Topic 5: Ethical Considerations and Non-Therapy Duties {by 6/25}

Based on the readings due this week consider the following two discussion points: (1) Based on Table 2.2, what best ethical practice do you think is the most challenging to uphold (either for yourself or other professionals? Explain.  (2) What required duties beyond therapy do you find the most frustrating and/or least enjoyable?  Why?

 

Your original post should be posted by the beginning of class 6/25.  Post your two replies no later than 6/27.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

37 Comments (+add yours?)

  1. Lilianne Elicier
    Jun 20, 2020 @ 10:13:49

    Based on table 2.2 the ethical practice that I think is challenging for me to uphold is understanding multiple relationships. Although I would always do my best to take this ethical practice into consideration and try to avoid placing myself in this predicament, sometimes this can provide unavoidable. For me although I read this from the ACA code of ethics is something I have not encountered yet and I have little experience with how to deal with this ethical dilemma were it to come up. The big factor for me would be remaining un biased. In multiple relationships this can be unclear and as stated in the table there can be a loss of objectivity and possible exploitation. With loss of objectivity the therapist could become emotional involved with these dual relationships and lose sight of the situation much faster. Exploitation also can happen to a counselor working with multiple relationships and can lead to the counselor losing their license ultimately. For me it will be all about learning how to navigate this professionally and with more experience feeling confident that ethically I am doing everything in my power to uphold my professional license.

    For me the duty I find least enjoyable beyond therapy is paperwork. For me I like to be on top of things due and don’t like to procrastinate until the last minute when its’ due, this gives me a lot of anxiety. Paperwork is not something that I enjoy but understand it is a necessity and I dislike falling behind on completing any of the required paperwork, whether that be notes or any other formats. There is no type of paperwork over the other which I find the least enjoyable but just the amount it bring with it. I think one of the reason has a lot to do if I have to write anything by hand myself (not because I won’t/don’t like writing) but because my handwriting is very often messy and illegible. This puts me in a pinch when I have to write anything by hand myself that are not my own notes which I can read.

    Reply

    • Julia Irving
      Jun 21, 2020 @ 13:55:02

      Lily,
      The duty I find least enjoyable beyond therapy is also paperwork. I also do not like to procrastinate and experience a lot of anxiety when notes are put off. For me, it is the progress notes in particular that can become overwhelming. When having back to back clients it can become difficult to finish the notes the same day, but that causes me the most anxiety when I don’t have the time. Time management has been something that I have been working on throughout management to attempt to lessen the anxiety.

      Reply

    • James Antonellis
      Jun 22, 2020 @ 21:41:45

      Lily,

      Managing multiple relationships is hard to say the least. I don’t think I would ever want to be in a position where I have to provide family therapy and individual therapy for a client. There just seems like there are too many opportunities for something to go wrong.

      Reply

    • Lynette Rojas
      Jun 25, 2020 @ 21:29:18

      Hi Lily,

      I also do not enjoy doing paperwork. I like to have all my work done by the end of the day because like you I like to be on top of my work and get it done ASAP. It can be definitely anxiety provoking when they pile up. I sometimes had to finish up notes the day after or even two days after. My problem was I would take too long sometimes to do my paperwork so I think that with practice I will get quicker or better at doing them in a timely manner.

      Reply

    • Chris
      Jun 27, 2020 @ 18:13:28

      Hey Lili,
      I can understand your dilemma when it comes to multiple relationships. Having to consider not just our normal power dynamic, but aspects in addition to that can definitely be confusing. I guess I’m wondering though, are there any types of multiple relationships that you’re worried about specifically? I understand as counselors we need to be aware of the possibility, but I don’t think it means don’t have friends. I think clearly defining that boundary at the beginning of treatment, while it won’t cover everything, is essential. I also agree wholeheartedly with your dislike of paperwork. Especially that there is no good kind. While it is required, it doesn’t mean we have to like it.

      Reply

  2. Tricia
    Jun 20, 2020 @ 10:56:08

    When I consider ethics, competency and malpractice may be challenging or threatening to professionals at times. While clinicians or mental health professionals would not deliberately engage in malpractice, I consider clinicians that are new to the field or clinicians that are still learning. Sure, counselors may go to trainings, or learn how to implement specific interventions but who is to say they are competent in that subject. As a CBT trained clinician, I implement the interventions I have studied, but I also have interest in TF-CBT and DBT, neither of which I have received training certifications. That said, I seek out other clinicians, supervisors, and research to have a well-rounded understanding of treatment interventions I wish to implement. I suppose for some mental health professionals, as time goes on, upholding this ethical duty can be challenging, though it is imperative. I consider the large caseloads some agencies have. While it is both the agency and the clinician’s responsibility to not take on clients they are not properly trained for, our internal desire to help others may want us to say yes now and learn later. While I take the best practices now to ensure I am practicing within my ethical boundaries and treatment modality, I will be mindful and stay well-intentioned in the future to consider my own competency when determining if I am a proper fit for my future clients.
    When I reflect on the responsibilities and duties beyond therapy I think consulting with Managed Care Organizations would be my least favorite as I have no experience working with them directly. I know what MCO’s do, and their responsibility to account for costs and make efficient practice, and so on. That said, as my only clinical experience was as an intern, I was fortunate enough to not work with MCO’s directly. I say fortunate as I know this can be a stressful task among administrative workers and clinicians. As MCO’s do not have a full picture understanding of your client, and you are their advocate to reach an optimal level of adaptive functioning, I can imagine the frustration, when you are limited to a certain number of sessions, or you are restricted on treatment approaches, or what the counselor chooses to work on. Unfortunately, while you can negotiate and spend significant time trying to advocate with MCO’s it really comes down to “my way or the highway.” Do as the MCO suggests or do not get reimbursed. While there are many things about MCO’s I find frustrating, you will be working with them in some shape or form, so it is best to learn how to navigate and work with what you are dealt with. Through supervision, and learning how to best frame documentation in ways that appeal to MCO’s, I will slowly learn how to navigate this process effectively.

    Reply

    • Abigail Bell
      Jun 26, 2020 @ 14:16:39

      Hi Tricia,

      I agree with you that ensuring that we as clinicians practice within our level of competency can be such a challenge when we are newer clinicians and especially in an agency that has a lot of clients. When I was at my internship I felt like I had extra work on top of my school work and internship because I was learning about interventions for things like trauma and psychosis, and it became a lot to keep up with. I think it is great that this is something you are staying mindful of. It is important to have a good understanding of what diagnosis and interventions are in our clinical wheelhouse for the sake of our clients.

      Reply

  3. Julia Irving
    Jun 21, 2020 @ 13:49:07

    Based on Table 2.2, Self-Disclosure became a challenge at times for myself during internship. My clients knew that I was an intern, so occasionally I would have a client or two ask me about my schooling, where I went, what year I was, how my classes were going, etc. I would give them minimal information and then revert the attention back to my client, but I felt like this was hard to do without being rude/disclosing too much information about myself. This was something I would also discuss during supervision. When self-disclosing, I would always consider whether this discloser was to help my client or if it was something that I just wanted to say. I wonder if my other classmates ever struggled with being asked about their schooling by their clients and how they handled the situation? The ethical practice that I believe is most challenging to uphold by other professionals would be confidentiality, particularly when working with children. I believe this would be hard because some parents would want to know how therapy is going but if the child does not want them to know then it is not appropriate for the therapist to disclose. I could see this becoming challenging if the therapist gets put in the middle.

    The required duty beyond therapy that I find least enjoyable is the paperwork, particularly the progress notes. I am very good at getting my notes done the same day or the morning after but it can be a hassle when I have other things going on. I become very anxious if I do not get my notes done on the same day and have noticed that when I wait to do them later in the day or the next morning that my notes are not as detailed as they would have been if I did them right after session. I jot down a few notes on a notepad during session but sometimes I don’t even understand my notes or understand the one or two words I wrote that were meant to jog my memory. I also fall into the trap of doing a working lunch so that I can get more notes done. I understand why paperwork and progress notes are important for client care and client records but when trying to do client notes on top of an already busy schedule can be anxiety producing for me. During internship I tried to work on time management around this, but I believe this will become even less enjoyable when I have more clients during post grad.

    Reply

    • James Antonellis
      Jun 22, 2020 @ 21:38:35

      Julia,

      Monitoring self-disclosure is tough. Especially with younger clients, sometimes you’re trying to disclose something in the hopes that it helps them relate to you, but it just ends up blowing up in your face and doing the opposite of what you hoped it would do. Documentation is also a pain in the rear. Especially because everything is moving online. When the EMR goes down and no one can file notes, it becomes stressful because now you have to rearrange your schedule so that when the EMR comes back online you can get notes submitted before deadlines.

      Reply

    • Sam
      Jun 24, 2020 @ 21:36:05

      Hi Julia,

      Although I discussed other ethical practices that I would find challenging, I like your post on self-disclosure and definitely agree. Sometimes I find it difficult to decipher between building rapport with your client, vs. disclosing too much or inappropriate information. During internship I definitely struggled with whether or not discussing the fact that I have a son with my clients was oversharing or relevant to the therapeutic process/ relationship. So, I like that you mentioned that prior to sharing some info, you would always make analyze whether or not it would work the the benefit of your client.

      Reply

    • Cynthia LaFalaise
      Jun 27, 2020 @ 20:40:41

      Hi Julia,
      I experienced the same situation with self-disclosure. i had clients asking me how school was, what school I went to and things related. I simply would just say good, and stated clearly that I couldn’t tell them specifics due to boundaries. They were pretty receptive of that and respected it. I think self-disclosure can be beneficial for building rapport and small talk but it should be limited. I also found paper work to be the hardest thing to do. It is very time consuming and usually would sacrifice leaving on time to finish all my notes so I wouldn’t have to wait until the next day.

      Reply

  4. Lilianne Elicier
    Jun 22, 2020 @ 17:02:47

    Julia,

    I also least enjoy doing paper work as was posted on my post. I also try to do this in the 15 minutes I have between client to not fall behind. This is an anxiety provoking situation for me as well when I put paperwork off. Self-disclosure for me personal proves difficult as well as I am a person who likes to share by nature. I find myself wanting to share some stories to help the clients realize that I can relate to them. I have had clients ask me about my schooling and the way I have handled that is by telling them that unfortunately it is protocol per the agency where I am that I am not allowed to self-disclose that information, but I also do feel bad about this when it is younger clients.

    Reply

  5. James Antonellis
    Jun 22, 2020 @ 21:33:49

    For me, self-disclosure is my biggest struggle. I try to keep what client’s know about me to what is therapeutically relevant, but would really have to work at redirecting the client back to what we were talking about. I find that working with adolescents makes self-disclosure’s even trickier, as I try to figure out what I can talk about so that I can relate to someone who can be someone who could be 10 years younger than me. I’ve been told that it is okay to talk about high school or sports that I did when I was younger, but I swear every time I bring up something to help build the relationship, it just sparks 100 questions and I spend the rest of the session getting the client back on track.

    What has to be the most frustrating ‘activity’ outside of therapy is documentation. I did my internship in a school, documentation was pretty easy; I would write a paragraph or two about the session, and my supervisor thought it was wonderful. I work in a DMH funded facility, (and would love to work as a clinician in the program when I graduate) and the documentation is awful. I would estimate that from the residential side, it takes at least 20 minutes to complete a client’s note. From the clinical side, it seems like documentation takes an hour per client. What has to be anxiety provoking are the deadlines and standards that these notes have to meet. I’m not sure of other people’s work flow, but I’ve seen clinicians staying till 7 or 8 at night to finish paperwork before the deadline.

    Reply

    • Julia Irving
      Jun 23, 2020 @ 10:20:44

      James,
      Self disclosure is my biggest struggle also. It becomes difficult to redirect clients without being rude when they ask you questions about yourself. I only had a few adolescent clients and I agree that they had more questions after self disclosure then me adult clients. I tried to use it as little as possible, but when it came to schooling my clients would always ask me how I was doing and such. It can be tricky to navigate.

      Reply

    • Lilianne Elicier
      Jun 24, 2020 @ 17:16:21

      James,

      I also struggle with self- disclosure , as I mentioned earlier in my reply to another student I think as a clinician this makes us relatable for our clients. I have personally gotten asked questions by my clients that I wish I could answer but per agency policy I have not been able too. I feel like documentation is one of the frustrating aspects of doing counseling and wish there was an easier way to do this. I have had similar experiences with the adolescents and kids I’ve worked with asking me tons of questions which is very tricky to navigate because you don’t want to come off as just plain rude or cold.

      Reply

    • Pat
      Jun 26, 2020 @ 20:47:28

      James,
      It sounds like a lot of us struggle with self-disclosure. I know I’m no exception to that either. I worked mainly with anxiety disorders and depressive disorders, so sometimes finding appropriate disclosures in those environments feel neigh-on impossible. Some disclosures that may instill hope would be too personal, and others may make the client feel as though the clinician hadn’t overcome similar struggles, so why could they? I know we’ve been told that these skills come with time and experience, but I frequently wonder when we get to cash that particular check. I suppose time will tell, but in the meantime, it’s good to know we aren’t the only ones that struggle with self-disclosure.

      Reply

  6. Patrick
    Jun 24, 2020 @ 16:01:30

    For myself, as well as other clinicians/professionals I’ve worked with, the thorough documentation is the most difficult thing to uphold. I always assumed it would be difficult, but I never thought that the difficulty wouldn’t be the amount we have to do, but the specificity we need to achieve. I try to hold myself to have all of my progress and personal notes completed the day the session was held. While it’s been fine with an internship caseload, I’ll be interested to see if this pattern can continue. That said, I always find that while completing a note, I’ll remember I didn’t ask which phone number of the three provided in the intake would be appropriate to call for scheduling, or if the client would be comfortable with the clinician saying where they are calling from, or if they’d rather us leave our name, or the email of the new psychiatrist they just started seeing, etc. The clinical documentation isn’t so bad – we’ve been taught what to do, what to look for, and the research guides us from there. It’s the day-to-day business stuff that I never feel like I covered all of.

    So far as the duties I dislike beyond therapy, I truly destain working with MCO’s. Sometimes that back and forth between us (the clinician) fighting for two additional sessions with them (a business major) for a client who is in extreme distress can feel so draining. There were plenty of times where I knew we were making progress with a client, and the “therapeutic momentum” was starting to build and then just like that, the MCO says that they need to cut costs and the client will not have any further financial help to pay for sessions. I knew I’d hate working with MCO’s for the most part, and I have had some good MCO interactions, but it can feel so frustrating to know that in maybe 3 or 4 more sessions there will likely be a significant change, but someone whose never met you or the client has the final financial say over what will happen.

    Reply

    • Chris
      Jun 27, 2020 @ 16:59:22

      Hey Pat,

      I definitely agree that thorough documentation is difficult. I also found that there were questions I forgot to ask or info I wish I had clarified when I was completing a progress note. It can be frustrating to realize after the fact and have to call the client again or wait until the next week. Its’ definitely the day-to-day interactions and workload that is more difficult in the long run. I’ve never personally had to work with an MCO for a client. But based on your description, they don’t sound generally pleasing. It bothers me as well when I’m working with someone who doesn’t have the client’s interests at heart, so I’d imagine I wouldn’t like working with them either. I also don’t like the idea that someone else besides the client has the financial say for treatment, but I should also do more research on what an MCO does.

      Reply

  7. Lynette Rojas
    Jun 24, 2020 @ 18:10:13

    Based on Table 2.2, the ethical practice I think can be challenging is self-disclosure. Sometimes clients ask questions about the clinician’s personal life out of curiosity. Some clients ask personal questions for other reasons. Some clinicians may decide to answer and some may decide to redirect the client. I realized that children ask a lot more questions about me than adult clients. I didn’t find it too difficult with children because I think it was easier for me to change the topic and redirect it back to the client. However, when an adult was to ask me a question about myself, I didn’t want to sound rude or defensive. This is something I talked about with my supervisor during supervision. I think it helps to ask the client his or her reason for asking. This can clarify whether answering the question will benefit the client or not. I think it can also be helpful to let the client know that time is valuable and you want to make the most out of the session to help him or her. This can help in redirecting it back to the client by letting him or her know that we are here to talk about what he or she needs help with and not about the clinician’s personal life. However, self-disclosure can be helpful when trying to build a therapeutic relationship which I have done during internship, especially with children and adolescents.

    A required duty beyond therapy that I find least enjoyable is documentation. I love having therapy sessions and helping clients, but when it comes down to having to complete paperwork about it, it can become a lot. I like to be thorough with my notes and make sure I cover all important information. I would try to complete my notes right after session, but sometimes when I had back to back clients it became more difficult and I ended up finishing up my notes later that night or the next day. This happened especially when clients showed up late and stayed till the end of the scheduled session until it was time to get the next client. I didn’t like when I had multiple unfinished notes because I wanted to be caught up and done with them ASAP. However, I found out that after completing many notes later that night or the next day, it helped me in memorizing my sessions. I found this very helpful when speaking to my supervisors about my clients and when completing my process recordings for internship seminar. I also found it very helpful in remembering details that did not need to be documented to be able to continue to build rapport with the client. These details included favorite colors, books, games, etc. I do prefer finishing my notes right after session though because it allows me to be fully present during session and the information is fresh in my mind. I also like to have all of my work done by the end of the day so that I don’t have paperwork waiting for me to get done the next day.

    Reply

    • Sam
      Jun 24, 2020 @ 21:40:59

      Hi Lynette,

      I enjoyed reading your post, and liked your discussion regarding frustration with documentation. I am a big “stickler” about my paperwork and always need it to be detailed and precise, so they always took me longer than others to complete, which became very frustrating. However, I really like how you mentioned that it helped you recall details in your sessions with ease, and that it worked to your benefit when discussing clients in therapy. I too feel that although it’s not enjoyable, it is helpful. So, in a sense, writing detailed progress notes helps me feel better than rushing through them (even though it takes time and is annoying). Very nice post, especially your discussion about paperwork.

      Reply

    • Kaitlyn Doucette
      Jun 25, 2020 @ 15:41:43

      Hi Lynette,
      You make a great point about self-disclosure. I have also found that clients that I have worked with were curious about my personal life, and I found it difficult to navigate sometimes without appearing rude. I think that it was especially difficult during my internship at Walden because a lot of the clients were around the same age as me. They never asked questions about my personal life in a rude way (I think that they were just trying to make conversation half of the time), but it still seemed inappropriate for me to talk about myself or my personal life with clients. I found that the easiest way to navigate this was through humor. I would usually just make a joke and then redirect their attention on something else. This way, they didn’t become offended that I wouldn’t answer their question, and I still usually didn’t end up having to self-disclose. I think that you have also given a great suggestion about not wanting to spend time during the session talking about things not pertinent to the client’s treatment. That also seems like a great way to move along to a different topic.

      Reply

    • Danielle Nobitz
      Jun 25, 2020 @ 16:52:10

      Hi Lynette,
      I agree with you that self-disclosure can be really tricky. I like your idea of turning it back around to the client and asking them why they need to know the information. I also like the idea of reiterating that time is valuable during session. I feel like that would really help to redirect the conversation. I also agree that self disclosure can be helpful in some aspects, because it can help develop rapport with clients. I think that it definitely does work best with teens and children, because you become more “relatable” when you self-disclose some information. It definitely is important to draw that line of what is appropriate and inappropriate, and it definitely depends on the client as well!
      I also agree that documentation is the least enjoyable task of being a therapist. It can definitely be really tricky to develop your thoughts and make a descriptive note that is acceptable enough for insurance while also running into another session within the half hour. I found it difficult in the beginning to remember what happened in session, because I would always write my notes later on in the day or a few days later; however I then decided that jotting down notes right after the session and keeping them in a confidential notebook was really helpful for me, and helped spark my memory when it came to writing that client’s note a day or so later!

      Reply

  8. Sam
    Jun 24, 2020 @ 21:31:40

    After reviewing table 2.2, I recognize that an ethical practice I found to be challenging during my internship experience, was that of understanding multiple relationships/ boundaries. In particular, I once described an instance in class, where the mother (who attended sessions regularly) of my 5-year-old client, offered me clothing/ toy “hand-me-downs” for my son. Of course, in any other circumstance I would gladly accept donations, but I certainly realized in this instance that, although the relationship between my 5-year-old client and I appeared to be that of a professional one, it may be the case that I established more of a “friendship” with the mother because of this. This may have been more of a boundary issue, compared to a second relationship—as I did not communicate with her outside of therapy unless it was clinically relevant. Nevertheless, this instance was a clear indication of how slippery multiple relationships/ boundaries can become, and how they affect therapeutic sessions. In addition, a second experience related to ethical practice regards practicing in my area of expertise. As an intern, I was encouraged to provide family therapy for a client per the request of the mother of my client. After numerous supervisions, I began the family therapy. However, the weeks leading up to my first session I felt quite anxious. This was most likely because, I, for one, had never conducted family therapy, and two, had no general knowledge of doing so as I had not yet taking any courses relevant to this modality. With this, I quickly felt that I was not practicing within my area of expertise, and there for not providing the best treatment for my client. Although this may not be difficult for clinicians with years of practice, it may prove challenging for us “fresh out of grad-school” clinicians.

    With regard to duties required beyond therapy, I suppose I would find working with MCO’s to be frustrating (especially as a new clinician). Although I have learned from research seminar, how to essentially write request for further treatment with clients, I can definitely say that having to do so in the future as a clinician will probably cause me some anxiety. Additionally, although I have not yet had direct experience with MCO’s, I anticipate having some sort of challenges with providing quality care for my clients should MCO’s allow for only a certain number of sessions with no extension. In this case, I feel that I would in a sense, “rush” to complete necessary interventions in treatment so as to provide the client with as many skills as possible before their insurance runs out. However, we all know this wouldn’t be effective. Finally, since MCO’s have their own sort of standards and guidelines for how treatment should be implemented (with a specific focus on diagnosis), I may undergo pressure to modify my client’s treatment plan to fit the MCO’s standards versus the needs of my client. Ultimately, I have little experience with MCO’s, but I know they encompass a large part of clinical counseling—So, I’m sure running into challenges with them will prove frustrating as a new clinician.

    Reply

    • Tricia
      Jun 25, 2020 @ 15:37:40

      Sam, I agree that as a new clinician working with MCO’s are going to be frustrating. We already want to ensure we are implementing treatment interventions that are effective without corporations who do not have sufficient understanding breathing down our necks. I think back to my internship and the clients I worked with. Practice helps, but 8-10 sessions, if you are lucky can fly by in the blink of an eye. I also would hate if I created a treatment plan that I knew to be evidence-based and the MCO advised for changes. This frustration will diminish slowly as I work with my supervisor but I at this point am reluctant to have this seemingly constant battle.

      Reply

    • Cynthia LaFalaise
      Jun 27, 2020 @ 21:19:52

      Hi Sam,

      I too had issues with boundaries with some of my clients. One in particular I mentioned before was my client who had a baby and offered me to hold her. I was able to make a joke out of it and not hold her but I felt like that would be crossing a personal boundary (too intimate). I think establishing boundaries can be hard because some some clinicians are more comfortable with certain things that others wouldn’t allow. I think following your gut is important, if you feel like something is off just address it with the client. I think having a conversation up front about boundaries and keeping your privacy.

      Reply

  9. Cynthia LaFalaise
    Jun 25, 2020 @ 02:19:00

    For me personally, documentation of notes is what I struggle with the most. It’s not the content or remembering details that I have a hard time with, it’s the it time management. Doing notes is very time consuming for me for various reasons. i tend to write paragraphs for notes because I want to make sure that I am very thorough about what was discussed and observed during sessions. I think that I could scale back a bit and keep minor details out.I also usually book clients back to back so I don’t have time to write notes until after I see my last client. By then I’m swamped and either staying later or coming in early to do the notes the next day. I have tried to type notes during sessions while my clients were speaking and I found that I would get distracted and miss key things they would share.

    Out of all the other duties the one I find most annoying is case management. I’ve realized that part of working in mental health interweaves with case management especially when part of their distress is connected areas of life that require getting in contact with other agencies (healthcare, court, unemployment ect…). However, there are certain agencies that I absolutely hate having to call like DCF and probation officers. It’s always a hassle and I always find myself thinking if I wanted to do case management I would’ve went for social work instead. Nonetheless I suck it up and try my best to advocate for my clients despite the irritation that comes with communicating with other entities.

    Reply

    • Kaitlyn Doucette
      Jun 25, 2020 @ 15:50:54

      Hi Cynthia,

      I appreciated your discussion of documentation because I struggled with this during my internship as well. I would be worried that I was not writing enough about the session in my progress notes, so I would end up writing too much about what occurred during the session. I think that I felt I had to prove to my supervisor that I was doing enough with the client in the session, if that makes sense? But I realize now that documenting with too many details does not really do anyone any favors except for the client’s insurance company (aside from special cases where details are necessary, of course). The insurance companies are typically the only ones actually using these notes to make treatment decisions (at least at my internship site), and the insurance companies do not need to know every detail of what occurs in therapy sessions. I found that this helped me to write more vaguely and scale back on the detail. Thank you for sharing!

      Reply

    • Lynette Rojas
      Jun 25, 2020 @ 22:17:45

      Hi Cynthia,

      I agree that documentation can become very time consuming. Over my time at internship I learned how to write more concise and without unnecessary detail. Talking about documentation in supervision was very helpful for me. I also found myself trying to finish my notes at the end of the day after having back to back clients and would also stay there later if I could or go in earlier the next day. I am glad to know I wasn’t the only one. Thank you for sharing your experience. Also, case management can get annoying but I do also try to do the best I can to advocate for my clients.

      Reply

  10. Abigail Bell
    Jun 25, 2020 @ 13:38:03

    [1]The ethical practice that I think is the most challenging for counselors to uphold is only practicing in their area of expertise. It seems simple, don’t work with clients that have disorders that you are unfamiliar with treating and don’t use interventions that you are not appropriately trained in. However, the reason why I feel like this can be challenging for clinicians to uphold is because as counselors we are going to encounter so many different people with a wide variety of issues that they need help with. Our background in CBT can be used with a lot of different disorders and modified to work with a lot of different populations, but it does not cover everything. I think it can sometimes be difficult to find the line between a situation where it is appropriate to refer out and situations where it is appropriate to treat an individual as long as you do extensive research into effective interventions for the disorder.

    I also feel like sometimes there can be pressure from superiors to practice outside of your expertise comfort zone. An instance that I had at my internship where I felt like I was being asked to practice outside of my area of expertise was when I had to do a DBT group with a group of inmates. The other intern had a lot of experience in DBT so she was able to lead her sessions without much preparation before hand. I on the other hand, know very little about DBT so I would sometimes take a couple of hours to prepare for the sessions I was leading and basically teaching myself DBT. My supervisor mentioned to me that she noticed I was taking a lot of time to prepare for group and that I did not need to prepare that much before hand. I felt pressure to not thoroughly prepare for sessions, which I felt would be a disservice to the clients that were in the group, because they were a population that would benefit from learning DBT skills from a competent clinician. I still took the time to educate myself thoroughly, but I felt pressure to not do that just because it was time consuming.

    [2]There are a lot of duties beyond therapy that I do not really like. I am sure almost everyone dislikes doing paperwork. It is tedious and different for every agency. The part that I do not like about doing paperwork is that there are so many different forms for different things. When I was interning at the jail they had at least 10-15 different types of note documentation forms and sometimes we would have to complete multiple forms for one client contact. We also had to complete these by the end of the day everyday regardless of how many clients you see in a day, which could be a lot depending on what task you had at the jail and what unit you were in. Another thing that also made them difficult to complete were that all 8 clinicians were jammed into one small room, which was super distracting and I would often have to stay after everyone else left to be able to complete my notes.

    Another thing that I know will be frustrating is dealing with agency politics. Sometimes agency policies and practices just don’t make sense and can be difficult to have to work around. At the jail this would be an issue because security staff had control over everything and mental health counselors were pretty much at the mercy of whatever the security staff would allow. For instance, security staff could refuse the clinicians entry to their blocks at any time for any reason, this could sometimes just be because they did not feel like watching the clinician while they were on the unit that day. This was super disruptive to our days, but ultimately it is a jail so we just had to roll with it. I am sure that I will encounter other unpleasant agency politics anywhere that I go and I will have to navigate them as gracefully as possibly as a mental health counselor.

    Reply

    • Tricia
      Jun 25, 2020 @ 15:29:36

      Abby,
      I agree with you about the ethical challenge of practicing in your area of expertise, especially when there are influences from superiors. I know we are expected to do a lot and handle a significant number of cases in our future jobs so I always question this as it never looks great to say no. I am sorry that you were pressured to implement a DBT group but maintained your ethical duty to study the modality, despite the advice from your supervisor. I think the time consideration is important as I am sure many of us want to take the time to get the proper training, but proper training tasks time away from counseling, which influences the company and the expectations that are set on us. I hope we all have supervisors that respond appropriately to us wanting to learn, and maintaining our ethical duty to practice within our area of expertise.

      Reply

  11. Kaitlyn Doucette
    Jun 25, 2020 @ 15:35:09

    An ethical practice that I would find most challenging to uphold would probably be maintaining confidentiality of my client when they disclose something to me that does not align with my own morals. Examples of this would be a client disclosing to me that they had physically abused their partner, sexually abused another person, or committed a hate crime. I do not think that my first response would be to want to break their confidentiality and tell someone, but I know that it would be hard for me to maintain a professional demeanor and I might have a difficult time maintaining a positive therapeutic relationship with them (which would lead to the ethical dilemma of whether or not I should continue treating this client or if I should refer them elsewhere). I have not experienced this in my career yet, but I know that some of my peers have and it is very likely that I will as well. They have told me that they were able to handle it differently and more professionally than they had originally predicted, however it is still something that concerns me.
    The required duty of counselors that I find the least enjoyable is case management, especially calling insurance companies and making phone calls to coordinate with other providers. During my internship at Walden, I had to call clients’ insurance companies to ask for more units (i.e. days in treatment) about once a week so long as the client still needed treatment. I dreaded this. I already am not one to enjoy talking on the phone, and I especially disliked having to call insurance agents to convince them of why my client still needed treatment. Additionally, I do not really enjoy making phone calls on behalf of clients. I know that it is often necessary and part of the job, but again, I do not like talking on the phone and it’s something I don’t find enjoyable at all.

    Reply

    • Danielle Nobitz
      Jun 25, 2020 @ 16:45:13

      Hi Kaitlyn,
      I definitely can agree with you that it would be extremely difficult to treat a client who discloses something as horrible as assaulting someone or committing a hate crime. I have witnessed a fellow intern of mine, who is part of the LGBTQ population, who was working with a client that disclosed that they are homophobic, and went on this rant about homosexuality (not knowing that the clinician’s sexual orientation). It was actually a long group discussion with all of the interns at our internship, and we tried to help her work through what was best for her to do ethically in this case. While she was incredibly upset and distraught by the comments made by the client, she decided to continue to work with this client and would continuously check in with her supervisor on her ability to work with this client. She decided to continue to work with the client, because she knew that she would most likely experience this again in the future, and wanted to work through it with her supervisor. I wanted to share that with you because I feel like it’s a really good example of how you might be able to work through something like this if it were to happen to you (if a client were to disclose something that goes against your own morals). I think in this case going to your supervisor and working it out with them and fellow coworkers would be really essential in helping you make the best decision.
      I also agree with you that case management is not enjoyable! When I was at my practicum, I was working mainly ICC, where I had to only manage cases, I wasn’t doing any psychotherapy, and I was coordinating and keeping multiple people on the client’s team, on the same page (schools, IHT clinicians, outpatient clinicians, PCPs, psychiatrists, DCF, etc). It was really difficult to do so. I also worked with DCF for some of my cases in my internship, and I can relate to you when you say you don’t like talking on the phone, especially when it involves making phone calls on behalf of clients!

      Reply

    • Pat
      Jun 26, 2020 @ 20:39:50

      Hi Kaitlyn,
      I can definitely relate to the concern/difficulty of maintaining a positive therapeutic relationship with someone who does any of those things. I had a client who had physically abused their partner. I had an incredibly hard time remaining positive, let alone professional with this individual. That client eventually dropped out of treatment due to moving away, but I had an incredibly hard time with them. I think we all know part of the job is likely working with individuals who’s behaviors we don’t like, but some things (physical/sexual abuse, racism, bigotry, etc.) are really hard to deal with. Hopefully, in time we’ll learn some skills to make that stuff easier.

      Reply

  12. Danielle Nobitz
    Jun 25, 2020 @ 16:31:35

    1) I think the ethical practice that is most challenging to uphold for any counselor would be self-disclosure. I believe that there is a possibility of walking a fine line between self-disclosing just enough information, vs. disclosing too much information. This line definitely varies depending on the client as well, their age, and the disorder you are working with. I believe that there are definitely benefits to disclosing some information. We have learned throughout different classes and research has shown that therapeutic relationships are almost just as important as the therapy and interventions themselves. This is what makes me feel like it’s important to self-disclose SOME information in order to seem more personable and maybe connect with the client to gain rapport, however drawing that line between what is too far is really important, and is something that I definitely am cautious about. I feel like I mention this all of the time, but working in the inpatient facility proved to me that it is important to only disclose some information, and be very picky with what you choose to tell clients, because they will remember specific details (one of my old coworkers had a client find them on Facebook and eventually ended up showing up to their house).
    On the other side of that, I have worked with kids or teenagers who really benefit from some self-disclosure, to feel more personable and relatable to you. Disclosing something about your favorite sports team, some of your hobbies, or things about pets can be really helpful with children or teenagers I have learned, in my case. Self-disclosure is something that I feel is sometimes necessary to develop rapport with a client. Just be careful with what you’re disclosing!
    I also know a lot of clinicians have difficulty with being truthful about billing, especially in the in-home therapy world. When I was in my practicum, many of the clinicians would lie and say they were in a session or out on the road for 3 hours, when in reality it sometimes only took 1.5 or 2 hours. It was really interesting as a brand new intern to see clinicians lying about billing hours, and I couldn’t fathom how they would get away with it.

    2) As I’m sure everyone else feels, I think the most frustrating and least enjoyable duties beyond therapy is documentation! I have mentioned this in previous blog posts, but I have been working on time management skills, due to my frustration with documentation. It was really difficult for me to focus on both work, school, and internship, and documentation proved to be very tedious to me. I have learned through my internship that sometimes, documentation can be very particular and clinical writing needs to be precise yet descriptive enough in order to receive billing from insurance companies (in the outpatient world). This makes me feel some pressure when it comes to writing descriptive and adequate documentation. It will take a lot of patience and scheduling in time to document a full caseload worth of notes, however I feel with more practice and less outside influences (after school is over and I am working full time as a clinician) I will get in the swing of things. However, I do think that documentation will always be something that is the least enjoyable for me.

    Reply

  13. Chris
    Jun 25, 2020 @ 16:40:00

    I feel as though this first question can be answered in a couple ways. I think the aspect on Table 2.2 that would be the most challenging for me professionally would be monitoring my self-disclosure. In a couple instances during my internship, I shared my experiences with mental health with a client. In hindsight, our rapport was not strengthened enough at the time and it ended up damaging the therapeutic relationship. Since then, I have consciously been working on understanding what’s not just appropriate to share with the client, but beneficial for their own treatment and progress. Another ethical practice that could be challenging for me work wise would be keeping track of documents thoroughly. Similarly, during my internship there were times that let my paperwork pile up and caused me unnecessary additional stress. In the future, I at least plan on doing a better job maintaining my documentations and not letting them snowball. However, I do understand the importance of having thorough in ethical practice to make sure that I cover all of my bases to protect both the client and myself.

    If I haven’t expressed it enough already, I’m really not a fan of paperwork. I’m also assuming this question is only referring to therapy as the sessions themselves. I don’t mind the book work in the sense of finding interventions through work books and such, but everyone knows that’s not the main part of it. Progress notes, treatment plans, maintaining charts, most of the things like that I don’t find particularly enjoyable. Overall, it can be very tedious, especially after working with clients for multiple hours. There were times however, that I found writing progress notes or updates to a treatment plan could be enjoyable, but this was usually only after a session where a lot of positive things happened. However, when sessions occur that are difficult or paper work begins to pile up, it can be frustrating and stressful to complete, especially the former. Moving forward, I understand that staying up to date with my professional documentation is an ethical standard, but it is a personal goal I want to get better as well.

    Reply

  14. Maria
    Jun 25, 2020 @ 17:22:01

    I personally think that the ethical practice of self-disclosure is something that would be challenging for both myself and other professionals. I’m often hyper vigilant about not disclosing things to my clients about my personal life because we have been told multiple times it is not helpful or beneficial to the clients to disclose information about ourselves. I find it easiest to keep my self-disclosure to a minimum with my older clients because I feel like they would judge me even more, but when it comes to clients who are closer to my age or my kiddos and their parents, it becomes harder to not share certain things. For this closer to my age, its hard not to say “yeah, I’ve been there” or something along those lines. I have often tried the line “I’ve had clients in the past who…” in order to help the clients feel less alone, but sometimes they do ask “You ever had that happen to you before?. When it comes to my kiddos, they are the ones who ask the tough question! They can also tell when you hesitate with answers… Also with the parents, I find it hard to deny or leave some questions unanswered. I think that this is something that we will master over time, but I have heard some horror stories about clinicians self-disposing some information that shouldn’t be spoken about. I wasn’t sure if it’s because they have just gotten to a point where they don’t care or it was in hopes to relate better to their client. Either way I think it is a challenge to uphold at times.
    The required beyond therapy I find frustrating is documentation! I honestly struggle with the amount we get. I’ve heard from other experienced clinicians that its a part of the job, but it does get slightly less annoying once you become use to it. I do not mind writing notes, but I feel like I am either too detailed or not detailed enough and that drive me nuts. Also when it comes to kiddo clients there added paperwork that I do not find enjoyable at all. And the fact that we have to continuously keep it updated every 3 or 6 or 12 months makes my head spin. I think most people think we have the 9-5 job and don’t need to do much at home, but thats not true at all. I remember times where I had to do work while my family was spending time together and all I kept thinking was this isn’t fair! I’m hoping with practice and time things will get better and not be as anxiety provoking or time consuming.

    Reply

    • Abigail Bell
      Jun 26, 2020 @ 14:01:49

      Hi Maria,

      I agree with self-disclosures being something that is challenging for clinicians. I also err on the side of caution with self-disclosure too. The horror stories about inappropriate disclosures are incredibly cringey and I hope to never be in that position. However, in practice I have seen some clinicians use it in a way that is super effective. It is definitely super hard to find the line of what is inappropriate and what would be helpful for the client. I also wrote about how documentation is the worst. It does seem so unfair that as clinicians we have even more work on top of our work that can sometimes bleed into our free time. Hopefully it will get better when we don’t have school in addition to working with clients!

      Reply

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Adam M. Volungis, PhD, LMHC

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