Week 2

ETHICS

The core concern in any discussion of dual relationships is the possibility of abuse of power and exploitation of the client. The therapist must always guard against abusing their position of power as a platform for meeting the therapist’s personal needs, whether it be the therapist’s needs for emotional support, friendship, financial stability, or sexual gratification. The therapy relationship should always remain single-mindedly focused on meeting the client’s needs and helping the client to achieve goals in therapy.

Therapists must remain aware of their own personal needs and how they are being met in their lives, ensuring that a client is never being exploited to meet the therapist's need. Most often, exploitation is not sexual, but rather may be emotional, such as allowing a client to be a source of emotional support for the therapist in one way or another. Another example of exploitation of a client is a therapist choosing to continue to work with a client despite knowing that the client's issues are outside of the therapist's areas of expertise and competence, due to concerns about loss of income if the therapist were to refer the client out to a more specialized therapist. The client deserves to have their needs met by the most equipped provider, a a therapist must be honest about the limitations of his/her own areas of competence, experience, and training.

Informed consent refers to the right of clients to be fully informed about the nature of the therapeutic process, about their rights in the therapy process, their responsibilities (payment, cancellations, participation in setting goals, honest self-disclosure, etc.) the counselor’s responsibilities and ethical duties, the boundaries of the therapeutic relationship, the potential benefits and costs of engaging in therapy, and the limits to confidentiality.

Part of the purpose of informed consent is to invite the client into a role in which they feel empowered to make informed decisions on their own behalf, and in which they have a right to ask questions, provide feedback, and be an active participant in choosing the course and goals of their own therapy. Establishment of goals for therapy should be a collaborative process between the client and the therapist. Client who are active in setting their own goals in therapy are more likely to stay engaged and committed to the process.

*Confidentiality in the therapeutic context refers to the ethical duty of therapist to maintain protection of their clients disclosures.

*Therapist must breach confidentiality in the following circumstances: 1) when a client is an imminent danger to themselves or others 2) in the case of abuse of a child, abuse of elderly, or abuse of dependent adult.

3) when the therapist is court ordered to release information, and in this case only the minimal information required by the court order should be released

4) when the client or parent of a client has signed an authorization specifically requesting for specific information to be released for a specific purpose (i.e., to allow for consultation between professionals).

5) In the case of minor clients, parents consent to treatment and parents are the holders of privilege, meaning that parents have rights to all information shared with therapist. It is important to discuss these issues with the minor client and to make sure that they do have an age appropriate understanding of the nature of the therapeutic relationship and therapy process. Remember that confidentiality is not just the clients' right but also the therapist's ethical duty to protect the client's privileged information. A therapist who does not protect their clients' confidentiality is violating their ethical duties. Also note that when a client is a grave and imminent danger to self or others, the therapist must seek hospitalization or emergency services for the client, and if the client is a clear and imminent danger to another specific person or group, then the therapist has a duty to notify police or the intended victim of harm.

EXISTENTIAL THERAPY

Existential therapy views human as unique in their capacity for self-reflection and self- awareness, which provides each of us with the ability to exercise freedom to chose how we will live and what values we will embrace. With this freedom to chose our lives, comes anxiety which is an inevitable feature of human existence. Anxiety must be accepted and experienced, rather than avoided. The goal of existential therapy is to guide the client in discovering and creating a life that has meaning and purpose. This requires the client to choose the values that will guide their life and to make decision about the direction of their lives even in the face of anxiety and uncertainty. Life is viewed as an adventure in which the client has the freedom to chose their path and direct their own journey. In the existential approach, the quality of the therapist-client relationship, in terms of depth, openness, genuineness, and honesty is valued over any specific technique.

GESTALT

Gestalt therapy stems from the existential framework and was founded by Federick Perls and Walter Kempler. The focus is on the “here and now”, the current choices, decisions, and behaviors of the present, rather than a focus on the past. Intellectual insight into the origins of ones’ problems is considered unnecessary in this model. Primary goals of Gestalt family therapy are active /honest self-disclosure and open communication. Self-awareness (knowing and accepting oneself), including awareness and openness to one’s emotional experiences, and awareness of the mind-body connection are additional goals of this form of therapy. Becoming “whole” or integrating/ resolving conflicting emotions within oneself is a primary objective. According to this model, clients need to develop awareness of what they do, how they act, and clients learn to take responsibility for these actions/choices. Strengths of this approach include use of creative techniques which allow clients to access their emotional experiences in the here and now, and the respect given to the client as an expert in their own lives.

Weakness include the lack of attention given to cognition and intellectual insight, as well as lack of attention to past experiences.

Remember that one primary objective of this form of therapy is to guide the client in becoming "whole" or integrating disconnecting parts of their sense of self. Much of this occurs through helping the client to become connected to their own emotions and internal experience. Also note that the focus is on the present or here-and now, rather than the past or future.

PERSON CENTERED The person centered approach is grounded in the work of Carl Rogers. Rogers viewed humans as being inherently driven to strive to achieve their fullest potential. In order to move along a pathway of self-actualization, one must experience unconditional positive regard from others. Without this, the individual experiences conditions of worth, and will cut off or reject parts of self that are not valued by others. For example, if I feel jealous of my sister, and I am scolded by my parents for my feelings of jealously, I will consciously reject that part of my experience, and will then have in-congruency between my true experience and my sense of self, which thwarts self-actualization. On the other hand, if my feelings of jealousy are met with empathy and understanding, I will be able to maintain congruency or "wholeness" in my sense of self. This can then be internalized to positive self-regard, and will lead to self-actualizing tendencies. The person centered approach seeks to facilitate this congruency or wholeness though providing unconditional positive regard in the therapeutic relationship.

Motivational Interviewing is an extension of the person centered approach and was originally designed by William Miller to address problem drinking. Motivational Interviewing (MI) embraces the key features of a person centered approach in focusing on empathy, reflective listening, positive regard, and a belief in each person’s inherent potential for growth. The goals of MI include reducing client’s ambivalence or mixed feelings about making behavioral changes and gently guiding the client towards setting goals for change within their own lives. Note that MI is non-confrontational and emphasizes acceptance of and respect for the client’s perspective, feelings, and goals. The therapist never pushes his or her own goals onto the client. Note that one key intervention in MI is for the therapist to selectively attend to and highlight any statements made by the client that suggest consideration of behavioral change or even just unhappiness with the status quo. The use of reflective listening is central to this approach, and the therapist uses reflective listening to act as human highlighter for the client, drawing his or her attention to his/her own statements that indicate a desire for change. Motivational Interviewing components/goals include

(1)Express empathy through reflective listening. (2) highlight discrepancy between clients' goals or values and their current behavior.

(3) Avoid argument and direct confrontation. (4)Adjust to client resistance rather than opposing it directly. (5)Support self-efficacy and optimism.

CBT

CBT views thoughts, feelings, and behaviors as being closely linked. Depression and Anxiety are viewed within a framework that breaks down the symptoms into a 5 part model: thoughts, feelings, physical sensations or physical experiences, behavioral reactions, and the environment. Intervention focus on changing either automatic thoughts, or problematic patterns of behavior. To treat depression, thought records are often used to help clients to identify automatic thoughts in relation to specific situations and to help them explore the evidence both for and against these automatic thoughts. In doing so, the client is able to arrive at a more balanced and less negative perspective of themselves, others, or the future. Also, depression is treated through behavioral activation in which the client learns to schedule into their day activities and experiences that will enhance their mood state. Clients learn to follow their schedule rather than their feeling state, as our depressed mood state will often guide us to withdraw and disengage from life. In the case of anxiety, exposure therapy is used to empower clients to feel capable of managing anxiety in response to specific situations or thoughts. Exposure therapy involves therapist-supported process of gradually and repeatedly facing situations, things, or ideas that cause marked distress for the client. Note that in exposure therapy, the client is NOT encouraged to use relaxation techniques to avoid experiencing anxiety, rather the person learns to tolerate the anxiety during exposure therapy and learns that 1) anxiety is not harmful, just uncomfortable, 2) anxiety fades on its own if you stay in the situation long enough or repeat your exposure often enough. The client will usually have the therapist immediate support in facing the anxiety producing situations initially, and will repeat exposures on their own for “homework” or practice. The client will gradually progress through a “hierarchy” of feared situations, people, places, things, thoughts. Exposure therapy helps clients to let go of unhealthy avoidance behaviors, safety behaviors, and rituals that may be keeping them stuck and limiting their freedom. Exposure therapy is highly effective in resolving anxiety symptoms, but many clients are fearful of engaging in it. This is why the quality of the therapist-client is so very important. CBT focuses on creating a warm, collaborative therapist-client relationship that is not authoritative and that gently invites clients to explore their thoughts, “experiment” with new ways of acting/coping. Collaboration and socratic methods are important in CBT.

POST MODERN THERAPIES

SFBT Solution focused therapy is by nature brief and focuses only on solving the client’s presenting problem. This approach does not include assessment of causes of the presenting problem, but rather is future-focused with the goal of helping the client to envision the future that they desire. The Miracle question poses to the client the following scenario: “If a miracle occurred last night and your problem was solved, how would you know it was solved? what would be different? “ This question opens the client up to future possibilities, which often allows the client to discover potential solutions.

The underlying assumption is that clients possesses the tools and the ability to find their own solutions to their problems, they just need guidance to discover these options for themselves. In this therapy, we look for “exceptions” or times in their life when the problem did not exist or was minimal. What was different in their life when the problem did not exist or did not bother them? One weakness to this approach is that only the presented problem is addressed, while underlying or contributing issues may remain unresolved, which could lead to emergence of additional problems due to the root cause not being addressed. Strengths include the short duration of treatment and emphasis on future-focused active solutions.

ETHICS

The core concern in any discussion of dual relationships is the possibility of abuse of power and exploitation of the client. The therapist must always guard against abusing their position of power as a platform for meeting the therapist’s personal needs, whether it be the therapist’s needs for emotional support, friendship, financial stability, or sexual gratification. The therapy relationship should always remain single-mindedly focused on meeting the client’s needs and helping the client to achieve goals in therapy.

Therapists must remain aware of their own personal needs and how they are being met in their lives, ensuring that a client is never being exploited to meet the therapist's need. Most often, exploitation is not sexual, but rather may be emotional, such as allowing a client to be a source of emotional support for the therapist in one way or another. Another example of exploitation of a client is a therapist choosing to continue to work with a client despite knowing that the client's issues are outside of the therapist's areas of expertise and competence, due to concerns about loss of income if the therapist were to refer the client out to a more specialized therapist. The client deserves to have their needs met by the most equipped provider, a a therapist must be honest about the limitations of his/her own areas of competence, experience, and training.

Informed consent refers to the right of clients to be fully informed about the nature of the therapeutic process, about their rights in the therapy process, their responsibilities (payment, cancellations, participation in setting goals, honest self-disclosure, etc.) the counselor’s responsibilities and ethical duties, the boundaries of the therapeutic relationship, the potential benefits and costs of engaging in therapy, and the limits to confidentiality.

Part of the purpose of informed consent is to invite the client into a role in which they feel empowered to make informed decisions on their own behalf, and in which they have a right to ask questions, provide feedback, and be an active participant in choosing the course and goals of their own therapy. Establishment of goals for therapy should be a collaborative process between the client and the therapist. Client who are active in setting their own goals in therapy are more likely to stay engaged and committed to the process.

*Confidentiality in the therapeutic context refers to the ethical duty of therapist to maintain protection of their clients disclosures.

*Therapist must breach confidentiality in the following circumstances: 1) when a client is an imminent danger to themselves or others 2) in the case of abuse of a child, abuse of elderly, or abuse of dependent adult.

3) when the therapist is court ordered to release information, and in this case only the minimal information required by the court order should be released

4) when the client or parent of a client has signed an authorization specifically requesting for specific information to be released for a specific purpose (i.e., to allow for consultation between professionals).

5) In the case of minor clients, parents consent to treatment and parents are the holders of privilege, meaning that parents have rights to all information shared with therapist. It is important to discuss these issues with the minor client and to make sure that they do have an age appropriate understanding of the nature of the therapeutic relationship and therapy process. Remember that confidentiality is not just the clients' right but also the therapist's ethical duty to protect the client's privileged information. A therapist who does not protect their clients' confidentiality is violating their ethical duties. Also note that when a client is a grave and imminent danger to self or others, the therapist must seek hospitalization or emergency services for the client, and if the client is a clear and imminent danger to another specific person or group, then the therapist has a duty to notify police or the intended victim of harm.

EXISTENTIAL THERAPY

Existential therapy views human as unique in their capacity for self-reflection and self- awareness, which provides each of us with the ability to exercise freedom to chose how we will live and what values we will embrace. With this freedom to chose our lives, comes anxiety which is an inevitable feature of human existence. Anxiety must be accepted and experienced, rather than avoided. The goal of existential therapy is to guide the client in discovering and creating a life that has meaning and purpose. This requires the client to choose the values that will guide their life and to make decision about the direction of their lives even in the face of anxiety and uncertainty. Life is viewed as an adventure in which the client has the freedom to chose their path and direct their own journey. In the existential approach, the quality of the therapist-client relationship, in terms of depth, openness, genuineness, and honesty is valued over any specific technique.

GESTALT

Gestalt therapy stems from the existential framework and was founded by Federick Perls and Walter Kempler. The focus is on the “here and now”, the current choices, decisions, and behaviors of the present, rather than a focus on the past. Intellectual insight into the origins of ones’ problems is considered unnecessary in this model. Primary goals of Gestalt family therapy are active /honest self-disclosure and open communication. Self-awareness (knowing and accepting oneself), including awareness and openness to one’s emotional experiences, and awareness of the mind-body connection are additional goals of this form of therapy. Becoming “whole” or integrating/ resolving conflicting emotions within oneself is a primary objective. According to this model, clients need to develop awareness of what they do, how they act, and clients learn to take responsibility for these actions/choices. Strengths of this approach include use of creative techniques which allow clients to access their emotional experiences in the here and now, and the respect given to the client as an expert in their own lives.

Weakness include the lack of attention given to cognition and intellectual insight, as well as lack of attention to past experiences.

Remember that one primary objective of this form of therapy is to guide the client in becoming "whole" or integrating disconnecting parts of their sense of self. Much of this occurs through helping the client to become connected to their own emotions and internal experience. Also note that the focus is on the present or here-and now, rather than the past or future.

PERSON CENTERED The person centered approach is grounded in the work of Carl Rogers. Rogers viewed humans as being inherently driven to strive to achieve their fullest potential. In order to move along a pathway of self-actualization, one must experience unconditional positive regard from others. Without this, the individual experiences conditions of worth, and will cut off or reject parts of self that are not valued by others. For example, if I feel jealous of my sister, and I am scolded by my parents for my feelings of jealously, I will consciously reject that part of my experience, and will then have in-congruency between my true experience and my sense of self, which thwarts self-actualization. On the other hand, if my feelings of jealousy are met with empathy and understanding, I will be able to maintain congruency or "wholeness" in my sense of self. This can then be internalized to positive self-regard, and will lead to self-actualizing tendencies. The person centered approach seeks to facilitate this congruency or wholeness though providing unconditional positive regard in the therapeutic relationship.

Motivational Interviewing is an extension of the person centered approach and was originally designed by William Miller to address problem drinking. Motivational Interviewing (MI) embraces the key features of a person centered approach in focusing on empathy, reflective listening, positive regard, and a belief in each person’s inherent potential for growth. The goals of MI include reducing client’s ambivalence or mixed feelings about making behavioral changes and gently guiding the client towards setting goals for change within their own lives. Note that MI is non-confrontational and emphasizes acceptance of and respect for the client’s perspective, feelings, and goals. The therapist never pushes his or her own goals onto the client. Note that one key intervention in MI is for the therapist to selectively attend to and highlight any statements made by the client that suggest consideration of behavioral change or even just unhappiness with the status quo. The use of reflective listening is central to this approach, and the therapist uses reflective listening to act as human highlighter for the client, drawing his or her attention to his/her own statements that indicate a desire for change. Motivational Interviewing components/goals include

(1)Express empathy through reflective listening. (2) highlight discrepancy between clients' goals or values and their current behavior.

(3) Avoid argument and direct confrontation. (4)Adjust to client resistance rather than opposing it directly. (5)Support self-efficacy and optimism.

CBT

CBT views thoughts, feelings, and behaviors as being closely linked. Depression and Anxiety are viewed within a framework that breaks down the symptoms into a 5 part model: thoughts, feelings, physical sensations or physical experiences, behavioral reactions, and the environment. Intervention focus on changing either automatic thoughts, or problematic patterns of behavior. To treat depression, thought records are often used to help clients to identify automatic thoughts in relation to specific situations and to help them explore the evidence both for and against these automatic thoughts. In doing so, the client is able to arrive at a more balanced and less negative perspective of themselves, others, or the future. Also, depression is treated through behavioral activation in which the client learns to schedule into their day activities and experiences that will enhance their mood state. Clients learn to follow their schedule rather than their feeling state, as our depressed mood state will often guide us to withdraw and disengage from life. In the case of anxiety, exposure therapy is used to empower clients to feel capable of managing anxiety in response to specific situations or thoughts. Exposure therapy involves therapist-supported process of gradually and repeatedly facing situations, things, or ideas that cause marked distress for the client. Note that in exposure therapy, the client is NOT encouraged to use relaxation techniques to avoid experiencing anxiety, rather the person learns to tolerate the anxiety during exposure therapy and learns that 1) anxiety is not harmful, just uncomfortable, 2) anxiety fades on its own if you stay in the situation long enough or repeat your exposure often enough. The client will usually have the therapist immediate support in facing the anxiety producing situations initially, and will repeat exposures on their own for “homework” or practice. The client will gradually progress through a “hierarchy” of feared situations, people, places, things, thoughts. Exposure therapy helps clients to let go of unhealthy avoidance behaviors, safety behaviors, and rituals that may be keeping them stuck and limiting their freedom. Exposure therapy is highly effective in resolving anxiety symptoms, but many clients are fearful of engaging in it. This is why the quality of the therapist-client is so very important. CBT focuses on creating a warm, collaborative therapist-client relationship that is not authoritative and that gently invites clients to explore their thoughts, “experiment” with new ways of acting/coping. Collaboration and socratic methods are important in CBT.

POST MODERN THERAPIES

SFBT Solution focused therapy is by nature brief and focuses only on solving the client’s presenting problem. This approach does not include assessment of causes of the presenting problem, but rather is future-focused with the goal of helping the client to envision the future that they desire. The Miracle question poses to the client the following scenario: “If a miracle occurred last night and your problem was solved, how would you know it was solved? what would be different? “ This question opens the client up to future possibilities, which often allows the client to discover potential solutions.

The underlying assumption is that clients possesses the tools and the ability to find their own solutions to their problems, they just need guidance to discover these options for themselves. In this therapy, we look for “exceptions” or times in their life when the problem did not exist or was minimal. What was different in their life when the problem did not exist or did not bother them? One weakness to this approach is that only the presented problem is addressed, while underlying or contributing issues may remain unresolved, which could lead to emergence of additional problems due to the root cause not being addressed. Strengths include the short duration of treatment and emphasis on future-focused active solutions.