Daily Archives: August 4, 2010

Impact of Values and Religious Beliefs on Therapy


On this we can agree; the idea that psychotherapy is value neutral is no longer tenable.  (Corey, Schneider-Corey, & Callanan, 2007, p. 78)  As we strive to maintain our prospective clients’ autonomy, it is important that we be honest and open with ourselves regarding our personal values and how those values affect the client-therapist relationship.  Values can impact that relationship directly and indirectly, and that impact can manifest as conscious effort on the part of the therapist or (perhaps more importantly) subconsciously.

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We as therapists are trained not only to listen, but to interpret the context and sub-context of therapeutic discussion.  Without consciously or implicitly doing so, it is entirely possible that we as counselors can lead clients to our predetermined conclusions (goals) and subsequently rob them of the ability to make that choice.  Self-determination is a key component in goal setting, and to what degree it is possible, it should be client driven not therapist driven.

Goals are usually based on values and beliefs, and clients may adopt goals that the therapist thinks are beneficial.  (Corey et al., 2007, p. 79)  I think this is of particular significance when you encounter a client who is indecisive about his goals.  To use couples therapy as an example, I anticipate that we will encounter situations where one party or the other insisted on counseling as a way to help resolve marital issues.  The “other half” may come to the table with little more than wish to fulfill the other person’s desire for marital counseling, and subsequently not have clearly defined goals to express to the counselor.  Even a well intentioned clinician is prone to suggesting possible goals for the indecisive other half, but even those gentle nudges have potential to skew the goal setting process and subsequently impair the ability of the couple to engage each other in the cooperative effort of goal setting.

I would suggest that, generally speaking, our own personal values can best be exposed in the form of a question.  Unfortunately, even the process of questioning our clients leaves potential for the client-therapist relationship to be inexorably altered by the values that produced the question in the first place.  For example, if we decide to proceed with a line of questioning involving religion and the role the spirituality plays in a specific clients life (on the basis that it plays a role in our lives) we may be wasting our time “drilling down” on the topic unless the client themselves shows interest or otherwise shows concern for religious or spiritual considerations.  If we ignore the absence of a response and continue to drill the religious line of questioning for our own benefit, we would be doing a disservice to our clients.

Conversely, if our client is passionate about religion and spirituality, and we do not share those beliefs… we do an equally damaging injustice to the client by passively ignoring those responses in favor of lines of questioning that better fit our own personal worldview.  When counselors fail to raise the issue, clients may assume that such matters are not relevant for counseling, and counselors may be guilty of excluding an important issue of diversity and experience.  (Corey et al., 2007, p. 93)  So our ethical concern is twofold, it is contained not only in what we do and say as it relates to sensitive subjects like religion, but also in what we choose NOT to do or say.  The ethical issue lies in our ability to choose to ignore (or otherwise gloss over) considerations that play a crucial role in our clients decision making processes, simply because we do not employ them in our own structures of decision making.

We should be consideration of clients who are in a crisis situation, and acknowledge that the spiritual domain may be a source of comfort and support.  Consequently, clinicians must remain open and nonjudgmental when discussions in this realm occur.  (Corey et al., 2007, p. 94)  This can be done without implying support for specific religious beliefs.  (Corey et al., 2007, p. 95)

Religious dogma is not part of the theoretical foundation of psychotherapy.  Therapists should neither impose their religions views on clients, nor should they pretend to be experts in religion any more than they are in medicine, culture, finances, or any other related area.  (Corey et al., 2007, p. 99)  If religion and spirituality plays a predominant role in the decision making process of a client, and we are operating outside of what we consider to be our own competency, it is imperative that we utilize a multi-disciplinary approach that utilizes religious resources when appropriate.  Leveraging the expertise of our colleagues and the religious community can allow us to continue to play a positive role in conflict resolution, all while allowing the systems we lean on to address the intricacies of faith.

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Reference

Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th  ed.). Belmont, CA: Brooks/Cole.

Countertransference: Ethical Implications


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Countertransferences represent “projections by therapists that distort the way they perceive and react to a client.”  (Corey, Schneider-Corey, & Callanan, 2007, p. 57)  Conversely, the Oxford Dictionary of Psychopathology further refines that basic definition of countertransference as follows:

Counter-transference (noun) In psychoanalysis, the analyst’s emotional reactions to the patient and to the patient’s transference, influenced by the analyst’s unconscious needs and conflicts.  It should be carefully distinguished from the analyst’s conscious reactions to the patient.  It was first mentioned by Sigmund Freud (1859-1939) in 1910 in an article on ‘The Future Prospects of Psycho-Analytic Therapy.’  Since the 1970s there has been an increasing tendency in psychoanalysis to exploit the counter-transference in a controlled manner as part of the technique of psychoanalysis, support for this approach being drawn from Freud’s comment in 1913 in an article on ‘The Disposition to Obsessional Neurosis’ that ‘everyone possesses in his own unconscious an instrument with which he can interpret the utterances of the unconscious in other people.’ (Colman, 2009, p. 177)

Using the latter definition, countertransference isn’t necessarily something we clinicians should avoid.  If instead we recognize, monitor, and manage our “output,” we can elicit genuine responses from our clients.

Consider the following example of psychotherapy of a military service member.

Just as a therapist avoids zealously demonizing the abuser in the therapy of a sexually traumatized borderline patient, the therapist avoids relishing in bloodlust or on the other extreme, exhibiting strong outward repugnance to combat while in the service of the patient’s therapy.  To do the former or latter could result in the patient closing off a valued aspect of themselves to the therapist, leaving the conflict maintained and the maladaptive behavior perpetuated.  (Kim & Gray, 2009, discussion para. 1)

As I reflect on the wide range of possible voluntary and involuntary reactions to the blood-spattered details of combat, I have to confess that I am probably prone to exhibiting disgust, and subsequently rejecting the client.  Generally speaking, the thought of hostility repulses me, yet it remains a constant concern (and source of post-traumatic stress) for our military service members who have served in combat.  Imagine the result if I were to share this aversion with a combat veteran without properly positioning the context.  It would inexorably poison the professional relationship, and it could potentially obstruct any attempt to proceed with psychotherapy in a productive manner.  There are a number of possible solutions to this dilemma.

Perhaps the solution to the predicament is to demonstrate some measure of therapeutic neutrality.  Neutrality has the therapeutic value of encouraging the patient to think for him or herself, and the ethical value of helping to avoid undue influence of the patient on the basis of the therapist’s values.  (Bishop, Josephson, Thielman, & Peteet, 2007, para. 2)  It could be argued that we could bottle up those concerns and allow for the therapy to continue.  Without a doubt, this is the “safe route.”  However, I believe in this situation it might be appropriate to push the boundaries of neutrality.

There is an alternative.  Individual psychotherapy with adults, if it is to foster such maturity, will accordingly adopt a flexible approach to the rules of therapeutic neutrality, balancing respect for the patient’s right to make his or her own choices with an acknowledgment that certain of the therapist’s values and beliefs will implicitly, and sometimes should explicitly, find expression in the therapeutic process.  (Bishop, Josephson, Thielman, & Peteet, 2007)  What I am suggesting is my reaction may be the reaction that he expects, and perhaps has even experienced when he has shared details of war with his support system of trusted friends and family members.  It is not out of the realm of possibility that the repulsive reaction itself is one that military people fear, and that subsequently contributes to one aspect of his post-traumatic stress.

So, instead of repressing that reaction and advocating therapeutic neutrality, I would suggest that we wield it to the benefit of the client.  I am implying that we could impress a line of questioning that addresses his support system, his friends, family, and trusted associates.  We could ask them if they have shared that experience with them, and subsequently ask the client what their reactions were.  We could continue that line of questioning to inquire about concerns regarding the sharing details of combat with his support system for fear of their reaction.  Inevitably the outcome of the discussion is indeterminable until it actually happens, but the end result is that our internal conflict as clinicians has been sufficiently leveraged to induce a positive line of questioning.

I would suggest this strategy has benefits for the client, the clinician, and the interplay of the clinical relationship.  Personally, not addressing the issue would cause me stress, which could inhibit my ability to perform my clinical duties.  Properly employed, a situation that was initially conceived negatively could be twisted to the benefit of the clinical relationship.  Ideally, the discourse would succeed in uncovering stressors that would have remained unaddressed otherwise, benefiting the client.  If, instead, we had remained neutral… we easily could have missed an opportunity to add value to the clinical relationship.

In closing, we should prepare ourselves for the inevitable event of conflicting feelings and values with our clients.  I believe this can be achieved through self-assessment and a rigorous commitment to accessing our emotional inventories. As our clinical experience grows, and our confidence grows with it, we should not only aspire to avoid the conflicts of countertransference, but aspire to wield it to the benefit of our clients.

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References

Bishop, L., Josephson, A., Thielman, S., & Peteet, J. (2007, Spring). Neutrality, autonomy and mental health: A closer look. Bulletin of the Menninger Clinic, 71(2), 164-179. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1317594011&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

Colman, A. M. (2009). Oxford dictionary of psychology (3rd ed.). Oxford, NY: Oxford University Press.

Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th  ed.). Belmont, CA: Brooks/Cole.

Kim, E. H., & Gray, S. H. (2009, Fall). Challenges presenting in transference and countertransference in the psychodynamic psychotherapy of a military service member. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 37(3), 421-438. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1871852121&sid=5&Fmt=3&clientId=4683&RQT=309&VName=PQD

Moral Principles to Guide Decision Making – Aspirational Goals of Universal Healthcare


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The purpose of this article is to frame the rational discussion of universal healthcare and equal access as it relates to the moral principle of justice.  Although the definitions of justice are many, for purposes of this discussion we will recognize the American Psychological Association’s (APA) official definition of justice as cited in the APA ethical code.  The complexity of the issue, compounded by the intensity of the debate, will inevitably raise more questions than answers.  The rationale is that by employing a decision-making model to the ethical dilemma of universal healthcare, we can guide the discussion in a productive manner by attempting ask educated questions.

The APA is unambiguous regarding equal access to psychological services.  The affirmation positions equal access as a mandatory requirement, not an aspirational goal.  Psychologists recognize that fairness and justice entitle all persons to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures, and services being conducted by psychologists.  (American Psychological Association [APA], 2003, p. 3)  We could extrapolate that statement as an admission of support for the underlying principles of universal healthcare.  The class text echoes this very sentiment with the declaration that Everyone, regardless of age, sex, race, ethnicity, disability, socio-economic status, cultural background, religion, or sexual orientation, is entitled to equal access to mental health services. (Corey, Schneider-Corey, & Callanan, 2007, p. 21)

Equal access is a challenging proposition in a nation that cannot come to consensus on universal healthcare.  The political right would have us believe that’s not what the medical community or the patient population want.  The dwindling number of doctors who accept Medicare patients resent politicians and government bureaucrats threatening their fees and meddling with their judgment.  This has aided the rapid expansion of private “concierge” medicine for seniors who can afford it and for physicians who demand more than what Medicare offers. (Gingrich, 2009, p. 7)

Meanwhile, the frontlines of U.S. healthcare providers are clamoring for a single-payer universal healthcare system.  The California Nurses Association/National Nurses Organizing Committee (CNA/NNOC) co-president Geri Jenkins said any measures short of extending Medicare to provide universal coverage would fail, adding “That’s the majority of the nation’s nurses and doctors – the very people who have the most daily interaction with our healthcare system and see its failures and tragedies up front, favor a single-payer approach, or expanding Medicare to all.” (“Nurses call”, 2009, p. 3)

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References

American Psychological Association. (2003). Ethical principles of psychologists and code of conduct. Retrieved March 18, 2010, from http://www.apa.org/ethics/code/index.aspx

Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th  ed.). Belmont, CA: Brooks/Cole.

Gingrich, N. (2009, Feb). The Market Can Fix the Problem. U.S. News & World Report, 146(1). Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=36883618&site=ehost-live

Nurses call for universal healthcare in US. (2009, Apr). Australian Nursing Journal, 16(9), 2/5. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=37215736&site=ehost-live