture, and their aim is to facilitate social action that will lead to change within the client's community rather than merely increasing the individual's insight. Both multicultural practitioners and feminist therapists maintain that therapeutic practice will be effective only to the extent that interventions are tailored toward social action aimed at changing those factors that are creating the problems of clients rather than blaming them for their condition. It is necessary to focus on both individual and social factors if change is to occur. The Role of Assessment and Diagnosis in Counseling Assessment and diagnosis are integrally related to the practice of counseling and psychotherapy, and both are often viewed as a prerequisite for planning treatment. For some approaches, a comprehensive assessment of the client is the initial step in the therapeutic process. The rationale is that specific counseling goals cannot be formulated and appropriate treatment strategies cannot be designed until a client's past and present functioning is understood. Regardless of their theoretical orientation, therapists need to engage in assessment, which is generally an ongoing part of the therapeutic process. This assessment may be subject to revision as the clinician gathers additional data during therapy sessions. Some practitioners consider assessment as a part of the process that leads to a formal diagnosis. Assessment consists of evaluating the relevant factors in a client's life to identify themes for further exploration in the counseling process. Diagnosis, which is sometimes part of the assessment process, consists of identifying a specific mental disorder based on a pattern of symptoms. Both assessment and diagnosis can be understood as providing direction for the treatment process. The purpose of diagnosis in counseling and psychotherapy is to identify disruptions in a client's present behavior and lifestyle. Once problem areas are clearly identified, counselor and client are able to collaboratively establish the goals of the therapy process, and then a treatment plan can be tailored to the unique needs of the client. Therefore, diagnosis begins with the intake interview and continues throughout the duration of therapy. Some clinicians view diagnosis as central to the counseling process, but others view it as unnecessary, as a detriment, or as discriminatory against people of color. Considering Ethnic and Cultural Factors in Assessment and Diagnosis A danger of the diagnostic approach is the possible failure of counselors to consider ethnic and cultural factors in certain patterns of behavior. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) emphasizes the importance of being aware of unintentional bias and keeping an open mind to the presence of distinctive ethnic and cultural patterns that could influence the diagnostic process. It is crucial that clinicians consider cultural factors and how these may influence the client's current behaviors, feelings, thoughts, and symptom presentation. Certain behaviors and personality styles may be labeled neurotic or deviant simply because they are not characteristic of the dominant culture. Counselors who work with diverse client populations may erroneously conclude that a client is repressed, inhibited, passive, or unmotivated when in reality certain personality characteristics may be considered quite normal for a particular population. The DSM-5 deals with a variety of disorders pertaining to developmental stages, learning and cognition, trauma, personality, substance abuse, moods, anxiety, sex and gender identity, eating, sleep, impulse control, and adjustment. The DSM-5 is based on a medical model of mental illness that defines problems as residing with the individual rather than in society. Critics argue that DSM diagnoses do not adequately consider contextual, social, and cultural factors, which may play a significant role in the problems of clients. The DSM system tends to pathologize clients, perpetuating the oppression of clients from diverse groups. Counselors need to think carefully before rendering a diagnosis and take into consideration the realities of discrimination, oppression, and racism in society and in the mental health disciplines. Assessment and Diagnosis From Various Theoretical Perspectives The theory from which you operate will influence your thinking about the use of a diagnostic framework in your therapeutic practice. Progress, change, improvement, or success may be difficult to evaluate without an initial assessment. Counselors who base their practice on the relationship-oriented approaches tend to view the process of assessment and diagnosis as external to the immediacy of the client- counselor relationship and believe it may impede their understanding of the subjective world of the client. Feminist therapists contend that traditional diagnostic practices are often oppressive and that such practices are based on a White, male- centered, Western notion of mental health and mental illness. Both the feminist perspective and the postmodern approaches charge that these diagnoses ignore societal contexts. Therapists with a feminist, social constructionist, solution-focused, or narrative therapy orientation challenge many DSM-5 diagnoses. However, these practitioners do make assessments and draw conclusions about client problems and strengths. Regardless of your theoretical orientation, you will most likely be expected to work within the DSM framework if you are practicing in a community mental health agency or in any other agency in which insurance companies pay for psychological services. Commentary on Assessment and Diagnosis Most practitioners and many writers in the field consider assessment and diagnosis to be a continuing process that focuses on understanding the client. The collaborative perspective that involves the client as an active participant in the therapy process implies that both the therapist and the client are engaged in a search-and-discovery process from the first session to the last. Even though some practitioners may avoid formal diagnostic procedures and terminology, making tentative hypotheses and sharing them with clients throughout the process is a form of ongoing assessment and diagnosis. This perspective on assessment and diagnosis is consistent with the principles of feminist therapy, an approach that is critical of traditional diagnostic procedures. Ethical dilemmas may be created when diagnosis is done strictly for insurance purposes, which often entails arbitrarily assigning a client to a diagnostic classification. However, it is a clinical, legal, and ethical obligation of therapists to screen clients for life-threatening problems such as organic disorders, schizophrenia, bipolar disorder, and suicidal types of depression. It is useful to assess the whole person, which includes assessing dimensions of mind, body, and spirit. Therapists need to take biological processes into account as possible underlying factors of psychological symptoms and work closely with physicians when necessary. However, clients' values can be instrumental resources in the search for solutions to their problems, and spiritual and religious values often illuminate client concerns. Ethical Concerns with the Use of Technology Issues pertaining to confidentiality and privacy can become more complicated when technology is involved. Section H of the ACA Code of Ethics (American Counseling Association [ACA]) contains the standards with regard to the use of technology, relationships established through computer-mediated communication, and social media as a delivery platform. Ethical Aspects of Evidence-Based Practice Mental health practitioners are faced with the task of choosing the best interventions with a particular client. For many practitioners, this choice is based on their theoretical orientation. In recent years, however, a shift has occurred toward promoting the use of specific interventions for particular problems or diagnoses based on empirically supported treatments. This trend toward specific, empirically supported treatment is referred to as evidence-based practice (EBP). Three pillars of evidence-based practice (EBP): 1) Looking for the best available research 2) Relying on clinical expertise 3) Taking into consideration the client's characteristics, culture, and preferences Abundant psychotherapy research consistently reveals that the client, the therapist, their relationship, the therapist's personality and therapeutic style, the treatment method, and the context all contribute to treatment success or failure. The central aim of evidence-based practice is to require psychotherapists to base their practice on techniques that have empirical evidence to support their efficacy. The best outcomes in psychotherapy depend on concurrently using both evidence-based treatments and evidence-based relationships. In many mental health settings, clinicians are pressured to use interventions that are both brief and standardized. In such settings, treatments are operationalized by reliance on a treatment manual that identifies what is to be done in each therapy session and how many sessions will be required. Many practitioners believe this approach is mechanistic and does not take into full consideration the relational dimensions of the psychotherapy process and individual variability. Indeed, relying exclusively on standardized treatments for specific problems may raise another set of ethical concerns because the reliability and validity of these empirically based techniques is questionable. Not all clients come to therapy with clearly defined psychological disorders. Many clients have existential concerns that do not fit with any diagnostic category and do not lend themselves to clearly specified symptom-based outcomes. Evidence-based practice (EBP) may have something to offer mental health professionals who work with individuals with specific emotional, cognitive, and behavioral disorders, but it does not have a great deal to offer practitioners working with individuals who want to pursue more meaning and fulfillment in their lives. The overarching goal of evidence-based practice (EBP) is to enhance the effectiveness of client services and to improve public health, and they warn that mental health professionals need to take a proactive stance to make sure this goal is kept in focus. Managing Multiple Relationships in Counseling Practice Dual or multiple relationships, either sexual or nonsexual, occur when counselors assume two (or more) roles simultaneously or sequentially with a client. This may involve assuming more than one professional role or combining professional and nonprofessional roles. When clinicians blend their professional relationship with another kind of relationship with a client, ethical concerns must be considered. Many forms of nonprofessional interactions or nonsexual multiple relationships pose a challenge to practitioners. Some examples of nonsexual dual or multiple relationships are: Combining the roles of teacher and therapist or of supervisor and therapist Bartering for goods or therapeutic services Borrowing money from a client  Providing therapy to a friend, an employee, or a relative Engaging in a social relationship with a client Accepting an expensive gift from a client Going into a business venture with a client Some multiple relationships are clearly exploitative and do serious harm both to the client and to the professional. Sexual involvement with a former client is unwise, can be exploitative, and is generally considered unethical. Although sexual relationships in psychotherapy are never justified and are clearly harmful, nonsexual multiple relationships are complex and multidimensional, which makes simple and absolute solutions unrealistic. It is not always possible to play a single role in your work as a counselor, nor is it always desirable. You may have to deal with managing multiple roles, regardless of the setting in which you work or the client population you serve. The ACA Code of Ethics makes it clear that counseling professionals must learn how to manage multiple roles and responsibilities in an ethical way. This entails dealing effectively with the power differential that is inherent in counseling relationships and training relationships, balancing boundary issues, addressing nonprofessional relationships, and striving to avoid using power in ways that might cause harm to clients, students, or supervisees. Perspectives on Multiple Relationships Some of the problematic aspects of engaging in multiple relationships are that they: Are pervasive Can be difficult to recognize Are unavoidable at times Are potentially harmful, but not necessarily always harmful Can be beneficial Are the subject of conflicting advice from various experts Except for sexual intimacy with current clients, which is unequivocally unethical, there is not much consensus regarding the appropriate way to deal with multiple relationships. Some of the codes of the professional organizations advise against forming multiple relationships, mainly because of the potential for misusing power, exploiting the client, and impairing objectivity. When multiple relationships exploit clients, or have significant potential to harm clients, they are unethical. The ethics codes do not mandate avoidance of all such relationships, however; nor do the codes imply that nonsexual multiple relationships are unethical. Ways of Minimizing Risk In determining whether to proceed with a multiple relationship, it is critical to consider whether the potential benefit to the client of such a relationship outweighs its potential harm. Some relationships may have more potential benefits to clients than potential risks. It is your responsibility to develop safeguards aimed at reducing the potential for negative consequences. Some guidelines to minimizing risk: Set healthy boundaries early in the therapeutic relationship. Informed consent is essential from the beginning and throughout the therapy process. Involve clients in ongoing discussions and in the decision-making process, and document your discussions. Discuss with your clients what you expect of them and what they can expect of you. Consult with fellow professionals as a way to maintain objectivity and identify unanticipated difficulties. Realize that you don't need to make a decision alone. When multiple relationships are potentially problematic, or when the risk for harm is high, it is always wise to work under supervision. Document the nature of this supervision and any actions you take in your records. Self-monitoring is critical throughout the process. Ask yourself whose needs are being met and examine your motivations for considering becoming involved in a dual or multiple relationship. In working through a multiple relationship concern, it is best to begin by ascertaining whether such a relationship can be avoided. Multiple relationships cannot always be avoided, especially in small towns. Nor should every multiple relationship be considered unethical. Therapists should document precautions taken to protect clients when such relationships are unavoidable. Establishing Personal and Professional Boundaries Establishing and maintaining consistent yet flexible boundaries is necessary if you are to effectively counsel clients. Developing appropriate and effective boundaries in your counseling practice is the first step to learning how to manage multiple relationships. A boundary crossing is a departure from a commonly accepted practice that could potentially benefit a client. For example, attending the wedding of a client may be extending a boundary, but it could be beneficial for the client. In contrast, a boundary violation is a serious breach that harms the client and is therefore unethical. A boundary violation is a boundary crossing that takes the practitioner out of the professional role, generally involves exploitation, and results in harm to a client. Some boundary crossings pose no ethical problems and may enhance the counseling relationship. Other boundary crossings may lead to a pattern of blurred professional roles and become problematic. Social Media and Boundaries Multiple roles and relationships between clients and therapists are becoming increasingly common online. These multiple relationships include social, professional, and business relationships, and all of them present new challenges for a therapist. From an ethical perspective, it is critical to understand the nature of these multiple relationships, when they may become problematic, and when they are a part of the therapeutic process. Multiple relationships via social media and the Internet potentially have both positive and negative impacts. The challenge is for practitioners who participate in social media with clients to develop a social media policy. Practitioners will have to translate and maintain traditional ethics when it comes to social media and offers these recommendations: Include clear and thorough social networking policies as part of the informed consent process. Limit what is shared online. Regularly update protective settings because social media providers often change their privacy rules. To avoid inappropriate multiple relationships, Reamer (2021) recommends that practitioners create separate personal and professional social media and websites that establish clear boundaries. It is not unusual for a mental health professional to receive a "friend request" from a client or former client. A typical social media policy informs clients that their therapist cannot become their "friend" on social networking sites, explaining that it is of the utmost importance to maintain clear professional boundaries. Becoming an Ethical Counselor Knowing and following your profession's code of ethics is part of being an ethical practitioner, but these codes do not make decisions for you. As you become involved in counseling, you will find that interpreting the ethical guidelines of your professional organization and applying them to particular situations demand the utmost ethical sensitivity. Even responsible practitioners differ over how to apply established ethical principles to specific situations. In your professional work, you will deal with questions that do not always have obvious answers. You will have to assume responsibility for deciding how to act in ways that will further the best interests of your clients. Throughout your professional life, seek consultation from trusted colleagues and supervisors whenever you face an ethical dilemma. Ethical decision making is an evolutionary process that requires you to be continually open and self-reflective. Becoming an ethical practitioner is not a final destination but a journey that will continue throughout your career. Little Albert Study One of the main studies in behaviorism. Anxiety disorders are prominent in therapy and much of what we know on how to support those people come from studies like this and other behaviorism experiments. The outcome of John Watson's Little Albert experiment was that classical conditioning is possible in humans, since the boy learned to associate a neutral stimulus (white rat) with a fearful stimulus (loud bang) to be scared of the white rat. Watson wanted to see if they can condition an emotion (fear) can someone become fearful of a previous non-fearful object. But they didn’t recondition to counteract conditioned fear (getting rid of the conditioned fear) This demonstrates that much of the knowledge that we have about psychology and the studies provided most likely wouldn’t have been ethically passed today. It also shows that informed consent is crucial – both in psychotherapy and in studies (telling people the full story of what to expect) Learned Helplessness Learned helplessness is when you feel like there is nothing you can do so you don’t try to change your circumstances. Martin Seligman, an American psychologist, developed his Learned Helplessness Theory with a classical conditioning experiment using dogs. The conditioned dogs learned to accept their fate and do not do anything to try and change the situation, even when a solution was easily accessible. Regulatory Hierarchy When deciding what these guidelines are and when you have an ethical dilemma and trying to figure out what to do, there are a set of ethical laws (acts / law, regulations, standards, and code of ethics). This is in a hierarchy that shows the steps you need to take into knowing what is considered ethical. Acts / laws ○ Regulated Health Professions Act, 1991 ○ Psychotherapy Act, 2007 ○ Psychology and Applied Behaviour Analysis Act, 2021 Regulations ○ Psychology and Applied Behaviour Analysis Act, 2021 ○ O. Reg. 195/23: Professional Misconduct Standards ○ College of Psychologists and Behaviour Analysts of Ontario Standards of Professional Conduct Code of ethics ○ The Canadian Code of Ethics for Psychologists Acts & Laws Some of the relevant laws that define psychotherapy include: Regulated Health Professions Act, 1991 ○ One of the main laws that defines any health professional  ○ Identifies individuals who are members of the following professions can use the title “psychotherapist” and conduct psychotherapy: Psychology Psychotherapy Social work Nursing Occupational therapy Physician / surgeon Psychotherapy Act, 2007 ○ Law that defines what psychotherapists can do ○ The practice of psychotherapy is the assessment and treatment of cognitive, emotional or behavioural disturbances by psychotherapeutic means, delivered through a therapeutic relationship based primarily on verbal or non-verbal communication. ○ In the course of engaging in the practice of psychotherapy, a member is authorized, subject to the terms, conditions and limitations imposed on their certificate of registration, to treat, by means of psychotherapy technique delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgement, insight, behaviour, communication or social functioning Psychology and Applied Behaviour Analysis Act, 2021 ○ Defines what psychologists are allowed to do ○ The practice of psychology is the assessment of behavioural and mental conditions, the diagnosis of neuropsychological disorders and dysfunctions and psychotic, neurotic and personality disorders and dysfunctions, the prevention and treatment of behavioural and mental disorders and dysfunctions and the maintenance and enhancement of physical, intellectual, emotional, social and interpersonal functioning ○ The practice of applied behaviour analysis is the assessment of covert and overt behaviour and its functions through direct observation and measurement, and the design, implementation, delivery and evaluation of interventions derived from the principles of behaviour in order to produce meaningful improvements ○ Assessment, prevention and treatment, and enhancement (making life better) are the most important parts of what psychotherapists do College of Registered Psychotherapists of Ontario Regulates registrants in service of public interest as per the Psychotherapy Act, 2007 and the Regulated Health Professions Act, 1991 (https://www.crpo.ca/legislation-by-laws/z) For more information visit: https://www.crpo.ca/wp-content/uploads/2018/10/CATG-Psychotherapy-With-a-RP.pdf Psychology and Applied Behaviour Analysis Act Defines “authorized acts,” including communicating a diagnosis and psychotherapy To communicate a diagnosis identifying, as the cause of a person’s symptoms, a neuropsychological disorder or psychologically based psychotic, neurotic or personality disorder.” To treat, by means of psychotherapy technique delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgement, insight, behaviour, communication or social functioning.” Defines restricted titles, including “psychologist,” “psychological associate,” and “behaviour analyst”. Restricted titles means you cannot use these titles unless you are with the governing body that uses those titles (ie: CRPO can only use the term psychologists and people outside the CRPO cannot use this title). It is important for these titles to be restricted so that those who qualify use them and people seeking services know the type of support they are receiving due to the governing body. Some disorders have more stigma, and a challenge to determine best methods to support without causes more harm due to stereotypes and stigma. For example, in personality disorders people don’t view it as a disorder but as part of them. Therefore it is difficult to get the idea of the support across to them. Regulations Regulations under the acts / laws: Regulations under the Psychology and Applied Behaviour Analysis Act ○ Registration Types of certificates and how they are obtained ○ General Self-assessment and continuing education  ○ Professional Misconduct Failing to maintain the standards of the profession Failure to obtain consent Abuse of a client Conflict of interest Improper use of protected titles Improper record-keeping Improper business practices Standards The College of Psychologists and Behaviour Analysts of Ontario (CPBAO) - Standards of Professional Conduct was developed as rules of profession. These rules include: 1) Acceptance of regulatory authority of the college 2) Protecting rights and meeting needs of service recipients 3) Equity, diversity, and inclusion 4) Supervision 5) Competence 6) Representation of services 7) Consent to services 8) Privacy and confidentiality 9) Records and record keeping 10) Assessment and intervention 11) Opinions 12) Objectivity 13) Impairment  14) Harassment, abusive and sexually inappropriate relationships 15) Financial matters 16) Cross-jurisdictional practice 17) Use of technology in the provision of psychological services Non-compliance to these rules is deemed as an act of professional misconduct. CPBAO Standards of Professional Conduct Important things to know about the CPBAO: Point 3) Equity, diversity, and inclusion Demonstrating respect and dignity toward all individuals in all aspects of practice Seeking consultation and personal training when working with individuals whose cultural background one is not sufficiently familiar with Point 5) Competence Have to apply to areas you are competent in and prove you are competent in them Must practice within authorized areas of practice (ie: clinical psychology, health psychology) and client populations (ie: adults, couples) Supervision / guidance and training required when expanding areas of practice Point 7) Consent to services Informed consent must: ○ Be related to and explain the treatment / service / research ○ Be given voluntarily ○ Be given by someone who is capable of consenting ○ Not be obtained through fraud or misrepresentation of information ○ Contain information regarding risks, benefits, alternate courses of action, potential consequences of not receiving treatment ○ Provide an opportunity for the client to ask questions / seek clarification ○ Continues throughout treatment  People need to be capable of providing consent, but there is not an age that tells you what this age is. The age is up to the professional if they feel that the client is capable to apply consent ○ Do they understand what the treatment is, why it is being recommended, what will happen if they do or don’t do the treatment? Point 8) Privacy and confidentiality The best time to mention confidentiality is at the beginning when you talk about clients rights. Do this before you start treatment to tell them the limits of confide Explaining the limits of confidentiality ○ Harm to self or others ○ Child abuse - Child and Family Services Act ○ Sexual abuse by a health professional - Regulated Health Professions Act ○ Abuse of residents in long-term care and retirement homes - Long-Term Homes Care Act and Retirement Homes Act ○ Legal proceedings - ie: court order ○ CPBAO auditing of record keeping ○ Missing persons - Missing Persons Act Point 10) Assessment and intervention Use of appropriate, up-to-date tests (ie: valid, reliable, standardized) Awareness of test norms and who they are applicable for Adherence to evidence-based practice ○ Registrants must be familiar with evidence-based tools and techniques. If they choose not to use such tools or techniques, they must be able to justify their decision and demonstrate competence in the tools and techniques they use ○ When evidence-based tools and techniques are not available or suitable, then registrants must evaluate and use any new or emerging tools or techniques with caution, ensuring safety to recipients  ○ Recipients of all services must be informed about the potential risks, benefits and alternative options Point 12) Professional objectivity Registrants must not undertake or continue to provide services where objectivity, competence or effectiveness is, or may reasonably be perceived as, compromised by bias or conflict of interest Avoiding dual / multiple relationships Avoiding influence on and exploitation of clients Not accepting gifts beyond “token value” Point 14) Harassment, abusive and sexually inappropriate relationships Registrants must not enter, or make plans to enter, into an intimate or sexual relationship with a current or past service recipient or a close relative of the service recipient, unless at least five years has passed since the last professional contact, and it can be demonstrated that the individual is not vulnerable and will not be reasonably expected to require additional services from the registrant Avoiding non-sexual intimacy Not engaging in any form of harassment – sexual, verbal, physical American Psychological Association Statement on Evidence-Based Practice Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences. This connects to point 10) Assessment and intervention on the CPBAO. We still have a long way to go with the type of research that we do. Behavioral health practice (here abbreviated behavioral practice) is a multidisciplinary field that promotes optimal mental and physical health by maximizing biopsychosocial functioning. Evidence-based behavioral practice entails making decisions about how to promote healthful behaviors by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected. This is done in a manner that is compatible with the environmental and organizational context. Evidence is comprised of research findings derived from the systematic collection of data through observation and experiment and the formulation of questions and testing of hypotheses. The diagram below shows three circles containing the elements that need to be integrated in EBBP. The diagram above may make it appear that integration of the three spheres involved in evidence-based practice could occur simultaneously, but that is not the case. There are five clearly defined steps in EBBP. Using an iterative, cyclical process, the practical outcomes of intervention decisions are then used to develop and/or refine local decision-making policies, generate new questions, inform future searches for best evidence, and/or identify needed research. https://ebbp.org/ebbp/definition Spring, B. & Hitchcock, K. (2009) Evidence-based practice in psychology. In I.B. Weiner & W.E. Craighead(Eds.) Corsini’s Encyclopedia of Psychology, 4th edition (pp. 603-607). New York:Wiley Steps of Evidence-Based Practice The evidence based practice process has five steps: 1) ASK important