Topics 7 & 8: Ethical Considerations and Non-Therapy Duties {by 6/30}

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 6/30.  Post your two replies no later than 7/2.  *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. Yen Pham
    Jun 27, 2022 @ 17:30:16

    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.

    For me, protecting client confidentiality is the biggest challenge because I have some concerns when I am going to work with the multi-person therapies (MPT). The MPT includes marital, family, and group therapy. I realize that in MPT confidentiality can be an issue because the asymmetry of professional duty is magnified, i.e., the practitioner has an ethical/legal responsibility while the group participants do not have a legal responsibility to the clinician or to one another. Therefore, it is hard for clients who participate in MPT to maintain their own confidentiality or the confidentiality of others in the group.

    Besides, confidentiality in group psychotherapy is more complicated than in individual therapy because self-disclosure is at the core of group therapy and there are numerous people hearing the disclosures. It is clear that absolute confidentiality in groups is difficult and often unrealistic.

    For example, confidentiality complicates MTP, especially in marital and family therapy because of some undebated questions. For example, should parents be able to sign away a child’s right to confidentiality? Often, couples may have difficulty in establishing boundaries and privacy concerning their own lives and those of their children. Adult clients can, and should, have the ability to assert privacy with respect to their marriage and to avoid burdening their children with information that may prove frightening, provocative, or simply beyond their ability to comprehend adequately. On the other hand, many attempts to maintain secrets have a manipulative purpose and do not serve the general goals of treatment.

    Therefore, at the beginning of the process to treat the MPT, I will provide informed consent about confidentiality educates group members or family members about confidentiality, and makes the discussion of confidentiality an ongoing process. I will encourage that is important for all group members to be mutually respectful of confidentiality regarding what each member says during treatment.

    (2) What required duties beyond therapy do you find the most frustrating and/or least enjoyable? Why?

    I realized that the expectations beyond counseling addressed in chapter 4 that Dr. V discussed include paperwork, case management, colleagues, supervision, managed care organizations, mental health community outreach, and professional advocacy. In my opinion, I think the most frustrating and/or least enjoyable is to work with Managed Care Organizations (MCOs) because of the is utilization review (UR) process, I sometimes feel restricted in my ability to care for my clients because I do not have full freedom to implement my treatment approaches as desired. This can put me in a difficult position because I may either need to follow the UR representative’s suggestions. I have experienced this during my internship. My agency mostly received the cases from the DCF worker, so each month we have a UR for each of my clients. This UR normally includes the DCF worker, social worker, and me. I have a duty to update in general about my process and treatment plans to the DCF as well as follow their suggestions to be closed or still open a case.

    Besides, I am not enjoyable in working with the MCOs because it sometimes impacted the relationship between me and my clients as well as some confidentiality between me and my clients too. Typically, my clients feel comfortable sharing any of their thoughts or feelings without being concerned that their information could go beyond the counseling room (unless the clients are a risk to harm themselves or others, of course). However, sometimes particularly sensitive client information may need to be shared with MCOs for treatment necessity as part of the UR. And of course, once this information is shared with MCOs, it is no longer under my control.

    Reply

    • Alison Kahn
      Jun 28, 2022 @ 14:24:32

      Hi, Yen!

      I completely agree with you about how frustrating it can be working in managed care organizations and having to follow a very specific (and sometimes not applicable or relevant) treatment plan. I have had similar experiences in my role where I have to choose goals from a drop-down list and try to tailor it to my client specifically rather than being able to come up with my own goals for the client. I can kind of understand the utility of these blanket treatment plans, but it is also super annoying!

      Reply

  2. Alison Kahn
    Jun 28, 2022 @ 14:21:17

    (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. 

    Within my current role, protecting confidentiality can be incredibly challenging. This is often because the clients I work with have family and/or government agency involvement that either pay for the clients to reside in the congregate care setting or have a lot of involvement and varying expectations for notifications and participation in treatment. Lately I have been working with a lot of clients who are legally of age and their own guardians, however, they still have family involvement and DCF is “paying for their bed”. It has been increasingly challenging to determine what I am and am not able to disclose to funders due to some of my confusion around confidentiality. I tend to ask the client directly what they are comfortable with me disclosing and I also seek supervision and guidance whenever I am in a bind. That said, I have received an angry email or two in the past from funders expressing frustration when I don’t notify them of something involving the client. I think a big part of the challenge is the culture of congregate care, and helping parents and outside agencies to understand that my obligation is ultimately to the client.

    (2) What required duties beyond therapy do you find the most frustrating and/or least enjoyable?  Why?

    I am assuming that my response will be similar to those of my peers, but paperwork is most certainly the most frustrating and least enjoyable required duty for me. In my current agency, paperwork takes up a massive amount of time and is super tedious and redundant. Our electronic health record seems incredibly outdated and is so frustrating to use. I also feel like I have to write several variations of the same progress note or treatment plan component in a million different places in order to be compliant with my agencies/the states expectations. On top of all the other expectations of my role, I feel like the added requirement of having to complete so much paperwork really takes away from my ability to meet with clients and doesn’t always seem truly necessary or efficient.

    Reply

    • Yen Pham
      Jun 28, 2022 @ 22:55:50

      Hi Alison,
      I agree with you that paperwork is not really enjoyable for us because it took us much time to complete it and sometimes it seems redundant as you discussed. During my internship, after meeting each client, I was responsible for updating clients’ paperwork in a common system of the center. Then every week I have to update this information for the supervisor, and every month I have to update this information for the DCF worker as well.

      Reply

    • Tayler Weathers
      Jun 30, 2022 @ 10:23:52

      Hi Alison!
      I totally agree – confidentiality can be tricky when the relationship isn’t a little therapist-client bubble. I think that’s interesting that agencies want notifications and participation – it makes me frustrated that they don’t seem to understand ethics themselves, yet are controlling their client’s access to therapy. I like the idea of asking the client directly! Families are tough too – I was in a at my internship I worked a lot with minors, where the boundaries are also a little fuzzier. For example, with a 10 year old client, I would tell the parents most things (in general/vague terms); but with a 16 year old, I wouldn’t. It’s tricky! I’d ask the parent what kind of feedback they expected (emails, phone calls, in what depth, etc.) and would usually send out something vague-but-enough if they wanted updates (like an even more watered down progress note!). This feels like a decent compromise, but it doesn’t always feel great.

      Reply

  3. Anna Lindgren
    Jun 28, 2022 @ 16:08:18

    I think that thorough documentation might be one of the more difficult things to maintain for ethical issues. Because of the huge amount of paperwork that is already required for the job, people may not think to document things that aren’t explicitly required by their agency or MCOs. There were a few times at my internship that I had collateral contacts or conversations with clients’ parents that weren’t an overt ethical issue, but when talking with my supervisor about them we agreed that they should be documented and put in the client file just in case something happened down the road. Having that documentation to look back on and remind you of what was actually said and how you responded can be a life saver if you end up in a legal or ethical dilemma (which I thankfully haven’t yet… knock on wood!).

    At my internship, all interns were required to have two case management hours per week where we had available time to assist town residents with housing assistance, fuel assistance, applying for DMH benefits, or just helping people with whatever they walked in with. This was definitely my least favorite part of the job, because most of the time when I was helping a case management client, I had never seen the piece of paperwork I was “helping” them with before, which was frustrating for all involved. I did learn a lot about the resources available in the area, though, and I feel more confident in my ability to point future clients in the right direction of accessing needed resources.

    Reply

    • Alexa Berry
      Jun 29, 2022 @ 10:15:35

      Hi Anna,

      I definitely felt similar frustrations during internship. I actually enjoyed doing case management for my existing counseling clients because I felt that it was profoundly contributing to their ability to engage or make progress in treatment! However, meeting with people from the community who we often times had little or no contact with prior to their appointment made things very difficult when we didn’t even know what resources to utilize. I’m glad we had the experience to build that skill, but I can’t say its something I will seek out in a future employer!

      Reply

    • Maya Lopez
      Jun 29, 2022 @ 14:41:16

      Hey Anna,

      I remember that was a learning curve for me when I first started my internship, thinking “I can’t even think about a client without documenting it”. We had so many different forms for when we called clients, collateral contacts, etc and there was always a timestamp needed with a. description of what was discussed and it began to really add on to my time because even if we need to make a call about a client we then have to take the time to document it with quality too! I also think you make a good point about what to include or not include in a note because sometimes we may get carried away and write down everything but this could take up too much time! It can be hard to stay efficient and high quality. I love that your internship let you schedule in time to do case management duties because they can begin to pile up! Not to mention trying to do case management things on Telehealth where we can’t see the documents is frustrating and not to mention for me, I didn’t even know much about the programs offered in MA having been from NY it was new for me and felt way out of my expertise.

      Reply

    • Cailee Norton
      Jun 29, 2022 @ 21:47:45

      Anna,

      I can totally understand why that would be frustrating and hard to keep up with at your agency! The sheer number of services, assistance programs, and other resources that are out there can be a lot to face, especially when on the phone with someone seeking out more information. I’m glad you were able to take that time to really learn more about those services to better prepare yourself for future clients, as this is a valuable resource wherever you go!

      Cailee

      Reply

  4. Alexa Berry
    Jun 29, 2022 @ 10:11:01

    Based on table 2.2 one of the outlined best ethical practices that raises some thoughts regarding it being challenging is caution with social media. Outlined in the “what you should consider” is the idea that counselors should consider private settings for their content because client’s do search for counselors online. “You should keep all your social media private in case clients try to look you up” is a sentiment that has been expressed to me before by other professionals in helping professions. My issue with this is why should I have to sensor my content because a client is curious? I have never felt the need to “private” certain profiles on social media platforms and I don’t intend on having my occupation control my life outside of work. To me, it is more worth knowing why a client felt it would be useful to access my personal content (not that I think they would ever bring it up that they had been looking). It is my intention to have an outlet for professional content that can be available for online information, and I have a LinkedIn account up and running! Beyond LinkedIn, I will now allow for any “following” or “friending” on social media, but again do not feel the need to sensor my content by privatizing my settings in the off chance that a client wants to look me up on Instagram.

    The required duty beyond counseling that I find the most frustrating is paperwork. I obviously see the utility in keeping documentation (i.e., in case of audits, appropriate treatment based on diagnosis, liability purposes). However, sitting down to write a progress note during my internship was a grueling process. Writing documentation is not difficult, but it is the most tedious task and arguably the bane of my existence as a counselor. I guess I do not have a great reason other than I just loathe paperwork and the way it seems to constantly be piled up. I felt like there were days during internship where I could do paperwork all day and still not make a dent in what I had to get done. I was “reassured” by my supervisor that it will get easier over time once I become more efficient writing them, but I think that was easier for her to say from an administrative role where she did not have to frequently write treatment plans, progress notes, and discharge summaries

    Reply

    • Maya Lopez
      Jun 29, 2022 @ 14:47:38

      Hey Alexa,

      I completely agree, it is a tedious task writing progress notes because sometimes everything that occurred seems very important to include and it does take up some time since, like you said, we aren’t as efficient as other people are! I do however like that prior to sessions I can review what was discussed last session and what my plan was for the current session, I find that helpful. But it can certainly feel like there is always paperwork nagging to be done and sometimes we want a break but unfortunately it shoots us in the foot to take one because then we may stay late finishing up the note we didn’t write or have a discharge summary to complete on the weekend.

      Reply

    • Anne Marie
      Jun 30, 2022 @ 10:15:49

      Hi Alexa, I agree that paperwork is tedious and I tend to procrastinate it as much as possible. However, I have found that by scheduling a time to get it completed it has helped. I also agree that social media is a fabric of our society. However, as professionals we need to continually be thoughtful of what we post, even when we assume it is private as clients and colleagues may end up having access to it. I have seen professionals reputation be called into question based on their posts. Whether it be violent content, sexy photos, or even taking vacations after they called out sick. I think for the most part people recognize that we have lives outside of work but what we choose to post about it on social media matters. Whether it should or not is almost irrelevant.

      Reply

    • Alison Kahn
      Jun 30, 2022 @ 14:51:40

      Hi, Alexa!

      I totally agree about the paperwork. That is the most frustrating thing for me, as well. I have to take literally an entire day remote if I want to put a dent in my progress notes. So annoying!

      Reply

  5. Maya Lopez
    Jun 29, 2022 @ 14:33:44

    (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.

    I think only practicing in our area of expertise is hard because in the program we have learned a lot about different disorders and how to treat them. This doesn’t make us “experts” however I think it fuels our confidence to want to help individuals when we hear of something we have information on. We may have the intentions of helping but only knowing surface level information, we may find ourselves in deep water. I also think it could be hard to honest with a patient that we are not experts in that because they may say “well why not? didn’t you go to school for it?”. It also may be especially hard if the patient has established a good relationship and rapport they may want to continue discussing the subject with the therapist they have. I also thought the one about billing was hard but not what was mentioned in the book, the correct and truthful billing seems fine but if a client was recently unemployed or going through a hard circumstance it may be hard for me as an empath to still bill them if they do not have the money or want to continue but cannot pay. This is why I hope I have someone else who can handle this because it may be hard for me to set that firm expectation and stick to it.

    (2) What required duties beyond therapy do you find the most frustrating and/or least enjoyable? Why?

    I find the lease enjoyable part beyond therapy is doing case management, when clients have issues with transportation or living arrangements and do not have their basic needs met it can be very hard to practice self-care or other means for treatment. I also find completing referrals, DCF, elder abuse, wellness checks, sectioning and all these duties to be a bit scary and only frustrating if my schedule does not allow for the time for me to complete these things, which occurred in my internship.

    Reply

    • Connor Belland
      Jun 30, 2022 @ 18:59:33

      Hey Maya,
      I think you are so right about not being an expert in something that we have learned about. We have learned about many things but only briefly which by no means makes us experts. I do think working with clients that present with things we aren’t familiar with can be a good way to learn about those things though.

      Reply

    • Yen Pham
      Jul 02, 2022 @ 10:41:37

      Hi Maya,

      I agree with you that the expertise of a counselor is important. This expertise, although we have learned in school, does not let us meet the needs of our clients. Like you, I was not confident and uncomfortable working with a client if my expertise is not good enough. However, more expertise will be accumulated when we have the opportunity to work and learn from supervisors and colleagues.

      Reply

  6. Elizabeth Baker
    Jun 29, 2022 @ 16:23:59

    1) I would say protecting kiddo clients’ confidentiality was difficult during my internship. I, of course, was protecting their confidentiality, but it was difficult to speak with parents while withholding information. I was always questioning during check-ins and session summaries if I was breaking confidentiality or withholding too much. It was difficult to work with that boundary. Additionally, there were moments working with adjustment counselors that were even more challenging. There were instances where client-student conflicts occurred at school, and I had to gain more information about the situation. However, the counselor could not give me more information due to their duty to protect their students. This led to very frustrating conversations that seemingly went nowhere. Meeting with parents after was felt dissatisfying without having anything to work with, or feeling the situation was out of our hands.

    2) Case management was the least enjoyable for me. During my internship, we had case management clients on top of our clinical clients, and there were situations where there was not much I could do to help the clients. Due to the timing of the issue or not meeting qualifications, it felt dissatisfying to meet with them just to tell them they need to continue waiting (even with the threat of homelessness). It was a very heartbreaking experience. On the other hand, this expanded my knowledge of various resources available to clients!

    Reply

    • Anna Lindgren
      Jun 29, 2022 @ 18:32:50

      Hi Elizabeth!

      I felt very similarly about case management clients at our internship. I felt so out of my depth in an area that had such high stakes for folks! But I am very happy to have that case management knowledge base now going into our first year of working as counselors.

      Reply

  7. Beth Martin
    Jun 29, 2022 @ 16:55:12

    1) I think the most challenging ethical practice to uphold was protecting child confidentiality, and I know it’s a line other’s find difficult to manage too. I had to get very good at saying no very early on with some caregivers, and ensuring that children knew that I meant it when I said I’d only be telling people things if they or someone else was at harm. I felt that certain caregivers were trying to wear me down at times, and would frequently tell me that the previous clinician talking to them about xyz. I get it, I really do, and I’d rather a caregiver want to know what’s going on than be completely removed from treatment, but it can be so exhausting to have the same conversation over and over again, especially when a caregiver is used to a different approach (if they even were, I could never tell or if they were just trying to get me to move from my stance).

    2) I’ve found paperwork honestly the most frustrating. The population I’ve primarily worked with has a lot of children in foster care, which means signatures from DCF workers, and running things by foster parent (or biological parent if I’ve been given a release to inform them in treatment due to reunification etc.), and at times it feels like herding cats. DCF workers are absolute saints who are massively overburdened, and foster parents were telling me that they were being asked to take on extra kids because the state had no where else to put them, so I completely understand how extremely busy they were. That being said, playing phone tag for weeks and not being able to get updated medical information due to the DCF worker being swamped etc. was really frustrating, especially when you’d open your wee electronic record and see the big red words of “not signed”. I try to stay on top of my paperwork, and I just found it really unmanageable at times with this population.

    Reply

    • Anna Lindgren
      Jun 29, 2022 @ 19:30:09

      Hi Beth!

      I also at times struggled with what to share or keep from my kiddo clients’ parents. My agency definitely took the stance of including parents in treatment as much as possible, but I can imagine that line gets blurrier when working with foster parents and DCF. Also, you are totally right that DCF workers and foster parents are asked so much of them, that the whole system is spread way too thin.

      Reply

    • Cailee Norton
      Jun 29, 2022 @ 21:44:54

      Beth,

      I somehow did not have an instance of calling DCF within my internship at Assumption, but based on my experience in undergrad I absolutely feel your pain with paperwork and DCF. Like you mentioned, they are quite overworked, and getting them pinned down to talk at a certain time often felt impossible. The need for signatures on everything, while important for recognition of information and legal necessity, was also as difficult to get done as well. I wish there was a more streamlined effort for these types of things, especially at sites that have kiddos as their primary population, as to avoid the often unmanageable work load it can be.

      Reply

  8. Cailee Norton
    Jun 29, 2022 @ 21:40:51

    I think the one of the most challenging ethical practice to uphold is that of thorough documentation. I know from my site we had pretty extensive paperwork, and with the time crunch of the program it was a constant rotation of completing the same paper work over and over, and sometimes feeling like something was missing but not knowing where it was. I think that type of flow will always lead to that “oh shoot did I write that down yet” feeling, and it definitely took some time to get the hang of it. Documentation is so important, and all organizations emphasize the absolute importance of it, so it can be a lot of pressure just starting out. It’s importance covers all areas of our field, and so getting the hang of it now, or at least learning one organizations form of documentation is a stepping stone onto the next in our careers.

    I think doing any type of collateral calling, or even just calling in general, really is the least enjoyable part. Whether it’s due to my avoidance of phone calls anyway (who likes to call and order pizza, absolutely no one), or just uneasiness of potentially breaking the confidentiality within conversations, there’s just nothing really enjoyable about calling in regards to therapeutic needs. In my experience it always was a back and forth phone tag effort, and often felt like the least efficient way to be doing case management. I’m sure that the pandemic made a lot of these outreaches more difficult than they needed to be, but ultimately it felt like I was chasing others who simply didn’t want to be reached. Besides being a lesson in patience, I felt it sometimes took away from getting my client’s needs met, but that could be due to the time constraints of my internship versus others experiences of yearlong client contacts.

    Reply

    • Tayler Weathers
      Jun 30, 2022 @ 10:23:23

      Hi Cailee!
      I totally agree about collateral calls – I find it sometimes stressful to know what is appropriate to say, too! Particularly when the issue is something I feel the client should bring up with the contact (doctor, teacher, etc.), but I need more information about it! Also, the phone tag with collateral contacts is the WORST. I had doctor’s office I called maybe 20 times, left all the voicemails because they weren’t answering the phones, and never heard back from. Over months! And like you say – I was calling because I needed the information! Particularly when medications were involved and I needed to know what was going on because the client didn’t, it was really frustrating. I think this is an internship thing, because for example I never got to talk to that doctor, but I do wonder how much this happens in full-time practice too!

      Reply

    • Beth Martin
      Jul 01, 2022 @ 18:00:11

      Hi Cailee,

      Shout out to the masterminds that came up with online ordering apps, because I hear you on calling people (even for pizza, it’s just unnecessary). Calling collaterals is the opposite of fun, and I can imagine, with the population you worked with, it got stressful and really frustrating playing phone tag in the period of time you had your clients. It feels really yucky to have to do something that you feel is taking away from your clinical care/time to provide services too.

      It sounds like you had a LOT of paperwork at your site too – did you find any helpful tips that helped you keep on top of it?

      Thanks for sharing!

      Reply

  9. Tayler Weathers
    Jun 30, 2022 @ 10:24:34

    1. I think in practice, practicing only in areas of expertise can be the most difficult. For example, we only cover treatment plans on so many different types of client presentations as required classes in this program (e.g., kids, substance use, PTSD, depression and anxiety are all electives. You end up taking them, but you don’t technically have to). And, the Massachusetts licensure requirements don’t actually specify learning the treatment of any particular issues – only theories and what seems like general information. I know in my internship I ran into some issues I did not feel fully trained in, and I relied heavily on my supervisor to help me out. Once we are fully-autonomous therapists, I think there is a definite danger that we might encounter something we don’t know how to do, and could be placed in a position (for example in an agency) where we can’t extricate ourselves from that case. Supervision and consultation is obviously important in these situations, and can help with seemingly most issues. But I guess I have some apprehension that issues will come up that I don’t know how to handle, and I worry about how to get out of those situations so that I stay within the ethical boundaries.
    2. Honestly, I liked most of the duties beyond therapy! The ones I liked the least though at my internships were case management (as many of my fellow interns pointed out) and having to call people for logistical reasons and talking to collateral contacts. I found that talking to people with whom you have a therapeutic relationship about scheduling can be kind of tricky, as the client may want to spend 30 mins venting or talking about something. Or, they don’t answer because it’s not a scheduled thing!! Phone tag was the worst at my internship. And with collateral contacts, it’s a similar issue – I found that the contacts either had no idea what I was asking about (concerning), had a million hoops to jump through to get the information (beyond consent forms) or wanted to give me their very biased opinion on things when I would have preferred to not get that information. This was very frustrating as it took a lot of time and energy, and didn’t always seem to have significant gain. The one or two times I got ahold of someone useful were very worth it, though!

    Reply

    • Anne Marie
      Jun 30, 2022 @ 10:36:40

      Taylor, I agree that only working in our areas of expertise as a beginning counselor is tricky as we aren’t really experts in anything yet. Only through supervision, training, and experience will we become experts. I think recognizing when you are out of your depth is the first step. Also, focusing on a specific population can help to hone skills to become more versed working with them. This field is huge and there is so much literature out there. That is why I like that Assumption focuses primarily on CBT as I can continue to become confident in that model.

      Reply

    • Connor Belland
      Jun 30, 2022 @ 14:58:29

      Hi Tayler,
      I agree staying in your area of expertise can definitely be difficult. Some companies will just throw you in with whatever type of client even if you have no experience with that population especially in internship which is good experience but in the future we probably want to specialize with populations we like.

      Reply

  10. Anne Marie
    Jun 30, 2022 @ 10:31:32

    I have found that in working with children that they do not have the same level of confidentiality as adult clients. It is a tightrope walk of protecting the child’s ability to share openly with also providing caretakers and providers (DCF, schools, etc.) with enough information to be beneficial to the child and appear collaborative. In addition, I have also struggled with self-disclosure. I have found it to be a useful tool in connecting and relating to both kids and parents but there have been times when I have felt I over shared. On those occasions it has been when I have given specific details and not just general information. My intent was always in the best interest of the client but I felt that I may have overstepped a boundary and quickly regretted it. For example making statements such as “I have a strong willed child too. I understand how challenging it can be” may be seen as helpful versus “My child once did [xyz]” which crossed a line of my own child’s privacy.

    We are all writing paperwork here, right?! It is a necessary evil that has its benefits but is tedious and time consuming to complete. Our goals are to help clients and doing paperwork does not always feel like it is working towards meeting that goal. Even though it essentially does to some extent.

    Reply

  11. Carly Moris
    Jun 30, 2022 @ 12:45:31

    1.
    I think providing through documentation will be the most challenging thing for me. When doing session notes for my internship I would take extensive notes that usually took me a lot of time to complete (20-45 minutes). I did this because I was usually working with other clinicians and it was important for them to know what I had covered in session. It was also helpful for receiving feedback from my supervisor and coworkers on what I could do differently in sessions. However, in my future practice I won’t need to write up an account of everything that happened and was talked about in a session. This level of note taking also will not be practical for me in the future. So I defiantly need to find a balance for making sure that I document everything important that occurred during the session in a concise manner and making sure I’m not leaving anything out.

    2. One of the duties that I found most frustrating at my internship was the monthly treatment team meetings for clients. These meetings involved updating the client and their whole team on various domains (nursing, school, residential, etc). The people involved in these meetings included the client, clinician, case manager, transitional specialist, a residential staff, nursing, the psychiatrist, a teacher, parents, the parent partner, OT, DMH, and a DCF and/or DYS personal if they were involved. These meetings were held over zoom and due to the number of people involved they were usually hard to schedule. These meetings would usually run for 45min to 1 hour, but in some cases they would go over an hour and a half. One frustrating thing was that these meetings were not well organized; for example someone would need to leave halfway through the meeting but no one would make sure they spoke first. So people regularly would sit in these meetings for 30 minutes before needing to leave, without being able to give their update. When it would then get to their part of the update other individuals (usually parents or DMH) would be upset they were not there to give an update. This would then happen again next month. Another frustrating thing was that there were multiple occasions when DCF and DMH would get into arguments about about who is responsible for what services for the client. Most of the time they were professional enough to not have these arguments in front of the clients and/or their parents, on a few occasions they were not.

    Reply

  12. Connor Belland
    Jun 30, 2022 @ 14:52:13

    1. I think the ethical practice that I struggle with often times is the caution with self-disclosure. When I am building rapport with a client it is important to empathize with them and try to relate to them but often times I will get carried away sharing about myself in hopes that we will relate on something. I need to work on limiting or restricting myself from self-disclosing in many situations where I might have the urge too because in reality it probably isn’t as beneficial as I may think it is in the moment. The therapy is for the client they don’t want to hear about me, unless they ask about me and in that case I may share some things about myself but I need to develop a line of what’s good to share and where I should stay private. There are definitely other ways to relate and build strong connections to my clients.
    2. The least enjoyable required duty beyond therapy is definitely the paperwork. I often get distracted when I have to complete my paperwork so it takes me a long time to do. So then in my mind when I think about having to do paperwork I think that I need a large block of time when really progress notes should only take about five minutes each. This then leads to procrastinating the progress notes until the end of the week and then having to spend extra hours and trying to remember things that may have happened days prior. I need to work on doing the paperwork as soon as it comes up and not putting it off.

    Reply

    • Brianna Walls
      Jul 02, 2022 @ 21:30:09

      Hi Connor, I agree with you, I too sometimes caught myself self-disclosing too much information with my patients but I don’t believe I have ever shared something too personal. I used to talk about my puppy a lot and other times I would talk about my anxiety with them. Hoping it would help normalize their symptoms of anxiety.

      Reply

    • Elizabeth Baker
      Jul 03, 2022 @ 23:46:26

      Hello Connor!

      I agree with both points you have made. With self-disclosure, it feels sort of insensitive when you can not show you can personally relate to a similar issue a client presents. Of course, we have universality and statistical responses as the encouraged alternative response, but some clients may benefit more from self-disclosures. As you said, rapport is one of the most important therapeutic skills, and it feels that self-disclosure can be a great aid in strengthening rapport.

      To your point of getting distracted while completing paperwork, I could not agree more. I get so distracted and spend more time documenting than necessary. It is very frustrating!

      Reply

  13. Brianna Walls
    Jun 30, 2022 @ 16:13:03

    1. Based on table 2.2, one ethical practice that I think is the most challenging to uphold for myself is multiple relationships, also known as dual relationships. Personally, this was challenging for me during my internship at Harrington Hospital. Throughout my internship experience, I came across multiple patients that I knew and/or had past relationships with. When this happens, the clinician is inclined to refer the patient to a different clinician however, because I was an intern at a partial hospitalization program the clinicians would run at least one group per day. Therefore, even though these patients were not my individual patients I still had to run group with them present. This was awkward at times for me and sometimes uncomfortable but each patient that I knew was talked to by one of the other clinicians to inform them that I would be running group and if they would like to remain in the program or not. This was also difficult for me because when someone I knew came into the program, I wanted to tell my family/friends. So, not only were dual relationships challenging but confidentiality was just as challenging for me during my internship. I’m hoping wherever I end up working after I graduate; I will not run into as many people I know/knew.
    2. One required duty outside of therapy I find the least enjoyable is paperwork/progress notes. For obvious reasons, it is time-consuming and just flat-out boring. I also feel like it takes time away from other important things such as being able to meet your client hours per week. This is extremely important, especially for clinicians who are trying to get their license. Also, paperwork is very redundant and I feel like I would overthink my progress notes when I am writing them so they would take 2x as long as they should.

    Reply

  14. Abby Robinson
    Jun 30, 2022 @ 17:12:17

    1. I think that after working with a mostly adolescent aged population, child limits of confidentiality is something that is challenging for me. This includes things like mandating reporting, disclosing information to managed care or other professionals, etc. Although, by law, I cannot disclose information to others unless the client is at risk of harming themselves or others, some of the population that I worked with disclosed concerning things to me that I could not disclose to their guardians. As well as they would also withhold telling me things because they knew I would have to file a 51A with DCF. Managing this grey area/in between “stuff” was extremely hard for me as their therapist who wants the best for my client but also needs to be sure their treatment won’t be impacted while following all ethical requirements.
    2. Besides paperwork, I think that “working” with insurance companies is mentally and emotionally exhausting- this is dramatic I know. But having to reach out to get to someone to talk to on the phone is at least a 10-15 minute process and then I usually get transferred b/w insurance workers a few times and then nothing usually gets solved. I think this is something that we all will struggle with continuously as insurance policies are constantly changing and updating.

    Reply

    • Beth Martin
      Jul 01, 2022 @ 17:55:52

      Hi Abby,

      I found that “withholding” aspect of working with caregivers really challenging too – it was really hard to sit with, and definitely an aspect of working with minors that has made me second-guess whether I do actually want to work with children in the future.

      You aren’t being dramatic about being exhausted by insurance companies! I know you work with them a lot, and it sounds like a bureaucratic nightmare multiple times a day. Even if it wasn’t (which of course will never happen because insurance companies are like this on purpose, I swear), having to do the same thing over and over gets really mind-numbing, and I can imagine when you’ve got other things to do, it feels really pointless.

      Thanks for sharing!
      Beth

      Reply

  15. Nicole Giannetto
    Jun 30, 2022 @ 17:33:58

    (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.
    I feel that the most challenging best ethical practice to uphold would be thorough documentation, as well as upfront and clear informed consent. I also feel that as I go along in my career in mental health, that my answer to this question could change. One thing I want to be on top of is documentation. I think that through my internship I saw just how often people were behind in progress notes for their sessions. I think that when it comes to documentation completion, procrastination can have especially negative impacts, and is unethical when it comes to therapy. In regards to clear informed consent, I would want to be extra on top of legal aspects of informed consent, and additionally, I would want to practice in order to present as clear and assertive when communicating serious legal practices. I think I would be able to achieve this through practicing, as I will be able to become more confident in my own style and how I can communicate with my client about safety.

    (2) What required duties beyond therapy do you find the most frustrating and/or least enjoyable? Why?

    I find that one of the least enjoyable required duties beyond therapy is the extra documentation. Although documentation can be necessary and valuable, I do think there can be easier ways of completing documentation for clinicians, that does not require the extra time. For instance, at my internship, when clinicians went to start a progress note, they were initially mainly blank. This meant that each time the clinicians needed to write a progress note, they needed to fill out the same information. After they worked to adopt a new electronic health record, clinicians were able to start a progress note that was already filled out with the required basic information. Through my observation, this technological change in the organization made work completion more efficient and employee satisfaction increased.

    Reply

    • Brianna Walls
      Jul 02, 2022 @ 21:25:22

      Hi Nicole, that must have been so frustrating before they changed to a different system. It is time consuming when you have to rewrite the same information over and over again. Glad they ended up upgrading though! Thankfully at my internship we were able to copy forward basic information so we didn’t have to rewrite it. This was helpful considering we wrote multiple progress notes for the same patient a day because they attended 5 groups a day.

      Reply

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Adam M. Volungis, PhD, LMHC

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