Laws and Ethics Course > Chapter 4 - Having a clinical self-awareness and counter-transference issues

Chapter 4: Having a clinical self-awareness and counter-transference issues

Practitioners need to have awareness if the goals of the client are uncomfortable to the practitioner for reasons of differing value systems.It is doubtful that practitioners will ever have identical value systems to those of their clients, so it is important to maintain a self awareness regarding how your values may impact the different stages of treatment.

"Certainly it is reasonable to assume that therapists who are upwardly mobile, socially marginal, non religious, divorced, and politically liberal will see social and moral issues differently from more socially integrated and conventional persons, and they will communicate quite different judgments. Because therapists' personalities and orientations are important aspects of therapy, and because psychotherapy is largely an influence process, the encounter inevitable involves the transmission of values.Therapists may wish to minimize personal biases, however, they cannot help but transmit what they stand for." (Mechanic, 1989)

Indeed, we certainly all have values.It is doubtful that we would have become healthcare professionals if we did not have a very strong belief system based on some closely held values regarding helping people.We must be aware of the counter-transference issues of those who see things differently, behave differently, or express themselves differently than what we are comfortable with.We are all influenced by where we grew up, our socio-culture context, our experiences, and even by the agency cultures we work in and the school of training we attended.We may not be conscious of our own ideologies and orientations because they are so much a part of how we view the world.We must be careful with these values that we hold so dear that we do not go against the client's wishes, because they conflict with our own, or be careful that we automatically have a greater knowledge than the clients about what is best for them. (Mechanic, 1989)

When treating a client, issues of counter-transference (personal feelings and thoughts we have towards a client) will often exist.When these go unchecked, they can have a harmful effect on the therapeutic process.These feelings may come up the most strongly when somebody we treat resembles a person from our past in looks, mannerisms, behaviors, or opinions.These feelings can either be of fondness, as the client reminds us of a person we have good feelings for, or they can go to the other extreme, creating feelings in us of severe anger or fear.Maintaining a healthy self-awareness regarding counter-transference issues and obtaining consultation when needed are appropriate ways to make sure that these feelings do not infringe on treatment.

The following scenario can help increase awareness of our value systems.This exercise, which is most enjoyable and effective when done as a group catalyst or a staff training, highlights how different cultures and upbringings cause people to make different judgments about the same circumstances.The activity is accomplished by passing out the story to each participant, have them rank the characters in the story, and then discuss why they ranked them as they did.Feel free to do it yourself:

A Case Study, Author Unknown:

The Girl, the Old Man, and the Sailor...

On a beautiful and sunny day five people boarded a boat for an afternoon cruise: A girl, her fiance, her fiance's best friend, an old man, and a sailor.A sudden storm blew in sinking the boat.The five passengers were forced into two smaller boats to survive.In one boat was the girl, the old man, and the sailor.In the other boat was the girl's fiance and his best friend.

The boats were separated in the swirl of the storm.The boat with the girl, the old man and the sailor ended up on one island and the boat with the fiance and his best friend on another island.The girl was distraught being away from her fiance and kept searching the horizon looking for him.They knew there was another island nearby but the boat would need to be fixed to get to it.She went to the sailor and asked him to fix the boat so she could be reunited with her fiance.The sailor agreed to fix the boat but only on the condition the girl sleep with him that night.

The girl did not know what to do so she went to the old man for advice.The old man listened to her and then said, "I cannot tell you what you should do.Follow what your heart tells you."Confused and desperate she agreed to the sailor's condition.

After the sailor fixed the boat they sailed and reached the other island.The girl was very happy to see her fiance and rushed into his arms.He was very happy to see her and she then told him about sleeping with the sailor to get there.The fiance became very angry and brushed her aside saying, "I never want to see you again." Crying profusely the girl began walking down the beach. The fiance's best friend followed her, and after about a quarter of a mile, came to her and said, "I know you two have had a quarrel. I will try to work it out, but in the meantime I will take care of you."


The Girl _________

The Fiance _________

The Old Man _________

The Sailor _________

The Best Friend _________

There are many issues and questions that can make a difference in how people rank the characters. For example, some like the old man the best.Others are very angry with him because he offered the girl no assistance.Others think the fiance's best friend is taking the opportunity to move in on the girl, but what if the fiance's best friend is a woman? Some find the girl to be immoral and at fault, while others are touched at her sacrifice and very upset with her fiance for not understanding.The case illustrates how culture and upbringing can result in different views of the same scene.

This example adds cultural diversity as an aspect to ethical dilemmas.It is the responsibility of the healthcare practitioners to be aware of these cultural differences.

Consulting with another professional when in doubt

When an ethical dilemma is complex, or occasionally when we are too close to a situation, we have difficulty seeing things clearly. It is a good idea to have an experienced professional with whom you can consult. A good consultant should be very helpful in the different ethical situations that may come up. Sometimes just being able to bounce ideas off another person can help you see the situation clearer. Consultation should not violate the agreed upon confidentiality of the client.It should be conducted in such a way that the identification of the client is not violated, or that there is a written waiver for such consultation as part of informed consent.Standards state that the practitioners should provide the least amount of information about the client possible to have a productive consultation. (NASW, Code of Ethics, 2.05c)

Another reason to refer a client is if the presenting issues are different than your current competencies or, as addressed later, the presenting issues are contrary to your value system in such a way as to interfere with treatment.

"Engage only in activities in which you are competent.If clients require services you are not trained to provide, refer them to appropriate agencies.Do not try to go it alone.If there are services you wish to offer but have not been trained for, obtain adequate training and experienced [consultation]." (Mehr, 1986)

Having good judgment and using common sense

There is a saying that common sense is not so common. Well, if it were, we probably would not need so many rules and regulations and codes. Be that as it may, without good judgment and common sense, the healthcare practitioner will probably find themselves in trouble. Remember that whatever decision you do make, you are responsible for.When making a decision you should take into consideration the construct you have learned regarding the priorities in making decisions, also, the client's best interest and how you would justify it in front of a review hearing. You need to feel that you could justify the decision in application to ethical principles.You are expected to not only follow the letter of the codes that govern ethics, but the intent and "spirit" of them.

Clients right to informed consent

In order to provide services to an individual in voluntary settings they must be clear about what to expect from the services so they may provide informed consent.This information includes appointment cancellation policies, limits of confidentiality, expected number of sessions and length of sessions, and agreement on the goals of treatment and policy of termination.In addition, it is a violation if "Prior to the commencement of treatment, [you fail] to disclose to the client or prospective client the fee to be charged for the professional services, or the basis upon which that fee will be computed."(BBS Laws, p. 27)Along with fees there should be a clear policy on what happens when the client fails to pay fees. You also must have written informed consent prior to videotaping sessions of clients (AAMFT, Code of Ethics, 1.12)

Guidelines for Selecting and Defining Goals

As mentioned, part of informed consent is having clear and measurable goals decided upon in a process with the client.These guidelines offer assistance in formulating goals:

Goals must relate to the desired end result sought by the clients.The healthcare practitioner brings into therapy their own set of values and belief system about how people should behave and what makes somebody happy.When listening to a client's problem the provider needs to be wary of imposing their own desires of therapeutic outcomes on the client.The client needs to feel like set goals are those they have had input on, and that the accomplishment of such goals will enhance their life situations.Clients will only pursue those goals to which they are emotionally invested; therefore, practitioners who define goals unilaterally or attempt to impose goals on clients are unlikely to enlist their cooperation.The client should be the final authority in deciding the goals of treatment, although the practitioner should take an active role in the goal setting process.

Goals should be defined in explicit and measurable terms. In order to ensure the desired results, goals must specifically define the desired end result.The client and the practitioner should be clear on their responsibilities to help meet the goals and how things will be different as a result of obtaining the goals.When goals are too general it is difficult to create a path to get there.The following provides examples of general vs. specifically stated goals which include the tools or activities learned in therapy to accomplish the goals:

1. Global: Gain increased control over emotions

Specific: Reduce frequency and intensity of anger outbursts by discerning cues that elicit anger, using internal dialogue that quells anger, and applying relaxation procedures that counter anger.

2. Global: Improve social relations

Specific: Approach others and initiate and maintain conversations by employing listening skills and furthering responses.

3. Global: Enhance social environment.

Specific: Obtain living arrangements in a center for elderly persons that provides social activities.

4. Global: Enhance self-esteem

Specific: Arrest habitual negative self-statements by engaging in self-dialogue about their destructive consequences: align performance expectations with realistic criteria; attend to strengths and positive qualities; silently express self-approval when merited.

5. Global: Improve quality of parenting.

Specific: Demonstrate competence and responsibility in assuring continuous child care, planning and preparing nutritional meals, and maintaining adequate sanitary and hygienic conditions.

6. Global: Increase social participation in a group context.

Specific: Resolve fears of "looking stupid," initiate discussion of personal views, ask questions, and participate in group exploring and problem-solving activities.

7. Global: Improve marital communication.

Specific: Express needs and wants to each other, listen without interrupting and check out meaning attributions, increase frequency of positive messages, avoid competitive interactions, reduce critical and blaming messages.

8. Global: Relate more comfortably with opposite sex.

Specific: Explore and resolve fears of rejections, introduce self and initiate conversations, ask for date, engage in appropriate activities.

Goals must be feasible. Practitioners should avoid setting goals with the client that are overly ambitious or most likely unattainable.As much as you would like to see all of the clients problems solved, and to see them living at the highest levels of functioning, this is not realistic. Clients usually come to therapy because their life, their current behaviors, feelings, relationships and attitudes are not satisfactory for them.Goals should look to reach a level where their functioning becomes satisfactory for them again.Some clients may expect too much of themselves and/or their abilities, or environment may limit their level of goal attainment.If a client has a goal that is too grandiose, it is better to divide such hopeful accomplishments into measurable smaller pieces. This way the client will improve and gain satisfaction of accomplishment.

Goals should be commensurate with the knowledge and skill of the practitioner. Just as a client's abilities can determine the level and types of goals that are set, so can the abilities of the practitioner.You should agree to work with clients only on those goals for which you have requisite knowledge and skill. As in the medical profession where doctors specialize in a variety of skills and service populations, so practitioners of therapy have some specific skills that are most useful for particular problems. It is not something to feel inadequate about, but rather understand that it is very difficult, with the variety of problems that a person may present in therapy, that you will be an expert in treating all of them. You can, however, work with the client on the goals that are within your scope and abilities.

Whenever possible, goals should be stated in positive terms that emphasize growth. Define goals in ways that stress growth and highlight beneficial changes or gains that will occur in the lives of clients as a result of attaining goals. In formulating goals statements, stipulating negative behaviors that must be eliminated tends to draw attention to what clients must give up. Defining goals in terms of gains rather than losses tends to enhance motivation and to mitigate opposition to change inherent in goal statements.

The following are examples of negative versus positively stated goals:

1. Negative: To reduce the frequency of criticism among family members.

Positive: To increase the family members' awareness of each other's strengths and to increase the frequency of positive messages.

2. Negative: To eliminate pouting and cold wars between marital partners.

Positive: To deal with disagreements openly, promptly, and constructively.

3. Negative: To eliminate subgroups and non-participatory behavior by group members.

Positive:To unite efforts of group members in working collectively and to draw each member into participation.

4. Negative: To eliminate or reduce the frequency of drinking binges.

Positive:To achieve ever-increasing periods of sobriety, taking one day at a time.

5. Negative: To eliminate yelling at the children and resorting to physical punishment.

Positive: To consistently apply new ways of influencing and disciplining children, such as utilizing "time out" procedures, increasing positive feedback, and employing a problem-solving approach with them.

Avoid agreeing to goals about which you have major reservations.If clients posed goals about which you have strong reservations because of them contradicting your own moral values or life philosophies it is generally better to refer the client to another therapist.It is important that with sensitivity you explain why you are referring the client elsewhere.Occasionally, you may have reservations about the client's goals that appear to be potentially harmful to the physical or mental well-being of themselves or others.Examples can be clients who want help exacting revenge on another person, or try in devious means to regain custody of children, or who want you to falsely testify for them in court.In cases like these you should explain why you have misgivings about such goals and express willingness to work on other goals that would be more beneficial to the client and others.

(Hepworth and Larsen, 1986)

Record Keeping

Records should be kept according to professional standards and laws. It is a good idea to document services at the conclusion of a therapy session, if that is the service provided.The record needs to reflect the services provided and the progress of the client and should help maintain continuity in services. Records should not contain every story and detail of the client's personal life. "...documentation should protect clients' privacy to the extent that is possible and appropriate and should include only information that is directly relevant to the delivery of services." (NASW, Ethics, 3.04d)It is also important to safeguard client records so that confidentiality is maintained. Records, both clinical and financial should be kept as long as state law requires.Records disposed of should be done in such a way that protects the confidentiality of the client.
Question No.13.Which of the following is not accurate in regards to receiving consultation?

a. It is especially helpful when facing a complex ethical dilemma
b. There are no ethical confidentiality limits in consultations
c. It should be done with an experienced and knowledgeable professional

Question No.14.Informed consent means the client is informed of and consents to all of the following except:

a. Appointment cancellation policies
b. Limits of confidentiality
c. Goals of treatment
d. Fees for services
e. Your marital history

Question No.15.Counter-transference refers to:

a. The patient’s feelings toward the practitioner
b. The practitioner's feelings toward the client
c.The ethical principle that it is counter-productive to transfer cases

Question No.16.Transference and counter-transference issues are minimal problems and should be ignored in order to save time:

a. True
b. False

Question No.17.Prior to the videotaping sessions of clients?

a.You must have written informed consent.
b.You must have a valid Authorization.
c.No need to have consent of client.
d.Both a and b

Question No.18. The guidelines in formulating goals as a part of informed consent are:

a. Goals must be feasible
b. Goals should be defined in explicit and measurable terms.
c. goals should be stated in positive terms.
d.All of these

Question No.19. Who should be the final authority in deciding the goals of treatment.

a.The practitioner
b.The client
d.The American Nursing Association (ANA)
Laws and Ethics Course > Chapter 4 - Having a clinical self-awareness and counter-transference issues
Page Last Modified On: October 10, 2015, 03:51 AM