Tag Archives: Trust

Paranoid & Delusional Disorders

The boundary between normal and abnormal appears to be largely subjective.  “One person’s excessive suspiciousness is another’s due caution, and one person’s trust is another’s gullibility.”  (Blaney & Millon, 2009, p. 362)  The “trade-off between vigilance and vulnerability” is something I had not considered… that balance is perceived to be the issue when it comes to paranoid personality disorder (PDD), paranoid schizophrenia (PS), and or delusional disorder (DD).  “Any stubborn genius will have ideas that happen to be wrong as well as those that happen to be right.”  This observation seems to suggest that the people who often suffer from these disorders are extremely intelligent, and thus, may have some beliefs that are in fact sane, relevant, and true.  It would suffice to say that I am going to use caution when pursuing this diagnosis… Einstein was considered to be delusional!

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Most studies that have been done to date have focused on persecutory delusions… either by design or because they are more common and subsequently easier to find suitable samples.  Persecutory delusions involve a degree of suspiciousness, or are generally mistrustful and/or wary.  It is suitably difficult to measure the tangible levels of suspiciousness via self report, however, since some sufferers may be too guarded to admit that they are suspicious.  The very process of self report is likely to “trip the defenses of” and subsequently increase guardedness.  Further compounding the efficacy of self-report inventories is the issue that sufferers may be reporting reality, betraying hypersensitivity, or some combination of both.  This highlights the necessity of multiple-peer reports that can confirm the interpersonal difficulties of the sufferer.  We, as clinicians, will have to be diligent about securing 3rd party sources (schools, work environment, relatives, other individuals whom are close to the client) in order to get as many perspectives on the conditions as possible.

There are several dimensions of delusions… most notably belief certainty (emotional commitment, conviction), self-monitoring (insight), distress, and frequency.  I was particularly interested in the “double awareness phase” in which a patient wavers between embracing a delusion and recognizing that its delusionality.  Of note, is the observation that psychotropic medications reduce engagement in delusions, thereby improving overall functionality, but ultimately leave actual beliefs untouched?  This seems to parallel the overall trend of medications “treating the symptoms and not the cause.”

Some patients may possess some distinctly protective attributes that account for the fact that they do not become delusional.  As a result, quasi-delusional or aberrant beliefs may not always be associated with clinical conditions indicative of a general mental disturbance or distress.  For example, low levels of anhedonia and high levels of openness are commonly thought to be a psychological asset… despite the fact that they may be quasi-delusional.  Such individuals may demonstrate greater levels of control over their unusual perceptions.  (Blaney & Millon, 2009, p. 366)  Perhaps this natural protection can be leveraged to direct treatment of people whom do not have that natural protection.  It seems to me that if we know what can prevent delusions, we should make every attempt to instill those protections in our clients whom suffer without them?

Paranoia and delusions are thought to arise from several different situations or events.  One possible event is migration, in which an individual finds themselves in a new environment that does not provide a sense of security.  Growing frustration with the new locale may leave migrants vulnerable to paranoid disorders.  As is the case with many other disorders, abuse and trauma during childhood often precede delusional experiences in adulthood.  In some cases the delusions are related to that specific event, like trauma flashbacks, or they may be more generalized due to negative schematic models of the self and the world.  This manifests in high levels of self-reported suspiciousness and/or resentment.  Paranoid individuals tend to be characterized by experiences involving victimization or stigmatization by others, whereas depressed individuals were characterized by interpersonal losses.  (Blaney & Millon, 2009, p. 369)  Personally, I am not at all surprised by the childhood abuse antecedent.  The toll of child abuse rises again this week… I am hard pressed to find a disorder that can NOT be predicated by child abuse.

Biologically speaking, some researchers have attempted to attribute these behaviors to processing defects or bias.  Theory of Mind (ToM), for example, suggests that the human mind is characterized by a system that facilitates inferences about the mental processes of other persons.  (Blaney & Millon, 2009, p. 377)  In essence, patients have difficulty discerning others’ intentions correctly.  Some have suggested that delusion-prone individuals are overconfident and quick to reach certainty in the face of incomplete information.  Other research suggests that delusional individuals may have a proposed tendency to attribute specific persons as a source of danger (personalization), thereby revealing an inability to distinguish between external negative events that are situational as opposed to interpersonal.  It has been posited that they may have an exaggerated version of self-consciousness in which they continually preoccupy themselves with how they are seen by others… and subsequently generalize that everyone feels like that.  (Blaney & Millon, 2009, p. 379)  On the whole, there are several theories… all of which seem “plausible.”  I can’t wait to get into the field to test the theory.

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Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Reactive Attachment Disorder (RAD)

The profile of children diagnosed with Reactive Attachment Disorder (RAD) is disturbing.  Although the diagnostic criteria speak for themselves, I believe Cline’s (2008) account of life on a RAD unit is as insightful as one can find into some of the “typical profiles” of children diagnosed with RAD.

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The reactive part of RAD is certainly correct, as these children react immediately with rageful outbursts to any feelings of abandonment, slight, or limit setting.  The attachment aspect of the diagnosis is broad.  For whatever reason, children with RAD were unable to bond with anyone.  There was no stability in the relationships they formed from infancy on.  Trust was an issue.  Care, whether physical or emotional, was inconsistent.  There was nothing they could count on, except having nothing to count on.  There was no foundation to build on.  From day one they felt unattended, rejected.  They cried.  They hungered.  They hurt.  As infants, their stresses were not relieved.  Their needs were disregarded.  They were uncomfortable.  Many were hit, used.  They may have been ill at birth and suffered much in the name of medical treatment.  Perhaps they were not touched more than was necessary for basic care.  They may have been intentionally or unintentionally neglected.  They may have been abused physically, sexually, or emotionally.  They may have come from overcrowded orphanages in other parts of the world.  Their parents may have been drug addicts, alcoholics, economically disadvantaged, single parents, or mentally ill-parents who were unable to attach themselves.  (Cline, 2008, expression PROFILES OF RAD)

DSM-IV-TR diagnostic criteria for RAD include the following:  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 130)

A)    Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either (1) or (2):

  1. Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hyper-vigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness).
  2. Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachment (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures).

B)    The disturbance in Criterion A is not accounted for solely by developmental delay (MR) and does not meet criteria for PDD.

C)    Pathogenic care as evidenced by at least one of the following:

  1. Persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection.
  2. Persistent disregard of the child’s basic physical needs.
  3. Repeated changes of primary caregiver that prevent formation of stable attachments (e.g. frequent changes in foster care).

D)    There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A.

E)     Specify Type

  1. Inhibited type is predominated by Criterion A1
  2. Disinhibited type is predominated by Criterion A2

Although we can not entirely eliminate the possibility of predispositions due to heredity or biological causes, RAD cases will typically present with a clear etiological path to pathogenic care.  There is also evidence that some familial circumstances may provide predisposition to RAD.  In a generational study of caregivers demonstrating unresolved loss and abuse, Zajac and Kobak (2009) found “a consistent association between caregivers’ unresolved loss and teacher ratings of children’s behavior problems… but solely among caregivers who had insecure (dismissing or preoccupied) states of mind.”  (Zajac & Kobak, 2009, p. 182)

RAD is prevalent in the foster care system.  (Schwartz, 2008)  However, children in foster care are not the only high risk group for developing the socio-emotional issues associated with RAD.  A recent study, concerned with the developmental issues impacting military families during deployments, found that young children with a deployed parent demonstrated increased behavior problems during deployment and increased attachment behaviors at reunion (compared with children whose parents had not experienced a recent deployment.  Children in their “deployment groups” had a deployed parent that was gone, on average, half of their lifetime.  These findings were conclusive despite the fact that some military families and children seem to show fewer detrimental effects in response to parent deployment.  (Barker & Berry, 2009)

“While there is no empirically supported treatment for RAD, evidence suggests that children with attachment problems are best served by therapies that promote environmental stability as well as caregiver patience, sensitivity, and consistency.”  (Wilson, 2009, expression Treatment Considerations)  Interventions suggested by Wilson include group-based interventions to encourage parent sensitivity and responsiveness, labeled “Circle of Security,” or direct instruction to guide parental response to child behavior via a “bug in the ear,” labeled Parent-Child Interaction Therapy (PCIT).

Other therapies use coercion, fear, and emotional dysregulation to address concerns in attachment formation.  Although less common, such controversial interventions remain in practice and claim to “cure” attachment disturbances by invasive techniques, such as restraining or confining a child for extended periods of time.  Sometimes called holding, rebirthing, rage, or past-life therapy, such interventions have little empirical support, are theoretically counterintuitive, ethically problematic, and of questionable utility.  (Wilson, 2009, expression Other Therapies)

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Barker, L. H., & Berry, K. D. (2009, Oct). Developmental issues impacting military families with young children during single and multiple deployments. Military Medicine, 174(10), 1033-1041. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1884841381&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Cline, L. (2008, Jan). Reaching kids with reactive attachment disorder. Journal of Psychosocial Nursing & Mental Health Services, 46(1), 53-59. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1411292941&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Schwartz, L. L. (2008, Summer). Aspects of adoption and foster care. Journal of Psychiatry & Law, 36(2), 153-171. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1602451041&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Wilson, S. L. (2009, Aug). Understanding and promoting attachment. Journal of Psychosocial Nursing & Mental Health Services, 47(8), 23-28. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1835014081&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Zajac, K., & Kobak, R. (2009, Jan). Caregiver unresolved loss and abuse and child behavior problems: Intergenerational effects in a high-risk sample. Development and Psychopathology, 21(1), 173-188. doi: 10.1017/S095457940900011X

Integrity & Respect: Building a Foundation for Psychological Fitness

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What is psychological fitness and how does a program determine the psychological fitness and character of a potential clinician?  Although grade point averages, scores on the Graduate Record Examination (GRE), and letter of recommendation are often considered in the selection process, relying on these measures alone do not provide a comprehensive picture of a candidate (whom wishes to enter the counseling profession).”  (Corey, Schneider-Corey, & Callanan, 2007, p. 332)  Psychological fitness and character are an integral part of determining of choosing who will represent us as the mental health community.  Foremost on my list of qualities I would look for in a potential counselor would be integrity and respect.  This essay will attempt to underscore the importance of these integrity and respect, as well as provide insight in their development.

Integrity is defined as “the quality or state of being complete or undivided, with a firm adherence to a code of morals or values.”  (Merriam-Webster Online Dictionary [MWOD], 2010)  Integrity implies incorruptibility, soundness with unimpaired condition, or an underlying position of honestly and truthfulness.  “Integrity is a quality that everyone has to some extent, for no one can survive without it.”  (Mellor, 2008, p. 194)  “Integrity is a virtuous character trait that is closely connected to reliability, trustworthiness, honesty, and having principles.  A person who has integrity can be counted on to be consistent and harmonious; someone who does not is fickle and discordant.”  (Hatcher, 2005, p. 1)

Integrity is imperative to being a successful clinician because the majority of us will be left alone with the cookie jar.  The concept of competence is a cookie jar that is invariably left open because the first line of defense against incompetence is a clinician defining his or her own boundaries while establishing a clear and meaningful scope of practice.  Without integrity, competence is difficult to quantify and largely unenforceable.  There is currently no formal or objective measure of competence, so it is incumbent on clinicians to police themselves and make a determination that is in the best interest of the client.  Making that determination cannot be done without integrity.

Unbridled integrity can work against us as much as it works for us, however.  Billow (2010) suggests that “integrity without judgment, self-examination, and relatedness is not sufficient, and can be inappropriate and even damaging.”  Integrity without judgment produces rigidity or blindness to personal contingencies.  Integrity may even be of questionable moral value if it is based on principles that are ill-chosen, ill-applied, or wrong.  (Billow, 2010, p. 18)  And so, the key concept that must be embraced with integrity is the word “balance.”  Pentland & McColl (2008) believe “living in occupational integrity can be defined as integrating into one’s occupational choices the values that matter most. The extent to which an individual can design an occupational life that is consistent with his or her values will be the extent to which he or she feels a sense of balance and well-being.”  (Pentland & McColl, 2008, p. 136)  This speaks to the importance of designing and living personal lives that are congruent with our vision of integrity, and living as models of integrity both in and (perhaps more importantly) out of the office.

In the article Four Faces of Respect (2006), an anonymous author put forth one of the best frameworks I have seen to date as it relates to framing a working definition of respect.  The author believes the various ways of showing respect have common elements of attention, deference, valuing, and appropriate conduct.  “Attention is shown when a person’s mind is focused on an individual’s particularities and commonalities.”  For example, a counselor who shows interest and awareness in a client’s nonverbal (as well as verbal) communication is demonstrating attention.  “Deference is a communicative act of acceptance towards another person without forfeiting one’s own individual worth.”  For example, a counselor who respects clients defers to them without feeling either more or less worthy than the students receiving respect.  “Valuing is the consideration that a person’s character has merit or worth.”  (Anonymous, 2006, p. 66)  Appropriate conduct is the constraint of certain forms of negative expressions, like arrogance or apathy, towards a person.  In my opinion, all of these qualities are absolutely necessary for a counselor to project respect of a client.  Perhaps more importantly, these 4 sub-qualities of respect represent an inward expression of self-respect.

Psychological fitness pertains to the emotional or mental stability necessary to practice safely and effectively.  (Corey et al., 2007, p. 340)  Given the above examples of integrity and respect, and their contextual use within counseling, I would submit that deficits either aspect could appreciably impair our ability to effectively meet our professional responsibilities.  Psychological fitness should be built on a foundation of integrity and respect.  Who among us would describe someone as psychologically fit if they did not possess some measure of balance as it relates to integrity?  Not many, I suppose…  Who among us would be well advised to seek out a counselor who displays a distinct lack of respect for self or others?  None, I would suggest.  These two qualities are pre-requisites to the success of a counselor and, in my opinion, none who willfully neglect them should be allowed into the profession.


Anonymous (2006, Summer). Four faces of respect. Reclaiming children and youth, 15(2), 66-70. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1127531901&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Billow, R. M. (2010, Jan). Modes of therapeutic engagement part I: Diplomacy and integrity. International Journal of Group Psychotherapy, 60(1), 1-28. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1944544101&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

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

Hatcher, T. (2005, Spring). Research integrity: Ensuring trust in the academy. Human Resource Development Quarterly, 16(1), 1-6. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=84&did=810778811&SrchMode=1&sid=15&Fmt=6&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1275164882&clientId=4683

Mellor, K. (2008, Jul). Autonomy with integrity. Transactional Analysis Journal, 38(3), 182-199. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1663742381&sid=1&Fmt=4&clientId=4683&RQT=309&VName=PQD

Merriam-Webster Online Dictionary. (2010). flexibility. Retrieved May 29, 2010, from http://www.merriam-webster.com/dictionary/flexibility

Merriam-Webster Online Dictionary. (2010). integrity. Retrieved May 29, 2010, from http://www.merriam-webster.com/dictionary/integrity

Pentland, W., & McColl, M. (2008, Jun). Occupational integrity: Another perspective on “life balance”. The Canadian Journal of Occupational Therapy, 75(3), 135-138. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1510794431&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

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Confidentiality in the Team Environment

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Although it can surely be a challenge, clients being serviced by a team of professionals are nonetheless entitled to a similar degree of confidentiality as their peers that are being serviced by individuals.  However, because group care requires a team approach, the team needs to share information in order to be effective.  For example, in the case of 24 hour inpatient service, there needs to be an effective communication between and among the shifts to determine if “Jimmy has had a good day.”  This contributes to a level of consistency in care, support, and treatment.

Just as in an individual relationship with a counselor, all staff members have a responsibility to breach confidentiality if the client is a danger to self or others.  So, if Jimmy is experiencing suicidal ideation, it is only reasonable that the staff that works directly with that specific client be made aware of the situation.  Secondly, if we have reason to believe that a child, elderly, or dependent adult has been abused, we should again breach confidentiality as a measure of compliance to mandatory reporting law.  In short, the mandatory reporting rules that apply to us as individual clinicians also apply in a group setting.

In my current position, it is generally understood that “anything said to one staff member is said to all.”  There are literally no secrets.  This policy comes with benefits and limitations.  First and foremost, it prevents us from inadvertently breaching confidentiality that was anticipated by our clients.  As higher functioning developmentally disabled adults, they have agreed to such policy, and have acknowledged that they understand it.  However, I also believe it places limitations on the relationships you are able to effectively build, in part because it pits “staff” against “clients.”  There would likely be situations where an individual client would share sensitive information due to the rapport and level of trust with an individual staff member… but that information would not be shared due to the implications of the policy.  The end result may be that the trusting relationship between individual staff members and a client is diminished, in part or wholly as a result of that policy.

Another implicit policy is that it is acceptable to disclose information “up” but not “out.”  This translates in our ability to share information regarding clients to our supervisors and bosses, but not with other staff that do not regularly interact with the clients themselves.  There are, however, situations where information may need to be shared on a need to know basis… for example, when someone picks up a shift, it is probably wise to let them know not to talk about Jimmy’s mom because she just got in a car accident.  In any event, information is provided on a need to know basis, where appropriate, with the client’s best interest in mind.

In the end, I agree with and support the policy of “what is shared with one staff is shared with all” because it is conducive to a team environment.  While it does place limitations on our ability to leverage individual relationships with clients, the benefits outweigh the limitations.  As a result, if I work in a group or a team environment, I would prefer to work in that “everyone knows everything” situation because I believe it’s what’s best for “Jimmy.”

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Confidentiality | Silence is golden!

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Confidentiality is at the foundation of safe therapy because it promotes open and candid communication between the therapist and the counselee.  This right to confidentiality has been repeatedly reaffirmed in judicial system, with the case of Jaffee v. Redmond (1996) serving as a key example.  In that ruling, Justice John Paul Stevens of the US Supreme Court wrote expressed that “effective psychotherapy depends upon an atmosphere of confidence and trust in which the patient is willing to make frank and complete disclosure of facts, emotions, memories, and fears.”  (Corey, Schneider-Corey, & Callanan, 2007, p. 214)  Justice John Paul Stevens couldn’t be more correct, because without a measure of confidentiality, the process of mental health treatment would not be possible.  Clients themselves would need to be constantly concerned about the ramifications of divulging sensitive information.  It is extremely important that we communicate a client’s right to confidentiality to promote that free flow of communication.  Not only are we ethically and legally responsible for disclosing it at outset, in the form of an informed consent document, but we should also endeavor to continue to have candid conversations around confidentiality as the relationships continues to develop.

We, as mental health professionals, should seek to protect the image of the larger profession and give our clients every reason to believe in our pledge of confidentiality.  That integrity aside, we also need to be candid and forthcoming regarding the limitations of that confidentiality, because it is not without exceptions.  If the client is a danger to self or others, we are bound by mandatory reporting procedures to report the incident, as well as “warn and protect” other people from potentially dangers clients.  In cases where abuse is detected, be it with children, elderly, or dependent adults, we are mandated by law to report such cases to proper authorities.  Furthermore, we should follow up on such cases to be assured that proper action has been taken.  In the case of counseling a minor, an underage client should be aware of specific limitations regarding disclosure of information to parents, particularly when he or she is a danger to themselves or others.  We also much acknowledge that confidentiality is the client’s right, and they also have the ability to waive that right.

I would hope that clients really believe what they say is confidential.  I would also hope that they understand the implicit limitations on that confidentiality before the process of counseling begins… so, they should also understand that some of what they may say is not confidential.  In any case, it very much depends on the context, the situation, the content of the disclosure, the professional judgment of the clinician, and the ethics codes, laws, and agency policies that govern our practice.

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