Monthly Archives: October 2022

Team from DePaul University wins first place in master’s ethics competition

October 7, 2022

This award recognizes exceptional, demonstrable understanding of the ACA Code of Ethics, the foundation of ethical professional counseling practice. Each year, ACA honors top-ranking teams in both Master’s and Doctoral level graduate degree programs.

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Supervision, Disclosure and Self-Reflection in Preventing Counselor Impairment: An Ethical Exploration

By: Courtney Griffin, Veronica McMillion, Anya Ross and Angela Sundstrom

Department of Counseling, DePaul University, Chicago

Faculty advisor: Alexandra Novakovic

 

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Prompt: Lila is a Limited Licensed Professional Counselor who, for the past five months has been working in federally-assisted, outpatient mental health and substance abuse counseling agency. For the past month, Lila has been counseling Stephen, a 56-year-old, White male, who has been living with HIV for the past two years. To date, she has had four sessions with Stephen. Stephen started seeing Lila because one month prior to his first session with her, he completed a brief stint in rehab for his cocaine and methamphetamine use disorders. So far, Lila has felt very positive about the progress Stephen has made. He has maintained his sobriety, he has complied with his HIV medications and his viral load is undetectable, and he actively engages in therapeutic work. Lila feels a lot of empathy for Stephen because she has been sober for over five years, but she has started to notice that when Stephen talks about his urges to use, she has felt her own old cravings reemerge. Lila has not discussed this issue in supervision because she has not disclosed her personal addiction history with her supervisor due to fear that it would impact her ability to get her full license.

In a recent session, Stephen shared with Lila that he just started a new relationship with a woman. He expressed that when he has sex with her, it triggers him to want to use coke and meth again. Hearing this, Lila became concerned and asked Stephen if he had disclosed his HIV-status to the new girlfriend. Stephen defensively replied, “That’s none of your business! She doesn’t need to know anyway.” Because it was toward the end of the session, Lila did not pursue the discussion any further. She also realized that she never told Stephen that she may have to report that. In her next session with Stephen, before Lila could bring up the HIV disclosure issue, Stephen stated he was struggling with feelings of guilt about something he did just before he decided to stop using drugs. Lila listened non-judgmentally as Stephen disclosed that about two and a half months ago, to get money to buy drugs, he broke into several houses in the area. In one of the break-ins, the owner unexpectedly walked in on Stephen. Out of fear, Stephen attacked the man who ended up in the hospital in a coma. Stephen was able to get away and was never caught by the police. Lila recalled seeing this story on the local news and remembered that the victim was still in a coma in the hospital. In that moment, Lila felt her strongest urge to drink that she has felt in years, and thought to herself, “I have no idea what to do.”

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The supervisory relationship is a foundational tool in preparing recently graduated, unlicensed counselors for independent practice. According to the American Counseling Association (ACA) Code of Ethics (2014), a counseling supervisor’s “primary obligation […] is to monitor the services provided by supervisees” to ensure that all clients receive competent care. A novice counselor’s ability to effectively use counseling techniques, adhere to the ACA ethical code, and seek consultation where necessary impacts the effectiveness of the therapeutic services they provide. Additionally, supervisees must be able to self-assess for possible impairment and commit themselves to regular self-care. This paper will examine a multi-faceted ethical dilemma regarding the importance of the supervisory relationship using the seven steps of the Practitioner’s Guide to Ethical Decision Making (Forester-Miller & Davis, 2016).

Identify the Dilemma

The scenario presents a Limited Licensed Professional Counselor named Lila who has worked for a federally-funded substance abuse facility for five months. Lila has a history of substance use disorder and has been sober for five years. She fears that this could prevent her from obtaining her license, so she has not disclosed it to her supervisor. Lila has had four sessions with Stephen, a middle-aged, HIV-positive, White man with a history of cocaine and methamphetamine abuse. Stephen has maintained sobriety since a recent stay at a rehabilitation facility, and is taking HIV medication to maintain an undetectable viral load. Still, Lila feels concerned that Stephen has not disclosed his HIV status to his girlfriend. Furthermore, she learns that Stephen’s decision to attend rehab was precipitated by a break-in he committed during which he assaulted a man, leaving him in a coma. The authorities have not yet discovered who is responsible for the crime. These revelations, in addition to discussions of Stephen’s urges to use drugs, have triggered intense alcohol cravings for Lila.

There are multiple dilemmas in this case: Lila’s concern about Stephen’s HIV status in relation to his partner, Stephen’s admission of guilt in the assault case, and Lila’s reluctance to disclose her increasingly urgent cravings to her supervisor. This paper will apply the ACA Code of Ethics (2014) and legal standards to each dilemma before selecting a recommended course of action.

Apply the ACA Code of Ethics and Determine Dimensions of the Dilemma

 

HIV Disclosure

HIV is not considered transmissible if there is no viral load, according to the Centers for Disease Control and Prevention (2021). Legally, there is little federal oversight in regard to HIV transmission, and the state of Illinois, where the authors of this paper will practice, repealed the Illinois Criminal Transmission of HIV Statute on July 27, 2021 (The Center for HIV Law and Policy, 2021). Therefore, no laws compel Stephen to disclose his HIV status to his partner. Additionally, Lila works for a federally-funded agency which is subject to Substance Abuse and Mental Health Services Administration (SAMHSA) laws, including Standards for Privacy of Individually Identifiable Health Information (HIPAA) (2004) and the Confidentiality of Substance Use Disorder Patient Records (2017). Here, it would be wise for Lila to seek legal consultation for clarification of these and all laws pertaining to the case.

Ethically, Lila did not discuss the potential limits of confidentiality with Stephen, which she must do immediately in order to maintain transparency and honesty in the therapeutic relationship (ACA, 2014, Section A.2.). Perhaps the most significant aspect of the counselor- client relationship, Lila must protect Stephen’s confidentiality, including the release of his records (ACA, 2014, Sections B.1.c., B.6.b.). Lila has no proof that Stephen has a communicable disease nor that he is putting his partner at risk; thus, she has a legal and ethical duty to maintain Stephen’s confidentiality (ACA, 2014, Section B.2.).

Past Crime Disclosure

Lila must be aware of Stephen’s legal rights and any legal mandates for disclosure of his crime. The Illinois Mental Health and Developmental Disabilities Confidentiality Act (1994) allows disclosure at the therapist’s discretion when there is a specific threat of violence “where there exists a therapist-recipient relationship or a special recipient-individual relationship.” In this case, Lila has no legal duty to warn because there is no threat of future violence, nor a special relationship with the assault victim. Additionally, according to the Professional Counselor and Clinical Professional Counselor Licensing and Practice Act, privileged communications are still protected because the crime was already committed and there is no new imminent risk of injury (2012). Finally, the confidentiality of Stephen’s records is federally protected (Confidentiality of Substance Use Disorder Patient Records, 2017).

Ethically, Lila must have ongoing conversations with Stephen about potential limits to confidentiality (ACA, 2014, Section A.2.a.). Lila should consider possible negative outcomes of disclosure, such as harm to the therapeutic relationship, legal repercussions for Stephen and herself, and value imposition (ACA, 2014, Sections A.4.a, A.4.b.). Ultimately, Lila must maintain client confidentiality because there are no conditions under which disclosing a previous crime is ethically or legally mandated (ACA, 2014, Section B.1.c.). Lila should focus on clinical work with Stephen regarding the past crime, while prioritizing consultation, documentation and self-care.

Examination of Moral Principles

Lila must examine Kitchener’s moral principles (1984) in relation to the personal conflicts she experiences while working with Stephen. Nonmaleficence, or the concept of doing no harm to her client, should be considered in relation to Stephen’s confessions regarding his HIV status and past crime. Lila feels a strong negative reaction to these admissions, but must consider the possible harmful consequences of breaking client confidentiality, such as jail time for Stephen or the dissolution of his personal relationship. Beyond preventing harm, Lila has a duty to uphold beneficence, or work for the good of her client and greater society. Lila could achieve this goal by assisting Stephen in processing the effects of his crime, thereby reducing the likelihood of a recurrence. However, Lila’s negative reaction to his confessions could signal internal conflict between honoring fidelity to her client versus protecting his partner and bringing justice to the man that he gravely injured. She must examine the conflict between these impulses and explore her resulting emotional response and urge to use alcohol. In doing so, she will honor the principle of veracity; honesty with herself, her supervisor, and her client about professional impairment she may be experiencing.

Lila’s Sobriety and Impairment

While Lila fears unfair treatment due to her substance use disorder, her status is protected by federal law. According to the Americans with Disabilities Act (ADA), which includes substance abuse disorders as a protected disability, “No covered entity shall discriminate against a qualified individual on the basis of disability in regard to job application procedures, the hiring, advancement, or discharge of employees, employee compensation, job training, and other terms, conditions, and privileges of employment” (1990). Furthermore, while the ADA applies to state and local governmental units, the Rehabilitation Act protects federal employees of organizations that receive governmental grants, such as Lila, from discrimination based on “information learned about an individual’s disability” (1973). Per the ACA Code of Ethics (2014):

Supervisors must endorse supervisees for certification, licensure, employment, or completion of an academic or training program only when they believe that supervisees are qualified for the endorsement. Regardless of qualifications, supervisors do not endorse supervisees whom they believe to be impaired in any way that would interfere with the performance of the duties associated with the endorsement. (Section F.6.d.)

According to the ACA Task Force on Impaired Counselors, “Therapeutic impairment occurs when there is a significant negative impact on a counselor’s professional functioning which compromises client care or poses the potential for harm to the client” (Lawson & Venart, 2005). Vicarious trauma (VT), or emotional and psychological symptoms experienced by counselors that work with clients addressing trauma, may contribute to Lila’s impairment in this case (Lanier & Carney, 2019). Vicarious traumatization can be viewed as “a cumulative process of personal change in helpers that happens through empathic connection with clients” (Lawson & Venart, 2005). Novice counselors like Lila are at elevated risk for experiencing VT for several reasons. Lila may have limited experience and training in helping clients to process trauma, and she may not have established appropriate boundaries with her clients in this early stage of her career development. Furthermore, her inexperience may affect her ability to recognize her own symptoms of VT as they develop (Lanier & Carney, 2019).

Supervisor Non-Disclosure

At the core of Lila’s dilemma lies her failure to inform her supervisor of her previous substance use and her current challenges treating Stephen. Lila should be involved in ongoing consultation with her supervisor, especially when ethical or professional questions arise (ACA, 2014, Section C.2.e.). Not only does she risk making poor, uninformed ethical decisions, she could possibly harm her client by providing incompetent treatment. Furthermore, Lila’s supervisor is obligated to monitor services she provides to clients (ACA, 2014, Section F.1.a.) in order to assess her professional development and performance. She risks her own professional growth and relationship with her supervisor in withholding key information about her triggers and substance use disorder. In time, she could face remediation, as it is her supervisor’s ethical duty to monitor her competency and effectiveness (ACA, 2014, Section F.6.b.).

Lila’s dynamic with her supervisor, termed “supervisee intentional nondisclosure,” is common, with one study indicating that of 107 prelicensed counselors, 95.3% reported withholding some degree of information from their supervisors, while 53.3% completely withheld a concern from their supervisors (Cook et al., 2020). This is significant in that supervisors are legally responsible for the services rendered to their supervisees’ clients (Magnuson et al., 2000, as cited in Cook et al., 2020). The same study noted that several factors contribute to the likelihood of nondisclosure: self-directed supervision, a more evaluative supervisory relationship tied to professional progress, reduced access to supervisors compared to university settings, and less direct monitoring of supervisees’ work. These considerations may shed light on Lila’s hesitance to discuss negative triggers she experiences in her sessions with Stephen.

Impairment and Self-Care

Above all, this case highlights the importance of vulnerability awareness, wellness monitoring, self-care and supervision in preventing counselor impairment, especially in prelicensed counselors. The ACA Task Force on Counselor Impairment promotes these exercises as a means of increasing counselor resiliency in the face of professional stressors (Lawson & Venart, 2005). Lila meets the standard of impairment as defined by the Task Force; her personal crisis regarding alcohol use and possible VT compromise her effectiveness as a counselor. Counselors should regularly perform self-assessments such as The Professional Quality of Life (ProQOL- III) to measure their vulnerability to burnout, as well as the Self-Care Assessment, which provides examples of various self-care techniques (Lawson & Venart, 2005). Lila must monitor her reactions and emotions, obtain consultation and process her triggers in treatment. Ultimately, “counselors engage in self-care activities to maintain and promote their own emotional, physical, mental and spiritual well-being to best meet their professional responsibilities” (ACA, 2014). Lastly, the Task Force maintains that “An active supportive relationship with supervisors and peers is an especially important component of self- care for counselors” (Lawson & Venart, 2005).

Generate Potential Courses of Action

Legal and ethical codes pertaining to Stephen’s HIV status and his past crime demonstrate that Lila should maintain confidentiality in these areas. Therefore, possible courses of action outlined here will focus on Lila’s sobriety and resolving impairment. One possible course of action is exclusive consultation with peers, which may provide Lila with a sense of confidentiality and safety outside of the supervisory relationship. Having recently finished her graduate studies, Lila may have a robust network of counselors with whom to consult. However, other inexperienced prelicensed counselors may not advise Lila with the same level of insight and expertise as her supervisor. Furthermore, Lila does not have legal or ethical basis to resist disclosure to her supervisor, so this course of action is not a comprehensive solution.

Another potential course of action is to refer Stephen to a different counselor. The immediate benefit of this solution is that Lila’s triggers may be reduced or altogether eliminated, but this is not a long-term solution. Removing the source of stress does not constitute an in- depth understanding of the dilemma, and will not help Lila maintain confident sobriety going forward. Additionally, referring Stephen to another counselor may be detrimental to his recovery and mental health. Stephen may experience feelings of rejection or abandonment if he is invested in the support he receives from his therapeutic relationship with Lila. Referral should be a final resort if all other paths fail.

Select Recommended Course of Action

The recommended course of action is that Lila disclose her sobriety status to her supervisor and speak candidly about her compromised mental health, sobriety, and ability to provide competent care. She is legally protected from discrimination due to her substance use disorder, but may not receive her license if she remains impaired due to non-disclosure. Lila will be honest with her supervisor about how sessions with Stephen trigger cravings, and how she fears being judged for her substance use history. Additionally, she will prioritize her mental health and sobriety, possibly calling on resources such as personal counseling, 12 step programs and support groups that previously helped her reach and maintain sobriety. She will also perform regular self-assessments such as the Professional Quality of Life (ProQOL- III) to check for signs of burnout and impairment. By pursuing this chosen course of action, Lila takes steps to resolve impairment and ensure that Stephen and other clients receive quality care.

Evaluate Recommended Course of Action

Before implementation, the chosen resolution must be evaluated for appropriateness using Stadler’s tests of justice, publicity, and universality (1986, as cited in Forester-Miller & Davis, 2016). The justice test examines whether the counselor would take the same action in parallel situations; the publicity test judges if she would deem it acceptable for her choices and actions to be reported by the news media; and the universality test asks if she would encourage counselors in similar situations to follow this course of action. The proposed solution adheres to recommendations from the 2014 ACA Code of Ethics and meets the conditions of all three tests.

Conclusion

As has been discussed in this analysis, the supervisory relationship is fundamental to the education and growth of new counselors. Counselors will encounter various challenges and ethical questions as they work toward licensure. It is their responsibility to apply relevant laws and ethical codes to their dilemmas, as well as consult their supervisors. In this case, Lila’s fear of personal disclosure isolated her from a fount of support, insight, and guidance that could have prevented her impairment. No counselor is an island, and from novice prelicensed counselors to experienced practitioners, all members of the counseling profession benefit from seeking new perspectives and networks of support.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Learning to be fierce in the face of intraprofessional challenges

By Emily St. Amant October 5, 2022

I started my counseling program in 2007, so after working 15 years in the field, I have … thoughts. One of the most difficult things for me along my career journey has hands-down been dealing with other people. And I am not talking about my clients; I’m referring to other professional behavioral health providers. Looking back, I’ve had some truly memorable encounters that taught me what no book, class or training ever could. 

I want to preface this with the acknowledgment that the people whose actions I’m discussing here aren’t all good or bad. There’s a spectrum ranging from having a bad day to having a bad character, and we all bounce around on that to some extent. I’m sure others could reflect on some of my less-than-stellar moments, where I was acting out of a bruised ego or was simply hungry, and I took out my own stuff on others. We all have a shadow side. Pretending we don’t is what gets us into trouble and what causes real harm to others.

In general, I do not feel we are preparing counselors to work in an agency or organization with other types of treatment providers, other types of professionals and even our fellow professional counselors. I don’t have time to address all of that in this article, so I’ll focus on one key area I personally wasn’t adequately prepared to navigate: my working relationships with others. This is especially true in times when there was a value or priority conflict between me and the other person. There is a certain idealism that plagues training programs, including ones in the counseling field.

I have learned a lot from my experiences working in various agencies and organizations over the years. I’ve encountered people who were exceptionally kind, generous, compassionate, patient and wise. And I’ve also encountered people who shocked and angered me with the lack of empathy and respect they showed to myself and others. Later, I realized I was more disappointed and hurt than surprised or angry. I have encountered several individuals in the workplace who, if nothing else, clearly demonstrated the kind of person I do not ever want to be.

With this article, my goal is to empower other clinicians to protect themselves and be better prepared to effectively manage difficult situations in the workplace. At the same time, I hope that we will all do a better job of ensuring we are not acting in such a way that others need to protect themselves from us. Let us never be cut off from hearing what others have to say — whether it’s about our attitude, work performance and quality, or the way our behaviors affect others. And we need to stay open-minded about what others know that we do not yet understand. I admit I have failed in this endeavor in the past and will certainly fail in the future, but I think the key is to be sincere and genuinely not want to. I never want to be remembered by others as someone who hurt them or let them down.

For me to be the best counselor I can be, I can’t stop reflecting on my own personal and professional demons, deficits and errors. I can’t stop being open to feedback and seeking out opportunities for growth. Being a counselor isn’t just a professional identity or set of skills to master; it is a way of being. Who I am as a human being is shaped and molded by the values of the counseling profession. We counselors all in turn shape and mold what it means to be a counselor. Who we are as counselors not only impacts the care we provide our clients but also shapes our experiences in the workplace, the broader health care field and our world.

Learning the hard way 

Something I wish I’d been explicitly told is just because you work in mental health doesn’t mean that everyone you encounter in the workplace will care about you. In fact, if you work with enough people for enough time, you are guaranteed to cross paths with someone who does not have your best interest in mind. They will not care about your success, well-being, and physical and mental health if it gets in the way of their agenda or bottom line. Even in a nonprofit setting, people still report outcomes of some kind to their managers, financers and stakeholders, no matter what impact this has on you. Even if you play a vital role on a team that collaborates on initiatives and projects, that doesn’t always mean you will be given credit or that the workload will be distributed equally. There will always be people who are willing to sacrifice your health and career for their own benefit. They may use you to build themselves up while also holding you back or to avoid having to do the work themselves or face the consequences of their own actions. Some will see you only through the lens of what you can do for them. It’s almost as if they’re asking, “How can I use your labor, skills and expertise to shape my own reputation? How can you make me look good?” People in more powerful positions and people who hold greater influence will essentially ask you, “How can you help me?” I have had almost that exact question directed at me explicitly, but more often that intention goes unspoken. We should be cautious to avoid creating exploitative and harmful power dynamics. We should be asking those we supervise, manage and work alongside, “How can I best serve and uplift you? How can we work together toward the greater good?”

Ego is a thing. You will work with people who lack awareness of or concern for how their own behaviors impact others around them. Some therapists I’ve worked with have appeared to be two separate people: They act one way in front of management and their clients and a completely different way with their peers or subordinates. Some people will be averse to any feedback, act spitefully or haughty, or seem to be easily threatened for no clear or rational reason. I’ve encountered other clinicians whose behaviors and/or explicit statements communicate they think they are superior because of their training, education, theoretical orientation, clinical focus or specific profession. Egos are walls. They get in the way of us being able to engage with others productively and deeply. One thing I’ve realized is that if you’re dealing with someone’s ego, you’re more than likely fighting a losing battle.

You will also encounter co-workers, managers, supervisors and directors who have poor boundaries. You may witness workaholism be glorified and rewarded, and you may have unrealistic performance expectations placed on you. People are routinely punished and shamed for attempting to strike a healthy work-life balance. This can happen directly; for example, I had a past manager say to me that if I didn’t work 60 hours in a week (without overtime pay, mind you), I “didn’t care about the kids.” The retaliation for boundary setting can also happen indirectly with people being fired for “not being a good fit” or being passed over for promotions if they don’t routinely work overtime. You will also see firsthand why ethical codes are necessary regarding boundaries with clients. There’s a reason codes explicitly state not to do something: Counselors are really doing those things. 

You will meet other mental health providers who plain and simple are not healthy themselves. There is a level of gatekeeping that should happen within the mental health professions, but the gray area between observably impaired and functionally problematic is inadequately addressed in practice. There is a difference between being a “wounded healer” and not being on a healing path at all. I often use the metaphor of a “healing train.” None of us will ever get to the destination of being completely healed and perfect; what matters is staying on that train and resetting ourselves when we veer off track. Yes, practitioners are trained and have skills that are helpful to their clients even if they have never experienced a specific clinical concern themselves, but this is not the same as a counselor who believes they can be an effective provider without doing their own personal work. We all have our “stuff,” and many of us are drawn to the helping field because of our own personal experiences. No matter how much training and education we receive, if we aren’t doing the deep and difficult work of examining our own weaknesses and healing from our traumas and pain points, then we put our efficacy as a clinician at risk. This is why self-care is an ethical imperative for counselors. We can’t lead others somewhere we’ve never been before.

Truths that guide me 

These lessons have taught me a few truths along the way — ones I wish I had known from the start because they could have guided me as I managed difficult interactions or situations.

The first and most important truth is that most of the time how other people treat me has nothing to do with me. We are all working out our own “stuff” in the best ways we can, and we often experience someone wrestling with themselves as they impact us negatively. Just because someone is educated, charming, brilliant, credentialed, licensed, published or highly renowned doesn’t mean they are immune to the human experience.

You will never know everything, and that is OK. It is genuinely OK that you can’t be the best at everything. This should be obvious, but I think this is at the heart of a lot of defensiveness and problematic interpersonal behavior. Everyone turns to counselors and therapists for answers and solutions, but we ourselves are fallible, limited human beings. That is not just OK — it’s why we are so good at what we do in the first place. Because we are imperfect human beings, we can help other imperfect human beings find meaning, purpose, joy and peace. So it’s OK to not have a perfect answer to why things are the way they are and how to best live, change and cope. When we refuse this truth and believe that someway, somehow we have managed to be special and the exception, then, of course, it will be uncomfortable and painful to be confronted with the reality that implies otherwise because we will always fail at perfection. If it feels unbearably embarrassing and shameful when others find us out, which will happen, then that is something to carefully examine and reflect on. We are setting ourselves up for failure if we place unrealistic expectations on ourselves, and in turn, we are also setting those around us up for failure because this will without a doubt morph into unrealistic or even exploitative expectations of other people. This shame can lead us to act out and engage with others in harmful ways. The work of being a counselor calls for radical self-compassion, but this is impossible without also reflecting on who we are in relationships and how we are extending that compassion to others.

Success is collective. By lifting others up and supporting them, we ourselves benefit. By sabotaging or disenfranchising others, we hurt ourselves as well. I need to make sure I am doing my best to live this truth by how I engage with others, and I need to be prepared to set boundaries and make needed changes if others in my life are not. I would have left some relationships and jobs much sooner than I did if I had only believed in myself and my intentions more. Do not trust anyone who acts in a way that pushes others down in any way; just because you aren’t their current target doesn’t mean you never will be. If someone doesn’t give credit where credit is due, they are a selfish person who will never be your true ally or partner. If someone seems frequently jealous and doesn’t get excited about the success of others, they may very well be more likely to try to hold you down and sabotage your health and success. Collective action is required for success, and this has to include communities holding people accountable for their actions and inactions when needed. We should all aim to align ourselves with people and organizations that are doing the work to uplift those around them and to stand up for others as well.  

Boundaries are everything. Boundaries help us navigate the reality that we are responsible for both ourselves and each other. Yes, the adage “with great power comes great responsibility” is true, but any level of influence comes with responsibility, no matter how small or insignificant it may seem. All too often we do not acknowledge the real impact we have on each other as humans, possibly to assuage our guilt and enable our avoidance of this burden of responsibility. Any encounter between two people is an opportunity for either healing and growth or, alternatively, harm and suffering.  

Personal relationships, workplaces and workplace relationships are all vital parts of our lives that have the potential for great positive impact as well as negative or harmful consequences. I like to think of the range in terms of spice levels:

  • Mild: unhealthy
  • Medium: toxic
  • Hot: abusive
  • Scorching: violent

Anyone in a mild to moderate situation has the choice to stay and accept things as they are or work for positive change. If it’s hot or scorching, the only real way to get relief is to get away and seek emotional “burn” care.

Not all “defensiveness” is bad. It’s unacceptable how a lot of us are taught to “manage” our defensive behavior. It’s upsetting when you are confronted with someone pointing out how sensitive you are to constructive feedback, but early in our counseling careers, we need to know that our internal emotional protective system isn’t our enemy. We need to be taught to trust ourselves, to listen to how we feel and to know that sometimes defending ourselves and others is what we absolutely need to do. By not teaching this balance of managing unhealthy defensiveness, that’s often ego-driven, with the reality that there are other people who can and will harm us if we don’t protect ourselves, we set a lot of people up to essentially be conditioned to be complicit in their own abuse or oppression. Yes, we need to remain open to feedback that’s constructive and comes from someone who genuinely cares about us, but we also need to have discernment and the wisdom to know what feedback we should absorb and what we should shield ourselves from.

We must take responsibility for setting our boundaries, and we must allow others to do the same. Remember the only thing you can really control are your own words, actions and reactions, including how much you tolerate other people and situations. Emotional responses are automatic and unconscious, and although we have influence over these responses, we can’t expect ourselves to have complete control over them. They exist for a reason, and one of the main reasons we have intense emotions and anxiety is to protect ourselves. 

I’ve had clients who have asked me to help them “just deal with” the situation that’s causing them harm, but as the saying goes, “You can’t heal in the same environment that is making you sick.” Leaving is often the best solution in relationships that cause us harm, be it with an intimate partner or an employer. I now realize that when I stayed in an unhealthy or harmful situation, I was not taking responsibility to care for myself or to consider how I was affecting the other person or environment. I am not referring to what could amount to blaming the victim of abuse or the recipient of boundary violations for another’s action; it is absolutely inappropriate to place any level of responsibility on the receiver of another’s behavior. However, by staying in an unhealthy environment or indirectly enabling unhealthy behaviors, I was essentially teaching that person that what they were doing was acceptable because I stayed put and tolerated it. I was not doing my part to stop them from not only harming me but also negatively affecting others. Oof! 

It’s important to know where the line is between what you are responsible for and what the other person is responsible for. Without this line, it can be a slippery slope toward excusing, enabling and even rewarding unhealthy behaviors in the workplace and our personal lives. 

If you set enough boundaries, you are guaranteed to get pushback. And it will be uncomfortable. To take a lesson from Nedra Glover Tawwab’s book, Set Boundaries, Find Peace: A Guide to Reclaiming Yourself, the only people who have a problem with others setting boundaries are the people who are benefiting from another’s lack of boundaries. We need to be prepared for how others may react when we stand up for ourselves and refuse to be taken advantage of or treated poorly. 

People who see relationships as only transactional or who want to use you for their own purposes will absolutely get irritated or angry for your refusal to comply with their attempts at control or manipulation. Often to further manipulate the situation in their favor, they label the boundary setting or the accompanying response as the problem. This allows them to preserve their reputation at the further expense of the other person being harmed. 

All too often, we blame the person reacting to another’s behavior instead of addressing the source. This criticism, invalidation and punishment of the reaction to abuse is what is called “reactive abuse.” This line of reasoning can also be taken to its logical conclusion and turn into excusing and enabling harmful or outright criminal behavior (for example, blaming the victim of assault for what they were wearing). This is commonly discussed in the context of abusive intimate partner relationships. However, I’ve seen this play out in the workplace, and it can lead to ruptures in trust and morale and causes real psychological harm. 

Abusive behavior is always the fault of the person doing the abuse. Unhealthy behaviors are always the responsibility of the person acting inappropriately. How we manage these encounters to protect ourselves and others are, in fact, our responsibility. By standing up for ourselves, setting boundaries, and leaving harmful and abusive situations, we are also helping others. We are teaching others what’s right and what’s wrong and what they can and cannot get away with.

Not everyone deserves access to your softness. Too often I believe counselors and healers of all kinds are expected to be “nice” and to be available for everyone for anything all the time. This is far from what’s healthy, sustainable or realistic. Just because we’ve chosen a helping profession doesn’t mean we have to sacrifice our own well-being, safety or sanity. It’s taken me years to learn and truly believe that yes, I am kind and sweet and silly, but I am not “nice.” I am fierce. And that fierceness is not a flaw; it is one of my most valuable strengths.

A part of who we really are is defined by how we meet life’s most uncomfortable and distressing challenges. As counselors, we will experience some of these challenges in the workplace, so we need to be prepared to navigate these and to support others as they navigate them as well. We need more humanity, compassion and humility built into the systems that train and cultivate providers whose very effectiveness depends on their own humanity, compassion and humility.

I leave you with these three reminders: You are not a leader if you don’t build up those around you, those coming up behind you or those who are in your charge. You are not successful if you hinder the success of others. You are not a healer if you are not allowing yourself healing.

 

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Keep pushing to be better

I’ve learned so much from people who have shown me grace and patience. They showed me what’s possible and what I want to be. And I’ve also realized what I do not want to be from those who were self-focused, judgmental, and, to be perfectly blunt, haughty and elitist.

Some of my most painful and anxiety-filled moments with managers, co-workers and educators in the mental health field have taught me that I never want to:

  • Be someone who can’t be taught something new and is unable to value perspectives that differ from my own.
  • Advocate for “the way things have always been.”
  • Argue that “it’s really not that bad so nothing needs to change.”
  • Support something because “I made it through it, so everyone else should have to also.”
  • Hire people who are experts at something I am not and then fail to listen to or consider their input and feedback.
  • Assume I know what is best for another person.
  • Manipulate or coerce others into doing something against their will.
  • Use an offer of “feedback” or an explanation that I’m “just trying to help” as a way to rationalize violating someone’s boundaries.
  • Forget we all carry unseen burdens.
  • Doubt the validity of anyone else’s sincere effort or report of emotional pain.
  • Yell at a colleague. (Yes, really.)
  • Expect those I manage or supervise to meet my social and emotional needs.
  • Jump to conclusions and assume I’ve been told the whole story.
  • Throw someone else under the bus to make myself look good.
  • Make promises I can’t keep or say yes when my actions say no.
  • Disregard the needs of others and forcefully try to get my way.
  • Punish or delegitimize someone because they defend themself when they have been wronged or harmed.
  • Publicly call out people for what they’ve done wrong or criticize others in front of colleagues.
  • Tell someone else they are providing inadequate or subpar care or work because they aren’t doing things my way.
  • Look down on other helping professionals in the field who provide services to people in other ways aside from psychotherapy.
  • Consider myself a superior clinician because “I do a deeper, more meaningful and more important” type of therapy.
  • Promote the further disenfranchisement and oppression of already marginalized people.
  • Fail to look at the whole person and their situation.
  • Cause someone more harm because they were already struggling.
  • Put my own pride and ego ahead of anyone else’s health, success or well-being.
  • Fail to use my power to stop someone from hurting or mistreating others and enable them to continue perpetrating harm.
  • Allow unsupportive, counterproductive and inadequate people to persist without consequences or be rewarded.
  • Make others work harder and longer hours to pick up my slack, or if I’m their manager, tolerate someone being ineffective and causing an inequitable workload to be placed on others.
  • Offer mentorship but fail to mentor and focus on my own advancement instead.

I’ve also had the privilege to work with some from truly inspiring and wonderful people. I’ve witnessed many examples of bold and commendable actions that have left me amazed, and looking back, there have been so many seemingly quiet and mundane encounters that really were so important and affected me more than I realized at the time. These encounters taught me that I always want to strive to:

  • Give credit where credit is due.
  • Help others network and introduce people who may share common interests or support each other professionally.
  • Show others how much they mean to me.
  • Be there for others when they need it most.
  • Genuinely care about others, not just their work performance but their humanity.
  • Listen with patience and kindness when others express their concerns and how their work environment is making them feel.
  • Ensure others feel connected and that they know they belong.
  • Tell people you see how hard they are working.
  • Praise in public. Offer constructive feedback and conduct disciplinary actions in private.
  • Show up and be present during meetings.
  • Keep my word and do what I’ve said I’ll do when I’ve said I’ll do it.
  • Recognize if the success and/or advancement of others depends on me in any way, and if it does, then act accordingly and timely.
  • Remind people to care for themselves and encourage them to do things they enjoy outside of work.
  • Set boundaries and have a life. Log off on time, take time off, etc.
  • Stand up for myself and others.
  • Speak the truth to those who have more power than I do.
  • Make work fun and connect meaningfully with those around me.
  • Push back against things that are unethical or fraudulent.
  • Leave relationships and jobs that I’ve outgrown or those that are toxic and harmful.
  • Trust that others are doing the best they can.
  • Give support when it’s asked for and when it is not.
  • Take responsibility for my actions.
  • Be true to myself. By letting my playfulness, weirdness, creativity and passion be seen, I give others permission to be true to themselves as well.

Becoming the best version of yourself requires work and self-reflection. Here are some reflection questions I offer specifically related to the topic of hand:

  • What would it be like if I let go of my need to be perfect?
  • What would change if l gave myself permission to get things wrong while I am trying to get things right?
  • Am I living out my values in all my relationships?
  • How do I impact my clients, peers, mentees, co-workers and supervisees?
  • How do I see those I serve, manage and supervise? Am I seeing them as individuals I have responsibility for, or do I only see them for what they can do for me or how they reflect on my personal reputation?
  • How am I supporting and building up those I counsel, manage, supervise and work with?
  • Do I really have this person’s best interests at heart? If I do not, what am I willing to do about that?
  • What am I doing to ensure my clients, co-workers, peers, supervisees, mentees and others feel truly safe, valued and uplifted?
  • What boundaries do I need to strengthen?
  • Am I taking on anything that is actually someone else’s responsibility?
  • How can I be fierce and brave? Am I ready to take on the challenge of being assertive?
  • How can I prepare myself in case I experience pushback and negative consequences when setting boundaries and speaking truth to power?
  • Am I doing my part to take responsibility for how I impact others?
  • Am I open to receiving feedback? No, really, am I?
  • Are my own needs met? How am I ensuring I am getting my needs met and in a way that is healthy?
  • What am I doing to care for my own mental health, physical well-being and overall life satisfaction?
  • What priorities do I need to shift? What do I need to do more of? What do I need to distance myself from or let go of?

 

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Emily St. Amant is a licensed professional counselor and board approved clinical supervisor (in Tennessee). She serves as the counseling resources and continuing education specialist in the Center for Counseling Policy, Practice and Research at the American Counseling Association. Contact her at estamant@counseling.org. 

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

‘Not a monster’: Destigmatizing borderline personality disorder

By Scott Gleeson October 3, 2022

Rose Skeeters, a licensed professional counselor in Eau Claire, Michigan, said she’s been in a room full of counselors who scoffed at the mention of treating an often-dreaded diagnosis: borderline personality disorder (BPD). 

The contemptuous response among clinicians is one Skeeters is used to. It’s also a common scenario that’s being replicated in private practices and agencies across the country. In a 2022 literature review of mental health workers’ attitude toward people diagnosed with BPD (published in the Journal of Personality Disorders), Karen McKenzie and colleagues found that mental health professionals have largely negative views of BPD — ultimately impeding proper treatment.

“BPD doesn’t just have a stigma in society; it’s in our profession too,” says Skeeters who was diagnosed with BPD in her early 20s before her mental health career fully launched. “Part of why I tell my story and experience with BPD is because it’s a diagnosis that is seriously misunderstood, and the mind of someone with borderline personality isn’t empathized with enough. There are clients out there struggling with this who need our help.”

Skeeters, who hosts the podcast From Borderline to Beautiful, is among a growing wave of clinicians who specialize in the treatment of BPD, which has become one of the most common personality disorders. BPD was first conceptualized as a mental illness by Otto Kernberg in 1975, and then it was officially introduced as a disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders in 1980. This disorder is characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self and strong emotional reactions. 

The high suicide risk and explosive emotional behavior often associated with BPD are among the many concerns that can prompt eyebrow raises among clinicians and a high referral rate. BPD is also frequently underdiagnosed, largely because it has varying and dynamic symptoms that can initially present as other disorders. Societal stigma doesn’t help either, with BPD being a diagnosis closely tied to hostile behavior in popular culture. During the recent controversial trial between former couple Amber Heard and Johnny Depp, for example, Heard was assessed and diagnosed with BPD by a forensic psychologist and portrayed as angry and impulsive, which was used as a way to discredit her by Depp’s legal team. 

Skeeters has the unique perspective of viewing this disorder from an “in recovery” client purview as well as from a clinical lens now as a professional counselor. She notes that despite the distorted perception of the diagnosis, recent research on the effectiveness of psychological treatments for BPD (such as Sophie Rameckers and colleagues’ article published in the Journal of Clinical Medicine in 2021) illustrates BPD to be highly treatable and the most healable among personality disorders.

“The biggest misconception about borderline personality is that it isn’t treatable,” Skeeters says. “It may be difficult to treat because emotions can rev up from 0 to 60 very quickly for someone with BPD, and in those moments, the logic of reality just isn’t there for that person. But this is not a life sentence and it’s not hopeless to get better. With proper treatment, clients can become self-aware and recover.” 

A trauma-informed approach 

Alisha Teague, a licensed mental health counselor in Jacksonville, Florida, says she’s seen the stigma associated with BPD perpetuate or even exacerbate symptoms for clients because of the damageability to one’s self-esteem. That’s why when working with clients, she makes determined attempts to redefine the disorder’s meaning by zeroing in on its symptomatology.

“Clients with borderline personality are so much more used to being rejected of love than actually healing,” notes Teague, the founder of the private practice Out of the Box Counseling. “When you call it ‘abandonment disorder,’ that helps them grasp a key part of the disorder while empathizing with themselves. I’ve seen clients say, ‘Oh, that’s why I have low self-esteem.’ Then when you tie in attachment theory, a client with BPD can see their behavior is tied to [a] fear of losing the closest person [to them]. That helps us move right into paths to push for secure attachment.” 

Lauren Lucas, a licensed clinical social worker for Fox Valley Institute in Naperville, Illinois, says she also treats BPD by first exploring the deepest root of the behavior. And trauma is often an underlying concern. In a 2021 literature review published in Frontiers in Psychiatry, Paola Bozzatello and colleagues found that up to 90% of clients diagnosed with borderline personality have experienced some type of childhood trauma or neglect. Similar studies have determined BPD is more prevalently linked to trauma than genetics. 

Lucas recommends counselors take a trauma-informed approach when working with these clients. “Nine times out of 10, a trauma is present for someone with borderline personality,” Lucas says. “Even if it’s ‘little t’ trauma, when clients can understand how their past pain shaped their world, it frees them up for self-acceptance. So often with BPD, there’s this reaction to fear of abandonment that’s driving their behavior.” She finds that being direct about what could be causing some of this plays a crucial role in the client’s movement and growth.

Lucas adds that a client experiencing BPD is often  plagued with self-hatred or self-loathing emotions, making a psychodynamic approach a direct pathway for clients to have empathy for themselves. “Sometimes the biggest hurdle can be a client’s self-shaming,” she says.

Shame is also a core feature of BPD, as noted by Tzipi Buchman-Wildbaum and colleagues’ 2021 meta-analysis published in the Journal of Personality Disorders. Christine Hammond, a licensed mental health counselor in Winter Park, Florida, says that for clients with BPD, feeling “seen and heard” with their root trauma (and in general) can help to offset those lurking shame emotions and accelerate their empathy for others. 

One way for clients to feel seen is by using a family systems approach — whether it be exploring upbringings or reconciling with family members directly and indirectly in session. “My approach for most personality disorders is to not necessarily treat the individual but the family as a unit itself,” Hammond says. Roles and dynamics within the households, she explains, often provide a blueprint for what’s happening in present day. 

“A lot of times, in a family dynamic, clients are used to matching volume for volume or verbal assault with verbal assault. It’s the only way to survive or be heard,” Hammond says. “Seeing that some of this isn’t their fault can lead to more empathy for themselves. The goal isn’t to hang out in the past or stay in trauma-land for too long, though. It’s to find paths forward.” 

An alliance based on patience and transparency  

As with any client, a therapeutic alliance is necessary for one’s emotional safety and well-being. Because people with BPD often struggle with mistrust, Hammond acknowledges that counselors may need to build trust gradually. 

“Part of the challenge as a therapist is accepting clients constantly pushing back and sometimes trying to sabotage because that can happen when they’re attempting to undo the deepest wounds of mistrust,” Hammond says. “No matter how safe therapy can be in their mind, trusting someone … takes building that stability over time because they’ve maybe never had it in their entire life.”

Because a lot of counselors are afraid to work with someone diagnosed with BPD, clients are used to constantly changing clinicians, Hammons notes, which only adds to the feeling that nobody understands or relates to them. But counselors can work against that pattern by simply being there, she adds. 

Sara Weand, a licensed professional counselor in Philadelphia, says that offering clients a safe haven through an alliance can be essential when they may be consumed with emotional turbulence. 

“The biggest thing you can do to build trust is honoring that their feelings are real,” Weand advises. “So many times, therapists can get lost in the facts, but that merely perpetuates invalidation. It takes a special skill to be able to meet the person where they’re at and accept them there before launching into work.”

Weand views the therapeutic alliance as a partnership where she and the client are working together toward a goal. This partnership, she says, relies on two things: the counselor understanding that they do not know everything and the client realizing that what they’ve been doing isn’t working. 

She often explains this concept to clients by comparing this alliance to being in a rowboat together with the goal of reaching the other side of the lake. “It’s not my job to row a certain way if it [the responsibility of rowing] is theirs. And it’s also not me rowing back if there’s a hole in the boat,” she says. “It’s important to have mutual responsibility. That may be fostering a healthy relationship of push-pull for the first time in their life because they can see I’m not going to ditch them or abandon them like maybe they have been in other parts of their life. But I’m also going to push them regularly.”

Lucas echoes Weand’s point about client accountability, noting that she’ll often be transparent from the start so clients know what they’re in for. 

“The need for a sense of safety and security is paramount, and as a clinician, you’re not going to make any progress without that,” Lucas explains. “I personally find that being direct can be really refreshing for clients with BPD when forming the alliance. We talk about how coming to therapy is not always going to be comfortable and pleasant. I can still provide unconditional positive regard while also not always agreeing or saying yes. Finding a way to articulate that with care and security can help work against the fear of abandonment or black-and-white thinking.” 

A proper barometer for diagnosis 

Transparency is also important when it comes to diagnosing BPD. Yet another casualty of the stigma tied to BPD is a reluctance among some clinicians to properly assess and diagnosis this disorder. In particular, practitioners who work with an eclectic mix of clients often have trouble determining if and when to diagnose a client with BPD, especially if another diagnosis such as posttraumatic stress or major depressive disorder exists, Skeeters says. 

Skeeters strongly believes a diagnosis, if accurate, is necessary to convey to a client for their well-being and stresses that clinicians shouldn’t sway away from delivering one.

“It’s always important to give clients [the] truth. If a clinician is afraid of how a client may act, then that is their own stuff coming up,” she says. “You wouldn’t tell someone who has diabetes they have something else or that ‘you maybe or could have diabetes.’ If you’re walking on eggshells because you don’t want to hurt the person, it will likely make it worse in the long run because one thing someone with BPD is craving more than anything is trust. Telling them the truth, even if it’s hard, will help toward that.”

In fact, Skeeters admits that one of her biggest complaints is that her BPD wasn’t diagnosed earlier. “In some ways I feel like I lost out on years of my life because therapists misdiagnosed me or were too scared of delivering the diagnosis. I was told that I had bipolar II and was treated for an eating disorder when the underlying issue was tied to borderline personality,” she says.

Hammond, however, cautions clinicians to consider the client’s age and development before giving them a diagnosis. She says timing is everything and resists assigning a BPD diagnosis to her teen clients because, as she points out, a client’s maladaptive behavior can more thoroughly be inspected in adulthood. “I hate adolescent diagnoses,” she stresses. “I go to Erik Erikson’s eight stages of personality development, and a client needs to be developed enough before diagnosing in my opinion.” 

Lucas also pays close attention to the delivery of the diagnosis, and she trusts her intuition on when the right time may be to discuss this with clients. 

“The approach I take is first having a discussion on what a diagnosis means to them,” Lucas explains. “Then I’m acknowledging their trauma and how it affects their behavior in the here and now. If they experienced neglect growing up and are struggling with their partners in relationships today, then I might say, ‘Here’s what we may call that.’ It’s never an easy conversation. But to my surprise, there’s a tremendous amount of relief that can come when a client is able to name why they’re acting the way they are. The language in the delivery matters just as much as the diagnosis.” 

Skeeters takes time to explain the diagnosis to her clients. She begins by saying, “This is what I’m theorizing with a diagnosis,” and then she describes why and how it applies to treatment. A diagnosis, when delivered from a collaborative sense, can bolster self-awareness and, as a result, improve a client’s work ethic in therapy, Skeeters notes.

DBT as the ‘gold standard’ treatment method 

The method of choice for BPD is undoubtedly dialectical behavior therapy (DBT), which combines standard cognitive-behavioral techniques for emotion regulation and reality testing with concepts of distress tolerance, acceptance and mindful awareness that largely spawns from meditation practices. Marsha Linehan, the psychologist who developed DBT in the late 1970s as a result of her own mental illness, defined the dialectical component of DBT as “a meditation-focus,” which is accepting things the way they are while simultaneously pushing for change to achieve happiness. Allowing clients to engage in both of these experiences at once paves the way for an increased emotional and cognitive regulation by helping them learn the triggers that lead to undesired explosive and reactive states. 

Weand, a DBT instructor in Philadelphia, describes DBT as a balance between meeting a client where they’re at while also pushing for change. DBT is all about building a client’s skill set to face their inner conflict in a way that projects outward in a healthy manner, she explains. 

“DBT is the gold standard of treatment for BPD for a reason, and that’s because it works,” Weand says. “It allows the therapist the opportunity to validate the client and really connect on a human level. The skills are all practical, but the meditation-focus creates room for slowing it down and honoring feelings as real. CBT [cognitive behavior therapy] can work as a standard therapy, but for people with BPD who feel so deeply, sometimes, painful shit is just painful shit and you can’t necessarily reframe that.”

“DBT can be effective with suicidal ideation,” Weand adds, “but it’s important to have proper boundaries as a therapist and refer to advanced care because DBT is not suicide prevention.” 

One treatment that is often complementary to DBT is eye movement desensitization and reprocessing (EMDR), which, as Lucas points out, can help with the dissociation a client with BPD may experience when they are unable to regulate intense emotion. 

“One of the biggest things EMDR can help with is the acceptance piece of regulation,” she says. “We cannot change what happens to us, but we can change how we react” to it. 

Hammond says that DBT’s focus on mindfulness can help to bolster a client’s self-awareness and therefore improve their ability to control or manage explosive and eruptive behavior. The overall gain from DBT isn’t necessarily removing a behavior; it’s slowing things down so that triggers can be managed and dysregulation can be altered, she explains. 

“We usually don’t see the behavior completely go away,” Hammond adds. But it provides clients “with a higher level of awareness and really knowing themselves.”

Untangling black-and-white emotional thinking

A common symptom of BPD is black-and-white emotional thinking (i.e., splitting), which involves seeing people or situations as all good or all bad. Skeeters says that type of intense relational trauma is a byproduct of an “emotional playground” that clients with BPD can find themselves trapped in and reactionary to when reenacting old wounds with partners. For that reason, if clinicians are working with a couple and one of them has BPD, then that individual’s treatment must come before couples therapy can begin. 

Nopphon_1987/Shutterstock.com

“Growing up, I viewed the world through a hyperbolic lens,” Skeeters recalls. “I was very sensitive and assumed that others viewed it that same way too. In my effort not to become abandoned, I ended up becoming this tyrant with dysfunctional beliefs. It can feel like other people are making you out to be a monster and that just makes it worse. I didn’t know that other people weren’t hyperbolic or lacked empathy the way I did. When it came to my relationships, to even start the path to recovery, I had to be brutally honest with myself and know how my behavior affects others around me when I’m on that emotional playground.”

Lucas says that the best way to address black-and-white emotional thinking and encourage accountability is through preventive measures and psychoeducation. 

“Because folks with BPD have more extreme experiences with emotions, it’s important to provide tools of regulating and grounding for moments of being triggered,” she notes. “When it’s showing up in a relational aspect, it’s [about] helping clients understand the way their brain may be operating in those moments [and] why they might fixate on how things should be or need to be. When someone is splitting or seeing in black and white, it can be difficult to see the gray area or the nuance of an argument or situation in a relationship. When we look at those patterns, not naming them as good or bad per se, but honor where they’re coming from and why they’ve served someone, then they can be adjusted better.” 

Weand says she’s noticed that most of her client’s black-and-white thinking comes after a big fight or a relationship failure. “I’ll have a client come in and their biggest pain is that ‘people think I’m crazy’ and [they] just want to feel like they’re not a monster,” she said. “They truly fear they’ll be doomed to be [perceived] this way their entire lives. The reality is they may be doing [and saying] things that look crazy [and that affect or hurt others]. … But once you show them where it comes from and that it can be regulated, there’s hope.”

Confronting countertransference 

Transference and countertransference can be ongoing issues when treating clients who have BPD, so counselors need to do their own work by becoming more self-aware and going to therapy themselves. 

Teague acknowledges that her own personal experiences with a family member who has BPD once challenged her ability to work with clients who are diagnosed with the same disorder. It took personal tragedy to push her to do her own self-work to develop the self-awareness and emotional availability that she now uses in helping clients with BPD.

“In 2020, I was smacked in the face by so many terrible things: a tragedy with a client happened, a friend from high school died [and] then everything with George Floyd came about,” Teague recalls. “I didn’t realize it right away but all of my own personal trauma was coming up. If I didn’t go back to therapy to do my own work and forgive myself to become self-aware, then I wouldn’t be able to work with this type of population. You need to have that awareness because countertransference is bound to come up for some types of cases. You need to have the tools within yourself first.”

Weand acknowledges that she needs to keep her caseload low and have only 10 clients so that she has full emotional availability for clients with BPD. “We have to be honest with our own limitations,” she said. “Mood-dependent behavior is tiring, so by setting those limits and having those boundaries, we’re giving our clients the best fit in a therapist.” 

Hammond said she’s seen therapists fret when working with clients experiencing BPD, and she can often trace it to their own inner struggles that may need to be worked out elsewhere. 

“Obviously, if you have countertransference that makes it unhealthy for the client, then a referral is necessary,” she says. “But I see too often therapists might have their own issues or misconceptions with BPD or don’t have the right education on it so they’re very quick to toss them [the client] to somebody else.” She acknowledges that this tendency is not helpful, and she hopes clinicians will develop healthier attitudes toward clients with BPD moving forward. 

“When you look closer, you can see that BPD clients are some of the most creative, imaginative and passionate people we have in the world,” Hammond says. “That’s why it’s so sad they’re misconstrued because I greatly enjoy working with them — seeing them fight to improve and then [eventually] get there is one of the most healing and powerful things you can do as a therapist.”

 

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Scott Gleeson is a licensed clinical professional counselor in the Chicago suburbs, specializing in trauma and relational dynamics. He spent over a decade writing for USA Today, where he won national writing awards from the Associated Press and NLGJA: The Association of LGBTQ Journalists. His debut contemporary novel, The Walls of Color, and its sequel, Spectrum, will hit bookshelves in 2024 and 2025, respectively.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

From the President: The four attributes of a good mentor

Kimberly N. Frazier October 1, 2022

Kimberly Frazier, ACA’s 71st president

Last month’s column illuminated the process you take when you discover the places you work, provide services or volunteer do not align with your own personal justice, equity, diversity and inclusion (JEDI) goals. I included an interview with Keith Dempsey on his decision to change his career path as an example of what this process may look like. Dempsey discussed how a conversation with his mentor helped him solidify his career change from working in academia to following his passion to do JEDI work within his community.

Building on Dempsey’s interview, I want to discuss the importance of mentoring throughout your career. Mentoring should offer four main things to the person seeking and being mentored: 

  • Support
  • Introspection 
  • Access 
  • Opportunity

I want to stress that you will need more than one mentor, and that mentor does not necessarily have to come from the same discipline or career. What each mentor provides depends on your personal needs and career goals. I have mentors that aid in various aspects of my career, leadership and personal development. I selected each mentor based on their expertise, my current needs and my future needs. Some mentors I have had from the beginning of my career, and others I have found along my journey as my needs have changed. 

When looking for a mentor, you need to be honest with yourself about the following: What are your career needs and goals? Are you willing to do the work to build a relationship with your mentor? Do you feel confident enough to discuss the changes you need to make in the relationship as you evolve? And are you willing to break up with your mentor if your needs are not being met?

A true mentor offers support to their mentee in times of triumph and in times of challenge. A mentor serves as a cheerleader throughout your career to help you navigate the times you are being celebrated as well as the times that you are being marginalized, not being seen and feeling your lowest. As the mentee, your job is to pay attention to whether your mentor is supporting you through the lows and highs of your career. And if they aren’t, you need to find a new mentor.

A true mentor offers introspection for various critical incidents and events that happen in your career (e.g., experiencing microaggressions, being passed over for a promotion, not being seen at work, not being able to progress to the next step). A mentor listens to your perspective as you provide context to these critical incidents and offers solutions and possible next steps. They allow you to vent, cry and be angry, but they also push you to move forward toward your career goals. If your mentor is unable to offer this type of introspection, you need a new mentor.

A true mentor offers access to spaces that you would not have access to or knowledge of on your own. Mentors include you in conference presentations, journal articles, grants and meetings, and they introduce you to people who can further your career goals. Mentors recommend you as someone who can provide expertise, leadership and consultation to organizations. If your mentor is not providing you access in these ways, you need to examine the people whom you consider your mentor and have difficult conversations as to why this is not being offered or happening in your current relationship.

Finally, a true mentor offers opportunities that will help you get to the next level of your career and leadership goals. These opportunities can include award nominations, networking for jobs, networking for leadership in various organizations, and chances for you to sit at tables that you would not typically be able to sit at or even know about on your own. Mentors provide these opportunities free of competition, and they have conversations with you about ways to make the most of each type of opportunity offered. If your current identified mentor has not offered versions of these types of opportunities, you need to talk with them about why this is happening.

This month I challenge you to reflect on your current mentoring relationships and ask whether they are offering you the four basic attributes of a good mentor — support, introspection, access and opportunity. These attributes should be mutually beneficial and should be offered consistently, freely and in the spirit of paying it forward. Until next month!