Daily Archives: August 8, 2010

Dual Relationships in Rural Areas


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Having grown up in small north-central Iowa town (population 2400), I can totally identify with the Nickel premise that extra-therapeutic contact “is not only unavoidable at times, but, under certain conditions, even uniquely beneficial.”  (Nickel, 2004, p. 17)  Smaller communities are indeed more interdependent, inevitably leading to situations where there are simultaneous overlapping relationships.  In a town the size of Eagle Grove it is a foregone conclusion that if you work with anyone in the community, you know most if not all of the significant others in that person’s life.  We used to joke that it was “unusual if a neighbor didn’t take note of what color underwear you were wearing today.”  The reality is that the closest hospital, or referral source for mental health treatment, would be 30 miles away.  That’s an insurmountable distance for some people who need access to local mental health facilities.

I wholeheartedly agree with the statement that “rural culture often upholds the prevailing notions that outsiders are not to be trusted, and that a community should care for its own.  (Nickel, 2004, p. 19)  I submit that it would be extremely difficult to a therapist to be successful in the absence of such multiple relationships, because it is those relationships that foster the foundation of the working relationship needed to make lasting progress in a mental health setting.  In any case, there are systemic risk assessments that should likely be engaged in.  “Age, diagnosis, life experiences such as abuse, and culture are key elements that need to be considered in establishing boundaries.”  (Corey, Schneider-Corey, & Callanan, 2007, p. 282)

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References

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

Nickel, M. (2004). Professional boundaries: The dilemma of dual & multiple relationships in rural clinical practice. Counseling and Clinical Psychology Journal, 1(1), 17-22. Retrieved from http://web.ebscohost.com.ezproxy.bellevue.edu/ehost/pdfviewer/pdfviewer?vid=2&hid=17&sid=1c482e9f-e9cf-44cc-a08d-39a86f74b8f3@sessionmgr10

Couples Counseling


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Stratton & Smith (2006) suggest that supervisors should be responsible for facilitating learning in three general areas of functioning: ethical knowledge and behavior, competency, and personal functioning.  I believe these elements are absolutely crucial to instilling a sense of trust that is foundational for conjoint treatment.  Specifically, this essay will address the issues of fidelity, competence, and reproduction issues within the context of conjoint treatment of couples.

Within the context of ethical knowledge and behavior, the article addresses fidelity, multiple role relationships, and confidentiality.  Specifically, fidelity refers to the working relationship, or therapeutic alliance, between therapist and client(s).  This therapeutic alliance is less explicit because in couples therapy because the counselor has to maintain individual relationships with two consumers instead of one.  Perhaps most importantly, the therapist has to attend to a 3rd relationship… the relationship between the clients.  A recent inquiry into the relationship between therapeutic alliance and treatment progress in conjoint psychotherapy concluded that the relationship with the therapist accounted for 5-22% of the variance in improvement in marital distress.  (Knobloch-Fedders, Pinsof, & Mann, 2007, p. 245)  The value of the therapeutic alliance cannot be underestimated within the context of couple counseling.  To that end, I endeavor to continue to develop my awareness and skills as it relates to the concept of fidelity as it relates specifically to conjoint treatment.  Specifically, I anticipate reaching out for consultation and guidance when I have difficulty balancing the needs of the relationship when compared and contrasted with the individual needs of each of the parties.

Competence is a criterion for supervision that is not confined to couples therapy, but couples therapy does present a different dimension to competence that is inherently different than that of individual therapy.  “When conducting evaluations or providing feedback, it may be helpful to keep in mind a developmental model of supervision whereby the trainee may be achieving certain levels of competence as an individual therapist but may be at quite a different stage in his or her work with couples.”  (Stratton & Smith, 2006, p. 346)  To that end, I endeavor to continue to develop my competence as a couples’ counselor through continuing education, ongoing guidance and consultation, and exploration of relevant contemporary research.  One more recent study, for example, has attempted to fuse the concept of hope, translated as “a belief and a feeling that a desired outcome is possible,” with couples therapy.  This marriage of hope and couples therapy encourages us to consider the ways in which hope (or hopelessness) is influenced through relational processes between the therapist and the couple, and between the couple themselves.  (Ward & Wampler, 2010)  Investing in the concept of hope can have a lasting impact on our competence with conjoint therapy.

Within the context of personal functioning, the article addresses religious beliefs, reproduction issues, same-sex couples, as well as culture and ethnic affiliation.  We often underestimate the trauma associated with terminated pregnancies and infertility issues.  A recent study “identified three key coping strategies- distancing, self-controlling, and accepting responsibility- that were significantly related to couples reports of infertility stress, marital adjustment, and depression.”  (Peterson, Newton, Rosen, & Schulman, 2006, p. 234)  Coping with the loss an unborn child, and the expectations that come with it, is a traumatic situation for couples that come to us for guidance and support.  To that end, I endeavor to give this situation its proper attention.  It is my intention to guide these clients through the process of grief, while continuing to encourage and nurture communication and bias recognition among those who have endured reproduction issues.

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References

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

Knobloch-Fedders, L. M., Pinsof, W. M., & Mann, B. J. (2007, Apr). Therapeutic alliance and treatment progress in couple psychotherapy. Journal of Marital and Family Therapy, 33(2), 245-257. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1270855501&sid=25&Fmt=3&clientId=4683&RQT=309&VName=PQD

Peterson, B. D., Newton, C. R., Rosen, K. H., & Schulman, R. S. (2006, Apr). Coping processes of couples experiencing infertility. Family Relations, 55(2), 227-239. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1023544611&sid=23&Fmt=4&clientId=4683&RQT=309&VName=PQD

Stratton, J. S., & Smith, R. D. (2006, Fall). Supervision of couples cases. Psychotherapy: Theory, Research, Practice, Training, 43(3), 337-348. Retrieved from http://csaweb107v.csa.com/ids70/display_fulltext_html.php?SID=7ebrnqjm09j979884nptv0vg23&db=psycarticles-set-c&an=2006-12148-011&f1=0033-3204,43,3,337,2006&key=PST/43/pst_43_3_337&is=0033-3204&jv=43&ji=3&jp=337-348&sp=337&ep=348&year=2006&mon=10&day=0033-3204,43,3,337,2006

Ward, D. B., & Wampler, K. S. (2010, Apr). Moving up the continuum of hope: Developing a theory of hope and understanding its influence in couples therapy. Journal of Marital and Family Therapy, 36(2), 212-228. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2016011871&sid=9&Fmt=3&clientId=4683&RQT=309&VName=PQD

Family Systems Theory


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Although I wouldn’t have considered myself a family systems theory advocate prior to taking this course, I have becoming increasingly fond of the perspective.  I do not believe you can work with a client, either individually or in the context of family therapy, without attempting to understand the systems (family, work, community, church, and other relevant social systems) that exert influence on and ultimately play a role in the decision making of an individual.  Regardless of whether I intend to work specifically as a family systems therapist, I think a foundation in family systems theory is needed in order to ethically and adequately treat individuals.  It’s even more important when working with couples or families, but I believe that is implicitly implied when you apply it to the individual.    As an aside, this is a great entry point for our earlier conversation about multiculturalism.  Culture is, by definition, is a bidirectional system that both exerts influence on, and is influenced by, our clients.  So, since we have all agreed previously that culture is a consideration we need to account for when providing mental health services, we are by default systems theory advocates (even if it is on a macro level).

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Client Crushes


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I think crushes on therapists happen a lot more than we actually realize.  It’s so common that Sigmund Freud coined the term “transference” to describe it.    Transference likely occurs in this context because clients are only exposed to the “ideal image” of a counselor.  The therapeutic environment is generally safe and supportive, and within that context, the clinician can be seen as a “provider.”  Within that environment, clients usually engage in what is likely one of the most intimate relationships clients will ever have… clients often tell clinicians things they wouldn’t tell anyone else!  Isn’t our job to be caring, responsive, thoughtful, and generally concerned for our clients?  Unfortunately, we reside in a world that is anything but that.

What are the signs of a client that a client has a crush?  Signs might include a client wearing suddenly provocative or revealing attire.  A client may compare the therapist to people in their own lives, like a spouse or a parent.  The client may verbalize expressions of love or adoration, or the same may manifest in the form of unexpected gifts.  The client may start asking more personal questions, like what the therapist likes to do, movies that they like, etc.  They may also ask questions about your relationships, your marital status, your children and their ages.

It is probably one of the more awkward positions for a therapist to be in.  If a client finds themselves attracted to a clinician, I would definitely encourage them to convey that to the therapist.  Having a client reveal their innermost feelings and ideas is at the core of psychotherapy.  Unfortunately, the client themselves is short-changing themselves if they don’t reveal the “crush.”  This is especially true if a client is intentionally hiding “undesirable traits or feelings” in effort to gain favor or “appear more normal” for the therapist.  It’s certainly not anything to be ashamed of.  Despite the fact that we are prone to be adored, I think we really need to keep a level head about the whole situation… in reality, if our clients really “knew” us; we probably wouldn’t be so attractive.  I can see how it would be easy for a therapist to be delusional with all this envy going around.

How would I respond?  In the case of an inexperienced clinician, there is good potential for those feelings to “get in the middle” of the client-counselor relationship.  As a result, a referral might be in order if the client has repeatedly crossed boundaries (like repeatedly calling the therapist at home during odd hours, or showing up at their residence unannounced, etc).  However, I would consider a referral as a less than ideal situation.  Ideally, a client’s feelings for a counselor can be employed and explored to help the client understand a great deal more about themselves.  If we can drive to the source of that transference in a professional manner, perhaps that can be utilized as a choice opportunity to advance our client’s best interest.

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