L is for Letting Go (and Hot Lava)

One day you finally knew
what you had to do, and began

                        –Mary Oliver

Hello, Dear Readers. This week has certainly been one full of lessons on Letting Go. It’s funny—as I make my way through the alphabet, ever so slowly, I have realized that each blog presents itself when it’s time. And not before.

So many things have converged in the past week, from family shit to online dating adventures, to the possibility of moving, to health concerns (not mine). As we emerge from this pandemic, like so many light-deprived moles crawling out of our long dark tunnels, blinking at the bright sun and shrinking from the intense heat (seriously, it was over 100 degrees here last weekend—that is not normal), we can only hope that the future is better, but it has not been a stellar re-entry back into the world.

The first lesson in Letting Go has to be that life is not going “back to normal.” What was before lockdown last March will not be returning. We have to let go of a “return to normal” and adjust to moving forward into something new. A friend invited me to a movie this week, at a theater. Inside. I’m not ready yet. And from the looks of the news headlines—shootings, forest fires, climate change havoc, declining vaccination rates, increased political polarization—it seems we should all just continue staying home. There needs to be a global Letting Go of the status quo. We cannot go on like this. I have no answers. Just a sense that if we don’t let go of what was, we will not be able to move forward, collectively.

On a more personal level, I have decided it is time to Let Go of my house. I put it on the market a couple of weeks ago. I don’t have a set plan yet. I just know that I’ve been in this house for 23 years, it has served me well, and now I no longer need it. When I was a kid, our family moved around a lot—I went to four different high schools—and when I landed in Bellingham 40 years ago to attend college,  I immediately put down deep roots. Maybe I didn’t even decide so much as just instinctually grounded myself here. I needed the continuity. But now, that need has subsided. It’s time for adventure. It’s time for me.

I spend my weeks urging clients to take care of themselves, reminding them that no one benefits if they aren’t getting their own needs met, that we can’t fill up others if our own wells are dry. Occasionally I remember to heed my own advice. But Letting Go of my home has repercussions beyond just me. My adult kids have feelings about me selling. Of course they do. I understand. My parents divorced and sold their home 20 some years ago, evoking all kinds of feelings of loss for me. I’ve had to Let Go of an intense urge to take care of my girls and to “do better” by them. But, Letting Go also means letting go of the past, of old wounds, of old habits, of old feelings that keep me trapped. Keeping my house is not going to heal the wounds I felt 20 years ago.

Letting Go means no longer being a place of refuge for others, and at times, I feel guilty for closing that door, but if not now, when? This house has been a refuge, a sanctuary, and now it feels more like a burden, a weight, an unnecessary commitment. Too much for me. I can’t wait. Some days, I am pursued by the specter of Alzheimer’s—it got my mom by 65 (in retrospect, it seems to have started there). She’s been robbed of her final decades—I cannot wait for it to get me too. I have to Let Go and Get Going into my own future.

Letting Go of my home also opens up a new range of possibilities—a life on the road, of Airbnbs in cities that call to me, of the possibilities of meeting people beyond the confines of this state, of opening myself, my life, my world up to more, bigger, different. Letting Go of what I thought work and the future held and embracing uncertainty.

When I work with clients who want to move forward but can’t seem to let go of what feels secure, I use a metaphor of the monkey bars. Remember hanging there, suspended over the “hot lava” your best friend breathing down your neck behind you, urging you to let go of the back rung in order to swing forward? The fear of falling, the knowledge if you didn’t let go, you’d eventually succumb to gravity and fall to the ground and be consumed by the metaphorical lava or crocodiles?

So, you took a deep breath, summoned your courage, and Let Go. Into the unknown, flying unsupported for one terrifying moment, the specter of death, of failure, of pain fleeting, until your hand met the cold, smooth metal and you were again safe. Ready to do it again, and again until you reached the end. Triumphant.

you strode deeper and deeper
into the world,
determined to do
the only thing you could do –
determined to save
the only life you could save.

-Mary Oliver, from Dream Work

B is for Behind (Already!) or Boundaries

I decided a few days ago that B was going to be for Boundaries—a relevant topic now that I am a counselor and caregiver (see A is for Alzheimer’s). But then life intervened in unexpected ways and while I should be cranking out my C is for . . . blog, I’ve still not gotten around to B. Also, there’s the little matter of a poem to go along with. Every time I sit down to write a poem, I get interrupted. Poetry is challenging enough without constant interference. I wrote one the other night, but I’m not sure it is suitable for public consumption—in fact, I know it isn’t. So, back to the drawing board.

A few words about Boundaries. Boundaries are those imaginary lines that we draw in the sand between us and the rest of the world. The word “no” is a boundary, as in “No, I cannot help you move this weekend (or ever).” Boundaries are personal bubbles, as in “if there are 90 empty seats in the movie theater, don’t sit right next to me if you don’t know me.” I am continually amazed at how often this boundary gets violated (especially in Bellingham). Boundaries can be fences, hedges, the edge of the lawn, a strategically placed flowerbed, or (if you are Cheeto Satan) a $65 billion wall between countries. What all of these borders, imaginary or actual, have in common, is they separate me from the rest of you in some way, or us from them, or my yard from your yard, or my body from your body, or my time from your time. Stepping across the line means I am choosing to merge some part of myself with you.

As a counselor, having boundaries means that I must keep our relationship confined to the counseling setting. It’s a bit odd, this particular boundary because while you (the counselee) may chose to tell me (the counselor) many intimate details about your life, I will not reciprocate with intimate details of my own. Normal relationships (friendships, intimate partners) rely on the mutual sharing of such information across boundaries to create a sense of closeness. You tell me an intimate detail, a secret, something you’ve not shared before, and I reward you with a secret/intimate detail of my own, our friendship grows, intimacy flourishes, the exchange is reciprocal.

Not so in counseling or therapy, which works differently. You tell me (the counselor) a secret, and I reflect it back to you, usually with a question. Something like “what meaning might you assign to the anger you have for your father?” or “what would it mean to you if she asked you out on a date?” or “how has being abused as a child affected your parenting of your own children?” Or maybe even (if I’m feeling stuck) “how do you feel about that?”

As a counselor, I have to have Boundaries because how helpful would it be if you disclosed your traumatic childhood to me, expecting insight and healing, and I said to you “Wow! My childhood was traumatic too”? Or, even if I did determine that some level of self-disclosure might be warranted (a quick rule of thumb re: self-disclosure: it can be ok if it helps the client, but not if it’s only for my own sake, i.e. to make me feel better), how helpful would it be if I confused you by having loose boundaries in the therapy room but then ignored you when I ran into you at the supermarket? If I took your money (or insurance payment) under the auspices of helping you but came to rely on your feedback and your insights? If you leave a counseling session knowing more about your therapist or counselor than he/she knows about you, somebody’s Boundaries are too loose.

Therapy is a very specific sort of exchange, one that depends on firm Boundaries. Less than firm Boundaries create all sorts of havoc and may result in the counselor or therapist losing their license. Lapses in ethics often result from lapses in Boundaries and can be a very slippery slope. Loose Boundaries can lead to inappropriate friendships and perhaps even sexual liaisons between therapists and clients. Sleeping with a client is never a good way to help them heal. It might make the client feel special initially, but will eventually destroy them (and probably the counselor as well).

Even something as seemingly benign as a friendship can become problematic between a therapist and client. As your friend, I have a vested interest in telling you things you want to hear, things that will keep you as a friend. As your therapist, I have a duty to tell you things that you might not want to hear but need to, things that will help you heal and move forward, things that a friend wouldn’t tell you. Boundaries make it possible for me to be your counselor.

Confused yet? It’s tricky, I know. But trust me, this is one lesson you’re better off NOT learning directly.

Related Haiku (this is an old one, but relevant)

Please do not invite
me in and then abandon
me at the threshold

Transracial Adoption, Research, and Me

So, I’m on the downhill side of this mental health counseling degree I started three years ago. I can see the light at the end of the tunnel—but before I can emerge victorious from the darkness, I must complete a handful of tasks:

  • First, I must accumulate three hundred hours of direct counseling experience. I am about a quarter of the way there.
  • Then, I must amass a dozen or so hours of direct observation of my counseling skills. I’ve got that covered—no sweat.
  • I must also acquire many hours of supervision, which I am working on and should have little trouble accomplishing.
  • Simultaneously, I need to add about 20 credits to my credit total, six of which will come from the two remaining required classes I must take, Intro to Research and Tests & Measures, eight of which will come from my remaining Case Consult classes, and the rest of which will have to come from a couple of electives.

I am taking Intro to Research now, right this very quarter, and it has me flummoxed. I should not have put it off this long. I should not have waited until I was in internship to take it. I should not have dropped it all those previous quarters when I registered for it. Nope. Bad decisions have come back to bite me in the ass, here Dear Reader. I have no room in my little pea brain for academic articles. I am up to my armpits in counseling clients who have many serious mental health needs, and I am having difficulty wrapping my head around how researching and writing a paper is going to help me be a more effective counselor. It seems an exercise for its own sake, a tuition-generating requirement, if nothing else.

So, while I could not give less of a fuck about this paper in general, I am quite interested in the specific topic I have chosen, which makes me reluctant to simply blow it off. I have decided to research Trauma and Transracial Adoption (TRA). It’s a topic that is near and dear to me, a topic that I neglected to address 27 years ago when I first adopted my oldest daughter, a topic that I am now ashamed to admit that I gave no serious consideration to until just recently.

cropped-me_nala_t_halloween941.jpgIt makes sense to me that if adoption is a traumatic experience, that transracial adoption would be even more so. I mean, think about it. How in the world can white people adequately prepare children of color to navigate our racist culture? I know now that our optimism when we adopted our girls was misplaced and the result of white privilege. We didn’t have a clue how steeped in white privilege we were. Of course, when the social workers asked if I would be willing to make sure my kids received information about their cultural heritage, I promised to provide it. Of course, I said. Of course. I will read them books. I will tell them about Martin Luther King, Jr. I will hang pictures of Rosa Parks and celebrate Black History Month. But I had no idea how, 27 years later, my ignorance would affect my girls.

I had no idea. I was so naïve, my friends. So very naïve. I did not imagine all those years ago that race relations would be WORSE in 2017 than they were in 1990. Who among us would have predicted? I had no idea raising two black children in our lovely little liberal bubble Bellingham would not prepare my daughters to live in the greater world as women of color, would not adequately prepare them for future encounters with racists, with white supremacists, with law enforcement officers who would just as soon shoot them dead as ask questions.

I should have known. I should have tried harder. I should have. I should have. I should have. And so now, here I am, trying to figure out what I wish I had known then, what I wish someone had slapped me upside the head with all those years ago: how will being raised in a white family impact an African American child? What will they learn? Who will teach them how to navigate this racist world? How did I contribute, willingly or not, to their marginalization? This is perhaps the toughest question: what was my culpability? Did I collude? Can I admit it?

Admittedly, getting to the place where I can acknowledge my culpability has been tough. When my ex-partner and I adopted our kids, we just wanted children. We did not think beyond our desire to have a baby. She wanted kids, and I was along for the ride. Don’t get me wrong, I love my daughters. I would not trade them for anything. But that love doesn’t mean I don’t have regrets about the way in which we went about the adoption process. I should have steeped myself in Black culture. I should have moved to a city more inhabited by Black people. I should have made an effort to connect my kids to their heritage. I didn’t. I admit it. I took the easy path. I surrendered my responsibilities.

And now, as a sort of atonement, I am writing this research paper. It is not enough, but it is a start.anna and taylor xmas

 

The Pinocchio Paradox, or How to be a Real Counselor

The doctor is effective only when he himself is affected. Only the wounded physician heals.”                                                                                                                                         —Carl Jung

methow morning
My writing table in the Methow Valley

A year ago I sat at this very table faced with the onerous task of writing a final class paper. Again, I have the same chore in front of me, albeit for a different class. Back then, I had to write a proposal for a group therapy group. Now I must reflect upon my time as a practicum student, as a fledgling counselor seeing clients for the very first time. What are my strengths? What are my weaknesses? (No, it doesn’t say weaknesses, the assignment says “areas of growth” but we all know what that really means). What did I learn about my clients? How did I experience myself in supervision, and how do I want to grow in this area?

Let me just say this at the outset: seeing clients for the first time, the first two, three, four, five times is flat out terrifying. I’ve had two years of classes and coursework preparing me for sitting in a room with someone who wants help. I’ve participated in numerous role-plays and fish bowls and practice sessions with my student colleagues. I’ve had more personal therapy than the average bear over the last twenty-five years, and still. What can I possibly do for the anxious or the depressed, the overtaxed, the under functioning, the overcompensating, the abandoned, the unloved, the overachieving, the lonely, and the traumatized who sit in the chair across from me?

How can I possibly help?

For years I wanted nothing more than to be a therapist. The women I most admired were the ones who had listened from that chair as I unburdened myself of my anxieties, depressions, anguish, loneliness, and traumas. I thought about how amazing it would be if I could bring the same sort of listening ear, the same sort of compassion, the same sort of hope to others that these women had given to me. But I didn’t think I was healthy enough to be a counselor. I didn’t believe that I had the capacity to help myself, let alone anyone else.

But then in the spring of 2013 I had a chance encounter with the author Claire Messud who wrote The Woman Upstairs and The Emperor’s Children. We chatted about her character Nora and what happens to us as we age and begin to realize that perhaps our previously unlimited horizons are shrinking. At some point, Ms. Messud said to me, you wake up and realize that you simply don’t have enough time left on this earth to fulfill all of your dreams. Where once so much was possible, you begin to grasp the reality that you’ve reached a point where that is no longer the case.

That is when I understood that regardless of what I thought about my own mental health or lack thereof, if I didn’t do something about pursuing my dream my horizon would shrink even further. If I didn’t enroll in school soon, my dream might slip away. I signed up for the necessary prerequisites and enrolled at Antioch a few months later.

And what I’ve learned in the time since then, and particularly this quarter as I’ve worked directly with clients, is that my experience on the other side of the couch, my years as a client, what I previously saw as my greatest weakness, is actually my greatest strength and most valuable asset.

What I have learned in practicum and in supervision is that I am enough. Who I am is precisely what I need to be to be effective with clients. I haven’t learned this from my clients. I’ve learned this from my peers primarily, and from my instructors, and from my own therapists. And slowly I’m beginning to see it for myself, from within myself. And that’s the thing—we usually can’t see in ourselves our own strengths. As I move forward into my second quarter of practicum and then into a full year of internship, my greatest opportunities for growth will be in recognizing my own strengths and trusting my own wisdom, sourcing my confidence from within rather than looking to others to reflect my strengths back to me.

I’ve learned from my clients that they too have all they need within them and simply need to be heard, to be given a chance to lay their vulnerabilities and fears out there in order to sort through them, evaluate and ponder, decide what’s working and what’s not, learn how to hang on to the useful and discard the useless. While self love and self compassion are the ultimate goals, sometimes we need external validation from someone we trust, someone whose values align with our own, someone who can see what we’re seeing and tell us we aren’t crazy or imagining things. Sometimes we just need to be seen and heard in a world that seems to be ignoring us.

I learned basically the same thing in supervision that I learned from my clients—I learned to trust myself, that I didn’t need to put on a persona or be an all knowing font of wisdom or channel the great mystics of the ages. I learned to be real, to be myself,

The actual Pinocchio
The actual Pinocchio

to trust my instincts, and to be present. I learned that I am enough and to bring my self to the sessions. I think my greatest learning this quarter came when I was seeing my own counselor and parsing through my anxieties about practicum and seeing clients. She stood up and walked over to a cabinet near me, opened the glass door and took out a porcelain Pinocchio statue. She set Pinocchio on the small table between us and asked me what Pinocchio wanted more than anything.

“To be real,” I answered. “He wanted to be a real boy.”

“Exactly,” she said. “Don’t be afraid to be real, Pam. When you are real, you are enough.”

 

 

 

 

S is for Stop. I Must Attend to Schoolwork and Self-Care

SToday I had my very first real client. (It went well enough that we have another appointment next week, and I am SO glad the first one is behind me), and I am  excited that I have chosen this career. To sit and hear people’s stories, to have them share their fears and triumphs, to be a part of the healing process. I am feeling honored and quite fortunate.

I know Mercury is in retrograde (whatever that means), but my stars seem to finally be aligning. My practicum is shaping up nicely, I’ve made some great inroads for my upcoming internship which starts in the fall. And, then I realized  I am very far behind on my school work.  I need to Stop this blog-a-day thing at S.

I love the challenge of writing something to post everyday (and even though I’ve clearly not posted everyday as I should be on W, I have actually written something each day, but not everything is worthy of being shared). I’ll miss it, but I took a look at my syllabus today and realized I have to do a 3-5 hour online trauma training and write a paper this week. I also printed off about 200 pages of “supplemental” reading material I need to delve into (besides the two textbooks, and I’m about 5 chapters behind there too).

All the things I need to read
All the things I need to read

One of the concepts our instructors bring up in nearly every class in this program is the need for self-care. If we don’t take care of ourselves as counselors, we will not be fit to help anyone with anything. So, something has to give. And for now, blogging everyday is what I have to let go of. I need a lot of time to think about what I want to write, to ponder, to come up with a point. And even if I take the better part of a day to do that, I still need more time to edit and revise and rethink what I’ve written. I don’t want to just throw something up here–it has to be somewhat meaningful and decently written.

I like the double meaning here
I like the double meaning here

So, since I don’t have time for long hot bubble baths, or the extra money for massages and pedicures, I’m going to have to take care of myself by cutting back where  I can and for now that means cutting back on blogging. I have to keep running or I’ll become very crabby, and I can’t possibly cut back any more on housework without endangering my health (besides, for me, having a clean house is self-care). So, here we Stop. With S.

Thanks for reading this far, Dear Readers. I’ll check in now and then to let you know how things are going.

 

O is for Old? Nah. O is for being Open to Options

OLet’s face it, I’m old enough to be the mother of most of my classmates. Some days it’s more obvious than others. Like last week, in Crisis, Trauma, and Disaster Mental Health Counseling class, we were discussing the September 11 terror attacks, and I realized that everyone in class except for me and the instructor was approximately eight years old in 2001. Eight. I was 38.

I’m even old enough to be the mother of some of my instructors if I’d gotten started on the kid thing in my late teens. But still. In many ways, age does not matter. And in fact, I’m often envious of the folks who get to start out in this career so young. How marvelous that they know what they want to do in their mid-20s.

And then, I remember that I too knew exactly what I wanted to do in my mid-20s. I wanted to be a writer, so I got a Master’s Degree in English. I had some classmates then who were in their mid-40s and older. I envied them because they actually had life experience to write about. I hadn’t gotten far enough to realize what I was doing would eventually count as life experience. I mean, who’s to say if I’d become a counselor at 25 I wouldn’t now be returning to school to get my MFA in creative writing?

We can only be where we are at any given time. We can’t know what our unchosen life would have been, where the road not takenfork-in-the-road1 might have led us. As Cheryl Strayed wrote in Tiny Beautiful Things, “I’ll never know, and neither will you, of the life you don’t choose. We’ll only know that whatever that sister life was, it was important and beautiful and not ours. It was the ghost ship that didn’t carry us. There’s nothing to do but salute it from the shore.”

We can’t spend our lives second-guessing our decisions. We decide what we decide when we decide it. There’s no going back, no do overs. Some people make better (and isn’t that a subjective term?) choices. Some are born into more privileged circumstances, and some people just get fucking lucky. Even if we plan, and listen to our parents, and invest properly and go to the right schools, there is no guarantee life will pan out according to plan.

All we can do is be open to the moment and what it presents, weigh our options, and follow our passions.

 

 

 

L is for Listening, or Oh? How Do You Feel About That?

LI can’t think of anything better than having a conversation with someone and really being heard. Walking away from an intimate exchange with another human being and leaving with that warm, fuzzy feeling that not only did that person give me the time and the space to express what was on my mind, but they really listened to me.

How do I know if someone has listened? Well, they reflect back to me what they heard me say. They ask questions related to what I’ve said, and they engage in active listening skills—nodding when appropriate, making sympathetic noises, maybe reaching out to touch my arm, hand, or leg in empathy and understanding. I had a therapist once who would get teary-eyed when I told a particularly poignant story about my child custody struggles. Her tears made me feel heard and validated.

One of the most challenging aspects of training to become a therapist has been learning to listen in a way that will help my clients not only feel heard, but helped, assisted, valued, and worthy. I remember when I used to think that being a therapist would be so easy—how hard could it be to sit and listen to people all day, throwing out only the occasional, “how does that make you feel?”

I didn't have a happy childhood, I was often misquoted.
I didn’t have a happy childhood, I was often misquoted.

Ha. If only. At school we practice on each other quite a bit. I’ve listened to my fellow students in nearly all of my classes thus far, learning to hone my listening skills, learning to take in what they say and ask relevant, useful, insightful questions in an effort to help them move forward. It’s not easy. There’s so much to hold in my head and pay attention to. Details to notice. Key words to focus in on. Facts to track.

We’re learning not how to give advice, but how to ask good questions, open-ended questions, questions that will encourage our clients to explore their feelings. For example, if a client were to tell me they’re anxious about a weekend outing with their partner and the partner’s family, what might I say in order to help the client better understand and deal with the anxiety?

If I were practicing gestalt, I might ask where in the body the client feels the anxiety and if they could talk to it, what might they say? What would the anxiety say? What does the anxiety look like? What color is it? How big is it?

If I were practicing narrative therapy, I might ask the client to give the anxiety a name and to imagine a world in which the anxiety no longer existed. What would that world look like? I’d ask the client to tell me about a time they didn’t experience the anxiety and ask them what was different about that time.peanuts-cartoon-about-listening

I have so many theories and approaches rattling around in my head, sometimes I think it might explode. What theory to use? What words to zero in on? And then, in one class, the instructor told us to not work harder than the client. And, yes, that makes sense, but oy vey.

The best approach might be Carl Roger’s—he believed that the therapist should always give the client unconditional positive regard. His approach, Person Centered Therapy, came in response to psychoanalytical models popular at the turn of the last century. He believed the therapist should be warm, genuine, and understanding.

He said, “It is that the individual has within himself or herself vast resources for self-understanding, for altering his or her self-concept, attitudes and self-directed behavior – and that these resources can be tapped if only a definable climate of facilitative psychological attitudes can be provided.”

I no longer think that being a therapist will be an easy job—in fact, I’m pretty sure it will prove to be one of the more difficult I take on. Listening to people, actually hearing them and reflecting back what I’ve heard, will take practice, time, and focus. I can’t afford to space out or daydream halfway through a session.

Maybe Stephen Covey said it best: “Most people don’t listen with the intent to understand; they listen with the intent to reply.”

My success as a counselor will not be measured by what I have to say, but in how much I understand.

 

 

 

F is for FOO

 

FWe would-be counselors all must take FOO (Family of Origin) before we take any other coursework in my graduate program. This class is the one in which we must sort through all of our personal Family Issues before we move on to counsel others. The idea, I suppose, is that we get our own stuff out of the way, but I’m not convinced we can do much with our FOO issues in 10 weeks. However, at 52, I definitely had an advantage over most of my younger classmates. I’d been working on FOO issues for decades.

Sitting in FOO for three hours every week was like attending group therapy—everybody cried, and I felt like I had one of the least traumatic childhoods of all. Some people had seriously mentally ill parents; others were abused by siblings, and still others grew up in remote, poverty stricken areas and no services for hundreds of miles. My heart ached for many of my classmates who still struggled mightily with their families.

Obviously, our parents leave a lasting impact on us, but one of the more fascinating aspects of FOO was how the same behavioral patterns played out over generations. Even when each generation may not even know much about previous generations. In one family, every generation included a pregnant 16 year old. How does that happen? How do we inherit such specific behaviors from our ancestors?gabor mate

Epigenetics. The research is fascinating. We inherit memories, behaviors, trauma. A 2013 article from the online Discover Magazine explains it thusly: According to the new insights of behavioral epigenetics, traumatic experiences in our past, or in our recent ancestors’ past, leave molecular scars adhering to our DNA. Jews whose great-grandparents were chased from their Russian shtetls; Chinese whose grandparents lived through the ravages of the Cultural Revolution; young immigrants from Africa whose parents survived massacres; adults of every ethnicity who grew up with alcoholic or abusive parents — all carry with them more than just memories.

Wild, yes? I find it all so fascinating. As the adoptive parent of two children, as the child of a mother who was adopted, and the sister of an adopted brother, I am well aware that more is at work in our development than simply what we experience. We are  complex beings, bundles of history and experiences that are not even our own. We are more than half mom and half dad, but carry in our very essence not just the physical traits of our foremothers and forefathers, but their memories, traumas, victories, and defeats.

I guess that’s one thing about becoming a therapist that I so look forward to—exploring with clients how they came to these difficult places in life and working with them to make positive changes. Not only will they change their own lives, but they have the power to make life better for future generations.

E is for (what else?) Ethics

 

EDon’t have sex with your clients. Just. Don’t.

Washington State law forbids it and even goes so far as to outlaw intimate relationships with former clients. Forever. The American Counseling Association (ACA), in section A.5 of its 2014 Code of Ethics prohibits sex with current clients as well, as do all of the other professional organizations, but they don’t put a complete ban on sexual relationships with former clients forever, instead imposing a five year moratorium on sex with former clients.

And still. Therapists have the dubious distinction of being disciplined most often for violating this particular ethical code. In fact, they (we) outpace all other helping professions in this area, leaving lawyers, doctors, and even massage therapists in the dust.mother

But say your aspirational ethics around this issue are intact. Say you are really clear that you would never, ever engage in a sexual relationship with a client or former client, or with their family members. There are still a thousand different ways to violate client trust or for a counseling relationship to go off the rails.

The ACA’s code of ethics state that the primary responsibility of the counselor is to respect the dignity and promote the welfare of the clients (Section A.1). The document goes on to say that counselors must act in such a way as to avoid harming their clients (Section A.4). It’s a lot like the Hippocratic Oath: First, do no harm.

But what causes harm, exactly?

Consider the following scenario (borrowed from my Ethics textbook): You are the only counselor in a small town. Another therapist is a two-hour drive away. When you moved here, you became good friends with the school principal, and her son and your son are best friends. She asks if you would see her son professionally. His grades are slipping. He has started acting out at home. He’s defiant and surly. She doesn’t have time to drive two hours each way to take him to a different therapist. Could you just talk to him a few times? You want to help.

What to do? What to do? What could possibly go wrong?

How about this situation: You’re seeing a client who is a writer. You, too, dabble in the written arts. The client mentions his blog during a session, and as soon as he leaves you Google his name, find his blog, and settle in to read it. Your curiosity piqued, you search for him on Facebook. Research, you tell yourself. What you find out will help you understand him better. The next time he comes in you say, “Great blog! I have one too. You should check it out. And if you have any feedback on my writing, I’d love to hear it.”

ethics cartoonWhat’s wrong here? Why not bond with a client over a shared passion? Maybe trade a few sessions for a critique of the novel you’ve been working on. After all, the writer doesn’t have a surplus of cash. It would be a win-win. Right?

No. To borrow a phrase from Cheryl Strayed’s book of quotes Brave Enough: “The short answer is No. The long answer is No.”

You are the therapist. He is the client. It is a one-way street. You must consider all the ways in which your actions could possibly harm the client. You are not friends, buddies, colleagues. You are the keeper of deep secrets, a confidant, a compassionate listener, a mirror. Just in asking, you’ve violated the trust implicit in the counseling relationship. And the client is paying you for a service. Asking for a personal favor, for feedback places an extra burden on the client, a burden he did not sign up for.

Okay. One more. How about this? You are seeing a client who struggles with self-esteem, with feeling heard and being seen. She shares with you some of the poetry she has written. You tell her it is beautiful and moving and wonderful. You email her a couple of poems from your favorite poets and hope they resonate with her the way the do with you. She sends you more of her poetry. It really is beautiful, full of amazing metaphors and gorgeous imagery. You tell her as much. She should be published, you say. She glows in your effusive praise.

What? Is there a problem?

The short answer is Yes. The long answer is Yes. Now the client is seen. Now the client is heard. But by you. Instead of helping her gather her inner resources and find her intrinsic value, you’ve taken a short cut. Basically, you have given her the needle and the spoon and pushed the plunger down, mainlining self-esteem. You are now her source, her dealer, her heroin. Congratulations, you’ve created an addict.boundary issues

There are so many other things to consider here as well. What is poetry? Who sends poems? Poetry is the language of love. People in love send poetry. Poetry is metaphor—a word can have a thousand meanings in a poem. What you read and what the client meant might be vastly different.

What would an ethical counselor do in any of these situations? And why? An ethical counselor must always consider the needs of the clients first. In some respects, a therapist has to see the future and ask herself, “How will my actions and words now impact my client down the road?” “Will I be helping or hurting my client by taking this action?” “What is my motivation?” “Am I getting my own needs met or am I meeting my client’s needs?”

Instead of praising a client’s poetry, ask them what writing poetry does for them? What do they get when they create? How do they feel when they are writing? What’s their process? Explore. Ask questions. Help the client find her own meaning in her work.

I could write for days on this topic. But the bottom line is this: There is a power differential in the therapeutic relationship. The ethical therapist uses her power for the good of the client. Never for herself.

And I’d love to hear your thoughts on the scenarios I’ve presented. What could possibly go wrong in each of these situations? Let me know what you think!

D is for Distal Contextual Affordances (ha ha, just kidding). D is for Diagnosis and DSM 5

Each quarter, as I take new classes and learn new material, I analyze and diagnose myself accordingly. I generally text a friend of mine who is a marriage and family therapist (MFT) during class. Our exchange goes something like this:

Me: OMG, I so have this.
MFT: what?
Me: I wasn’t properly attuned to as a baby. That’s why I’m so fucked up.
MFT: gawd
Me: well, it could be that or it could be that I experienced a trauma as an infant.narcissist chicken
MFT: maybe
Me: I was dropped on my head once.
MFT: well, that explains it.
Me: I know, right?
MFT: it’s just one lens, Pam. A theory.
Me: oh. Sorry for being so narcissistic.
MFT: You’re not a narcissist.
Me: borderline?
MFT: ugh.

And so it goes. Each quarter I learn new and fascinating ways to make sense of human behavior.

A few years ago, when I began working on my memoir, I asked my (by then former) psychologist if I could have access to my records. I wanted to reconstruct a timeline of events and double-check my memories. Since she had seen me through some of my darkest hours I figured I would find a good record of events that I had been too depressed and distraught to remember. And I did. But I also discovered how I had been diagnosed, and I found it all a bit unsettling to see the DSM codes next to the list of my symptoms.

If you read yesterday’s blog, Dear Reader, you know that I was depressed. So it came as no surprise when I decoded the DSM codes to find variations on that theme: major depressive disorder, recurrent episode; major depressive disorder, recurrent episode in partial remission; major depressive disorder, severe. And so on. I was fine with these diagnoses and also with the occasional Adjustment Disorder diagnosis that I found. I knew enough by then to know that when a mental health provider doesn’t know what else to use, when a client just needs to chat a bit to clear things up, they use the somewhat ambiguous 309.9 (Adjustment Disorder, Unspecified).

Diagnosing someone with an illness or disorder that appears in the DSM 5 is an art, not a hard science. This latest version of the Diagnostic and Statistical Manual is arranged quite differently from its predecessors with disorders arranged according to lifespan. So, disorders that affect children come first—neurodevelopmental disorders, followed by illnesses that appear in adolescence and early adulthood: schizophrenia and psychosis, depression, anxiety, OCD. These are followed by trauma related disorders, dissociative disorders, somatic (body disorders), feeding and eating disorders, elimination disorders, sexual dysfunctions, substance abuse issues, personality disorders, and paraphilia.

Gone are Axis I, II, III, IV, and V. Used to be that the most acute and familiar disorders—those requiring immediate attention fell under Axis I: schizophrenia, major depressive disorder, panic attacks; ongoing personality issues—narcissism, borderline personality disorder, intellectual disabilities, obsessive/compulsive disorder—fell under Axis II. Axis III was reserved for related medical conditions such as terminal cancer, which might contribute to a client’s depression. Axis IV diagnoses included life events: marriage, job loss, promotions, divorce, death of a parent or child, and Axis V is used for the Global Assessment of Functioning Scale, a 100 point questionnaire evaluating the client’s ability to function in daily life.

What we CMHC (clinical mental health counseling) students all learn early on in our clinical program is that diagnosis is a necessary evil if a mental health care provider wants to take insurance. Insurance companies will not pay if we don’t attach a diagnosis to our clients. At the same time we learn that our clients are much more than walking bundles of diagnoses.

The bottom line is that when a person presents in my office and tells me what’s going on in their life, how they are coping day-to-day, and want to pay for their sessions with insurance, I have to give them a diagnosis. One counselor I’ve talked to diagnoses everyone with PTSD. After all, she says, we have all had trauma in our lives. Others consult the DSM and match the client’s presentation with the best diagnosis.

Failure to attend to details? Difficulty sustaining attention with tasks? Often lose things? Easily distracted? Often forgetful? ADHD 314.

Heart palpitations? Sweating? Trembling and/or shaking? Shortness of breath? Nausea? Choking feelings? Fear of losing control? Fear of dying? Panic Disorder 300.01

Marked distress? Significant impairment in social, occupational or other areas but doesn’t meet the criteria for another mental disorder? Adjustment Disorder 309

When I left the psychologist and started seeing the counselor, I stopped feeling like a hopelessly troubled person and more like a person with some troubles that could be resolved. Instead of being treated for my “mental illness,” I was treated like a person and we looked together at why I might be feeling depressed or anxious or sad or worried. I began to see that my inability to come off my meds for depression had more to do with the fact that in my case, I had been treating the symptoms, but not the root of the issue.

Over time, I came to understand that my behaviors, moods, and thought patterns had more to do with how I had learned, over the course of the last few decades, to deal with the world. Starting in infancy we all learn how to get our needs met. Some of us learn to trust that we will be taken care of, that our needs are important, that our voices are valued. Others not so much.

There are many lenses through which to evaluate human behavior: family systems, attachment theory, behaviorism, post-modernism, Jungian. There are many schools of thought on how to best help people: cognitive behavior therapy, exposure therapy, psychoanalysis, narrative therapy, play therapy, art therapy, drama therapy.

There are a multitude of diagnoses I could apply to my future clients, but my clients deserve more than a label and to be compared against a checklist of criteria.

I must to remember Carl Rogers and not ask, ”How can I treat, or cure, or change this person?” But instead,“How can I provide a relationship which this person may use for [her] own personal growth?”