Tag Archives: therapeutic alliance

Building rapport with clients experiencing psychosis

By Tina C. Lott April 13, 2023

a person looks off to the side with her hand over her mouth and the other by her head; another person sits across from them with a notepad

Ground Picture/Shutterstock.com

When discussing working with clients experiencing active psychosis, I once had a counseling student ask me, “Dr. Lott, what’s the point of trying to build a relationship with a client who isn’t even sure they are on the same planet as me? I mean, does it really matter at that point if I get to know them?” Taken aback, I responded, “If this client were your loved one, would you still have this question?” This exchange helped the student realize the importance of seeing clients from a place of compassion, no matter their symptoms, but it also made me wonder how often other students and counselors have pondered this same question.

In a traditional counseling session, building rapport is one of the most important tasks that the therapist will have. Rapport building helps the client feel welcomed, heard, seen and validated and helps improve the therapeutic process. In addition, research supports the notion that the counselor-client therapeutic alliance has a significant impact on treatment outcomes. Thus, regardless of the issues clients bring to session, the relationship bonding between the therapist and the client is essential.

But what about clients who are actively experiencing psychosis? Should therapists take the same time and effort to build a relationship with them? The straightforward answer is a resounding yes, but unfortunately, many clinicians do not always intentionally practice this.

Research studies indicate that counselors agree on the importance of rapport building with this population. So, if counselors know that this is important, then why do some struggle with this when it comes to working with individuals diagnosed with active psychosis? Nearly all the supervisees I have worked with have told me that they initially had a difficult time building rapport with clients experiencing psychosis. Because this process can be challenging and unique for clients with severe mental illnesses, I offer insights from my own experiences on why building rapport is important for this population and effective strategies on how to do it.

The need for rapport building

Throughout my research and work with the mental health community, I have noticed many articles implying that individuals living with severe mental illnesses are violent or dangerous and that caution should be taken when working with this group. Some articles talked about the importance of managing a hostile environment and being aware of exit doors and ways to call for help should things escalate. Although this is possible in some cases, hostility and danger have not been my experience when working with this population, and I have worked with some of the most severe forms of psychosis. In most cases, I have not felt threatened or on edge when working with this population. This sort of thinking is more prevalent due to the stigma associated with severe mental illness. I have found that people are often afraid of what they do not understand, and therefore those with severe mental illnesses are often ostracized, discriminated against and stereotyped.

During my 11 years working with clients experiencing severe mental illnesses, I have found that my rapport with clients supports them in treatment by helping them adhere to medication (when applicable and desired) and engage in services specifically designed to help reduce symptomatology. Clients who are experiencing active psychosis are likely to be skeptical of anyone outside of their world. Some symptoms, such as paranoia and severe anxiety, may have convinced them that others, especially mental health professionals, do not have their best interests in mind. Often, their reasons for suspicion and skepticism are warranted. Many clients with severe mental illnesses have had negative and often traumatic experiences with the counseling profession due to well-intentioned but poorly trained or unaware clinicians. Therefore, the odds are against us when it comes to building the therapeutic alliance.

Even though it is challenging, I’ve found that building a therapeutic alliance with this population is one of the most effective interventions counselors can implement. In addition, it can be a positive interaction that counters any potential negative mental health experiences clients have had in the past. It is safe to say that regardless of whether a client is experiencing active psychosis, having someone that they trust is always helpful when it comes to the treatment plan, emotional and psychological commitment, and their overall well-being. And for clients with severe mental illnesses, it is a necessity.

There are many benefits to creating a strong therapeutic alliance, but here are three main reasons why rapport building is important for clients with severe mental illnesses:

  1. Trust creates relationships and relationships can lead to progress. A client’s trust in their mental health professional provides an opportunity for the client to receive care. No matter how severe one’s psychosis may present, trust is important when it comes to adherence. If a client does not trust their team, they are less likely to engage in the services offered to them. Clients need to know that mental health professionals have their best interests in mind and that the goal of counseling is to help them find relief from the symptoms that may have caused them to seek or receive treatment. Building a trusting relationship with just one mental health professional can help clients de-escalate when they are in a state of crisis, assist with medication and therapy adherence, and encourage the client to be an active change agent when addressing collaborative treatment plan goals.
  2. A sense of connection and belonging can build community. Those with severe mental illnesses often feel alone and misunderstood, which can cause them to self-isolate. Research has shown that people diagnosed with severe mental illnesses tend to connect with others who have severe mental illnesses because they do not feel a sense of belonging with people who do not have similar diagnoses. According to Patrick Corrigan, the program director of the Honest, Open, Proud program (which aims to reduce the self-stigma associated with mental illness), one of the best ways to understand people with severe mental illnesses is by forming connections, having conversations and engaging in shared activities with them. Counselors can establish a healthy connection with this population by engaging in the client’s community as an observer, remaining curious by asking questions, dispelling biases and stereotypes, and working with the client in a benevolent and nonjudgmental way. When counselors approach clients from this perspective, clients are more willing to allow the counselor in, which helps foster an authentic relationship and a sense of community.
  3. A strong rapport positively affects treatment outcomes. In the first edition of his book The Basics of Psychotherapy: An Introduction to Theory and Practice, Bruce Wampold said the therapeutic alliance is one of the most important aspects of the counseling process and it often leads to favorable outcomes. This continues to be true today. Wampold stressed that the stronger the alliance early on, the better the outcome. The trust developed between the counselor and the client is a sacred and unique connection that happens within the counseling session, and it creates a safe place for the client to express their inner thoughts without judgment. For some clients, it may be the first time they have experienced a healthy relationship. Individuals with severe mental illnesses have most likely felt betrayed by the mental health system and are therefore reluctant to share how they truly feel. For example, a client once told me that he did not want to share how he felt because he feared he would be hospitalized or punished. After taking the time to reassure the client that I was there to listen and support him, he started to share his true emotions. Gaining the client’s trust could help uncover many other symptoms that get in the way of the client living their optimal life. Lessening of the severity of symptoms and connecting the client to the appropriate resources, in turn, can reduce their need for mental health services and address symptoms that may have led to hospitalization in the past. In other words, the bond formed between the counselor and client has the potential to decrease the cyclical impact of overutilized mental health services because clients are listened to and validated.

Strategies for building rapport

I think that depending on the environment, the culture of the clients you are working with and the clinician’s skill set, there are many ways to connect with clients with severe mental illnesses, including those experiencing psychosis. In my extensive work with this group, I have found that the following strategies work exceptionally well.

Get on the same page as your client. The counselor and the client should always work collaboratively toward the client’s stated goals. Frequent check-ins to make sure that the goal has not changed are important when it comes to assessing progress. When counselors make goals for the client as opposed to with the client, a therapeutic disruption occurs, resulting in the client not being an informed and active change agent toward their goals.

When working with psychosis, establishing a common goal may require the counselor to be more flexible and creative in their approach. For instance, I worked with a client who heard voices and her main goal was to stop her voices from disrupting her while she studied. Of course, I could not guarantee that she would achieve this goal, but what I could do was offer ways in which the client could learn to tolerate the voices so that she could still study. So we adjusted the therapeutic goal to focus on learning coping strategies to distract her from the voices.

Counselors have the responsibility to make sure that treatment is geared toward the client’s benefit, wellness and preferences. When this alliance is in place, treatment outcomes can improve.

Stop talking and listen. One of the most effective interventions for working with any client, especially those who are experiencing psychosis, is to listen to the message that the client is trying to convey. When working with psychosis, there is some truth in even the most delusional of statements. I once worked on a psychiatric unit and had a client who believed that the devil lived in his rectum. Most of the mental health providers that he had encountered before me dismissed this statement, often attributing it to his psychosis. When I did my assessment of him, I asked more questions about this “devil.” I asked what it looked like and why it might have chosen to live in his body. Although his response was tangential and disorganized, I learned that this “devil” was really the client’s way of telling us he had been sexually abused. This “devil” was a result of trauma. It represented one of the most detrimental moments in his childhood. Had others mental health professionals listened and been more patient, it is possible that his trauma could have been addressed much sooner.

Hold back your urge to assess and evaluate. Over the years, the agenda in the counseling profession has been clear: Diagnose and then move the client through the treatment process. So it has become second nature for clinicians to walk into a session, assess a client, assign a diagnosis for billing purposes and move on to the next client.

The problem is that clients can see right through this. They can tell when there is an agenda or when they are a part of this system. Clients come to the session to feel heard and validated. They do not want to be a part of the “mental health assembly line.” Clients who have had a long history of being a part of the mental health system often feel like just a number or another item to cross off a counselor’s checklist. This has decreased their trust in the mental health profession. In addition, it has made clients not want to disclose and tell their stories because they are in the room with yet another entity who will write it all down, not thoroughly address what was shared, and then move them through therapy without ever really addressing the core issues or providing resources for dealing with what they shared.

Clients are constantly asked to be vulnerable and do not always get what they need in return. Clients with severe mental illnesses have often experienced significant trauma in their attempts to address their mental health needs, so having a counselor who is curious, welcoming and nonjudgmental can create for a strong foundation for a therapeutic alliance. Diagnosing is necessary, but it does not have to come before a therapeutic relationship is built.

Do not argue with delusions; they are a symptom of something bigger. When working with clients who experience symptoms such as delusions or hallucinations, I have seen new and even seasoned counselors get into a power struggle with clients. This never ends well, and it greatly diminishes rapport. Counselors who enter a power struggle often focus on the wrong things in session. This is especially true with clients who present with psychosis. It is human nature to debunk something that seems untrue. When aware, it is even natural to debunk things that are irrational. But this is not ideal in the beginning stages of rapport building. When working to build rapport, telling a client that their delusions and perceptions are not real is like saying you do not want to hear what they have to say. It communicates that you are another person in their life who is not listening to them.

Instead, if counselors focus on the symptoms that are getting in the way of the client’s everyday goals, they could help the client make more progress. For instance, I once worked with a client who believed that people put snakes in her soup. Because of this, the client would not make or eat any soup. Instead of confronting the client and making a case that there were no snakes in her soup, I focused on the foods that she enjoyed eating. Last time I checked, you cannot starve from not having soup as a part of your diet, so I focused my attention on the symptoms that mattered in her day to day and did not spend energy debating about delusions that had no real bearing on her well-being. I have found that when we concentrate on helping clients focus on their personal goals and everyday functioning, some of the psychotic symptoms tend to take a back seat and are less of a disturbance.

In her master’s thesis, “Best practices of building therapeutic alliances with clients living with psychotic disorders” (published by St. Catherine University in 2017), Nicole Rominski expressed similar thoughts when she stressed the importance of focusing less on diagnostic criteria and challenging delusions and more on the distress that the symptoms cause because this is the more significant issue. Doing this does not mean the symptoms go away, but they are less likely to consume the client’s attention, which would be a positive outcome for many clients with psychosis.

Ask how you can assist and do what you can to help. Our main role is to assist, advocate and support the clients that we work with. If you work with clients who are actively experiencing psychosis, you may wonder what they would need to feel supported. That’s a great question, and the client is the person best suited to answer it. Asking a client how you can be of support to them or what you can do to help them can open the doors in two ways. First, the client understands that you want to listen to them and you are there to help them. Second, it helps build trust between you and the client, especially if it is the first time a mental health professional has directly asked them this question. Even if you cannot support them in the exact way they want, you can still listen, provide resources that address their needs and show the client that they matter.

Humanize the experience and share the client’s story with the treatment team. Once you have done the important work of taking time to listen, validate, empower and advocate for your client, share what you have learned with the interdisciplinary team. You have an insider’s view of what the client is experiencing. You have deciphered the hidden messages within the delusions and gotten to the core of the message that the client is trying to share. It is important to make sure that others who will be working with this client know this information as well.

This approach also benefits the client in three ways. First, sharing the client’s story humanizes them and allows their diagnosis to take a back seat to who they are as a person. In other words, we see the person first and not just their diagnosis. This does not mean that symptoms will be ignored and unaddressed; instead, understanding the client in context is crucial to effectively treat their symptoms. Second, sharing this information also helps family, friends, mental health providers and others know how to approach the client, which in turn can help the client feel safe. And it saves the client from having to repeat their story. Third, the treatment plan will be more individualized for the client now that their symptoms can be understood and addressed in context. In turn, health professionals can better understand and target the underlying causes of distress, thereby improving the client’s mental health and well-being.

Conclusion

There are many reasons why it is important to build a trusting bond with our clients. For those with severe mental illnesses, building rapport is the most important step when it comes to seeing positive change and progress. Stigma has exacerbated some of the most harmful myths associated with clients living with severe mental illnesses and has caused significant misunderstandings related to how to establish a rapport and working relationship with them.

I am thankful to the student who bravely asked about the point of trying to build a relationship with a client in active psychosis. Not only did it help me realize how common it is for people to contemplate this question, but it also motivated me to provide some clarity and understanding regarding this population and the challenging work that comes with it. I am grateful to the hundreds of clients I have worked with that have taught me how to remain curious, compassionate and solution focused to address their needs and wants from the counseling profession.

 


headshot of Tina Lott

Tina C. Lott holds a doctorate in counselor education and supervision and is a licensed clinical professional counselor, certified alcohol and other drug counselor, national certified counselor, approved clinical supervisor and board-certified telemental health provider. She serves on the board of directors for the National Board for Certified Counselors’ Center for Credentialing & Education, and she is an academic program coordinator and core faculty member at Walden University. She has a YouTube channel specific to addressing stigma and all things mental health. In addition, she is an independently contracted therapist at PATH mental health, a mother of two fantastic kids and wife to her life partner. Contact her at tina.lott@mail.waldenu.edu.

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.


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.

The loss of our ‘humanness’

By Suzanne A. Whitehead February 24, 2023

DC Studio/Shutterstock.com

Recently, I needed to undergo some medical tests in a hospital-based clinic. I arrived a few minutes early and was eventually called inside for my tests, which required four separate parts. Immediately, as I put the swaying, open-backed gown on, I began to feel my humanity slowly slipping away. I now looked like all the other patients in similar attire, and I felt the loss of myself as a human being. I started to feel like an “it” to be worked on. I had felt this way previously for other exams and tests — this was just a “refresher.”

I was prepped, injected and told to wait again; my questions went unanswered. Inside myself, I could feel my anxiety starting to well up and get the best of me. I was finally led to another room and told to lie on a table. The table was cold and uncomfortable and hurt my back, and the feeling of somehow being an “it” to be worked on, not a human being any longer, returned. I was told to raise my arms over my head, and the technician quickly left the room.

The overhanging equipment suddenly whirred noisily and began getting closer and closer to my chest and head, increasing my uneasiness. The machine rotated a bit overhead; I couldn’t see around it at all. I suddenly felt claustrophobic and a bit panicky, and finally called out for the technician after several minutes. He answered from an adjoining room and asked what was wrong.

I said I was feeling a bit anxious, asked what this test was for and asked how long it would last. He answered bluntly, “It’s for the tests you’re having.” He then aimed a fan at my head to help “with people like me,” he stated. I immediately felt demoralized again and was told it would be another five minutes under the whirring machine.

I was finally released from the “jaws” of the overhead machine. As I started to rise, I felt dizzy at first, perhaps because I had my arms stretched over my head for several minutes. I was escorted out of the room and sent back to the waiting room, again, alone with my thoughts. (It’s been my experience that human beings do not like a void of information. We try to obtain it the best way we can, and when that fails, we begin to make assumptions, which are often inaccurate. It’s simply what people do and is part of the human condition — if only the medical profession acknowledged that.)

There sat the others, all waiting for their time under the machine. I didn’t dare tell them not to worry, our eyes never meeting. Internally, I felt scared about what the tests could reveal and what else was in store. The same concern seemed etched on the faces of those in that waiting room. I wondered, “What if someone had just taken the time to explain what was happening to us and what we were about to experience?”

Taking time to connect

As I sat there worrying, waiting for my next exam, I began to wonder, “As counselors, do we take time during the essential beginning session to discuss with our clients what counseling is really all about?” Often, clients don’t know what to expect from counseling. Ours is a relatively new profession, and many clients, for example, did not even have counselors in their schools when they were growing up. Or the counselor role was so diminished, they rarely met them in person. Moreover, many schools did not even employ counselors until recently. Are we selling our clients short by taking it for granted that they simply intuitively know what to expect?

My diagnostic testing felt demeaning. With no sense of control, I felt a bit overwhelmed. In the end, I just wanted it all to be over. So, I sullenly complied with every command, didn’t ask more questions and couldn’t wait to leave. The experience — which was more psychologically than physically painful — left me with a bitter taste in my mouth, and I never wanted to return.

The parallels with counseling jumped out at me. Do our clients feel the same sometimes? Is that why many don’t want to return? For instance, according to Joshua Swift and Roger Greenberg, in a meta-analysis published in 2012 in the Journal of Consulting and Clinical Psychology, 1 in 5 clients end psychotherapy prematurely. As counselors, do we spend the necessary time to understand the culture and concerns of our clients, as well as address their fears?

Those special medical technicians who do take the time to develop a human connection first make all the difference in one’s experience. Can we say the same for ourselves as counselors? As human beings, we all crave human connection; it is the very heart of counseling. For the sake of time, are we rushing through this vital aspect of the process?

How we treat our clients

I am reminded of the many times I got extremely busy as an agency clinician and, later, as a school counselor in my own career. I would see the long line waiting at the door of our school counseling offices or sigh a bit when one of my clients finally disclosed that huge revelation they’ve been holding back the last six sessions, with five minutes left in our meeting. My heart would sink as I realized I couldn’t go over the session time because my next client was waiting. During those times, I remembered that as counselors, we are instructed not to get “too close” to our clients for fear of losing our objectivity.

Although being objective is vital to the counseling relationship and the client’s well-being, does it also mean that we must sacrifice their humanity? Sadly, I have worked with some physicians, nurses and respiratory therapists (one of my former professions) who have become cold, distant and indifferent to their patients. They have absorbed the “lesson” about not getting too close to their patients all too well and have become detached when their patients don’t respond well to their interventions or ultimately die. It allows them to not “feel” and to go on with their “routine” activities as if they were working on “machines.” Their patients know, though, and are left feeling demoralized, defeated and not heard — just like I was during my exams.

The ability to have empathy is the cornerstone of being a counselor and a counselor educator. Without this ability, we are doing our clients and students a disservice and, possibly, irreparable harm. To a degree, the ability to have empathy for the “least deserving” of our clients (e.g., individuals who have committed murder, rape or child abuse) is what sets us apart from those who are not counselors by trade. If we reject our clients for the behaviors they have committed, then we too have lost our sense of humanity for them and will judge them, harshly, just as society has.

As counselors, we never have to condone or agree with a behavior that a client has done, but we do have to see them as a human being, deserving of our care, and believe in their willingness and abilities to want to change. If we also reject these clients for the behaviors they have committed, then we have endorsed their beliefs of self-loathing and pity. We reinforce their negative self-beliefs that they are unable to ever heal and that they are undeserving of comfort, compassion and understanding. Arguably, we doom them to repeat their behaviors by our rejection, disdain and judgment. If we don’t believe in this fundamental aspect of counseling — that all persons can change and deserve our respect — then, sadly, it may be time for us to find a new career.

Finding our own balance

Not getting “too close” to our patients or clients is a self-protection mechanism. It is fundamentally a correct premise, but humanely flawed. Finding a balance between objectivity and empathy is the key. Whether we are treating patients or clients, the same premise applies. It is essential to their well-being and, I posit, to yours as well that you find your balance and always reevaluate and assess it. If you feel yourself becoming resentful toward some of your clients, or feel too rushed with them, or feel that you are becoming too preoccupied with the time spent on them, challenge yourself to be proactive to take the internal steps to work on this.

If the system needs changing, find the courage to be the voice for your clients. If working with clients in a group setting makes more sense, initiate that adjustment. If challenging the status quo requires speaking up, do so for the sake of your clients. Remember the basic tenets of your code of ethics — to always advocate for social justice, equity and cultural competence. If you need more training, obtain it. If you need more supervision, don’t be afraid to ask for it. Not only will you be following the ethical principles of self-care and wellness, but your clients will benefit from your self-investment tenfold.

If any of this resonates with you as a clinician, that is a healthy response. Human beings were not designed to be “garbage bags,” to continually just stuff our feelings until we are about to explode. If we do so outwardly, we are accused of just being too angry and emotional; when the implosion is internal, it can lead to deep and unresolved depression. No one wants to feel like they are not being listened to, are not being heard and are simply “taking up another’s time.”

If you can relate to having felt this way during a medical exam or trip to your doctor, then you can relate to what it may feel like being a client and being afraid no one will understand you. Some clients can get past some rudeness or hurriedness of staff, but they won’t do so with you as their counselor. The adage that a person may not remember everything that you say but will definitely remember how you made them feel is so true.

When we are treated as less than human, we lose our humanity. For those who do it to us, unconsciously or not, they do too. Our treatment of each other becomes rote, mechanical and unattached. The preambles to the ethics codes for both the American Counseling Association and the American School Counseling Association share the principles of autonomy, beneficence and nonmaleficence; these are essential tenets to practice our counseling craft and to live by. A basic premise of counseling is to form a therapeutic relationship of trust. It is incumbent upon all of us as counselors and human beings to always remember to do just that.

Best wishes to each of you.

 


Suzanne A. Whitehead is an associate professor and the program coordinator of the counselor education program at California State University, Stanislaus. She is a licensed mental health counselor, a retired school counselor and a licensed addiction counselor. Contact her at swhitehead1@csustan.edu.


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.

Resisting a savior mentality

By Caitlin C. Regan December 5, 2022

When I first began counseling as a teenager, I often did not connect with the clinicians sitting in front of me. They lectured me. They told me what I could and could not do. They told what I should and should not feel. Needless to say, that approach was not effective. 

But when I was 23, I started working with a psychiatrist who had a different style. She provided me with information about my condition, and then she would ask how I related to that information, what I felt, if that made sense or if I was connecting with it. She didn’t tell me what I could and could not feel or what I should and should not think; she just allowed me to be myself. 

This different approach allowed me to make a lot of progress. She was the first practitioner to diagnose me with bipolar II disorder because she was the first one I felt comfortable telling about my earlier manic episodes (which I later learned are actually hypomanic episodes). I felt like I owed her a lot because of how much she helped me during therapy. 

During one of our last sessions together, I thanked her for all she did for me and told her how she had saved me and changed my life. She stopped me and said, “I didn’t save you; you saved yourself. You’re giving me credit I haven’t earned. Give the credit to yourself. You’ve done the work, you’ve taken the knowledge and made change with it, and you’ve made a difference for yourself.” Her words in that session have always stuck with me even as I now sit in the therapist’s chair working with my own caseload of clients.

A humble helper 

I too have clients who thank me at the end of counseling for the difference I have made in their lives and for saving them, but I always remember to do the same as was done for me. I do not take credit for my clients’ triumphs and successes because it is not mine to be had. I take extreme joy when I witness clients have revelations and make progress, but I do not hold it as my success. It is theirs; they have rightly earned it. As a clinician, my role is to provide clients information and the tools they need to be healthy. I have modeled empathy for them by being a shoulder to cry on and an ear to listen, which made them feel heard. So many who have come my way have not felt or had empathy in their life for the longest time. But I am not the one doing the work, making the choice to change and putting behavioral change into place, so I cannot take credit. 

As clinicians, we are not saviors. Instead, we should strive to be helpers. We do not enable clients or have them so reliant on us that they cannot choose or change for themselves. Instead, we work with our clients to help them move toward self-empowerment. I love being a counselor; I am blessed to be able to do it each day because seeing changes in clients’ lives unfold before me is a powerful experience.

It is important for clinicians to remain in a humble mindset and give clients credit for their successes. I see many clinicians who take this path and clients are more thankful for it. I once had a client, who after I told them it was not my credit to take, turned back to me and said, “Thank you. I do need to give myself credit when it is earned and stop giving my credit and my power away to people.” The client patted themself on the back and walked out the door. We worked together for several more sessions, and the client’s confidence continued to bloom to the point they no longer needed counseling, and I was thrilled to witness their success. 

When clients gain courage, confidence, strength and self-esteem in counseling, they are able to apply those skills outside the session and continue to have success even after their time in therapy ends. It will also better prepare them to face and overcome challenging moments and disappointments and move back toward living and thriving. Roy Baumeister and colleagues’ research, published in Psychological Science in the Public Interest in 2003, shows that people with high self-esteem are better able to overcome challenges. Encouraging clients to take credit for the success they have while in treatment is another way clinicians can work to increase a client’s self-esteem. In turn, helping clients increase their self-esteem allows them to make greater strides not only in treatment but also after they leave a clinician’s care.

Empowering clients 

If we work from a belief that we are “saving” clients, then we are stripping them of their ability to be empowered. Empowerment is a key aspect to any mental health treatment. The strengths-based approach in counseling, created by psychologist Donald Clifton, works on the premise that focusing on a client’s strengths, rather than their faults, allows them to see all they are capable of and develops their belief in themselves and therefore their success. Helping clients see the capabilities that lie within is the essence of clinical work. 

Moreover, if a clinician assumes the role of a savior, the client’s setbacks and successes becomes theirs as well. This belief makes it the clinician’s fault if they do not “save” a client. Clinically, we cannot make clients put actional and behavioral changes into place. We can help them learn how to make changes, but they have to want and choose to do so for themselves. So, when a client does not choose healthy actions, clinicians should not blame themselves, and at the same time, when clients do choose healthy actions, we should not take the credit for being their savior. We can rejoice with our clients for making healthy decisions that will help them progress and grow, but it is not fair to take away the client’s empowerment and say we saved them. 

I do not think that clinicians who take on this savior mentality are trying to strip clients of their empowerment. They are excited when they see clients have success, but when they assume this “savior” frame of mind, they get caught up in the wins and lose sight of their role in empowering the client. We as clinicians must constantly remember the importance of empowering the clients, not ourselves, to improve our work and therapeutic relationship with clients.

As clinicians, it is our role as to encourage, empower and guide clients as they begin to make changes and healthy life choices. We walk beside them on their journey to remind them of all they are worth. When clients are able to walk ahead in their journey because they have grown and changed and no longer need us by their side, it is something they earn themselves.

SynthEx/Shutterstock.com

When my psychiatrist taught me to give myself credit, it allowed me to further my successes because I realized I was capable of empowering myself. If she had just said “thank you” when I gave her the credit, then I may still believe that she alone is responsible for my progress and not recognize the hard work I put into those sessions to help me develop a healthy frame of mind that now allows me to help others. Her assuming the role of a savior would have done more harm than good. What do I mean by this? I have seen how detrimental it can be to the recovery of clients when clinicians take on the role of savior. Clients in this situation become dependent on the counselor and believe they won’t be able to progress without that clinician. They may even think they are only able to make progress with the help of others rather than believing in their own ability to change. 

By assuming the role of helper, we can help clients learn to do things for themselves and give themselves proper credit. They grow in their self-esteem and belief in their own capability, rather than relying on yet another person telling them how to live and function. Clinicians need to work to remove the role enabling has played in many of our clients lives or the low self-esteem that has created the belief of not being able to do for themselves. When clients are enabled, often by clinicians and others in their lives, it leads to clients not taking responsibility for their good or bad choices. In addition, enabling often leads to lower self-esteem because clients do not feel like they are in control of their own lives. As clinicians, it is not our responsibility to “fix” people but to help people recognize all the wonderful pieces that already lie within.

Am I helping or saving?

Maybe you are asking yourself, “Am I helping or am I saving? How can I even tell?” To answer that, you first need to explore your underlying motivations by asking, “Do I rejoice in my clients progress because I am excited for them or because I think it makes me look good?” If any part of you is saying because it makes me look good, then that is a good sign you are assuming the role of the savior. 

The truth is that much of what counselors do is not about looking good. As an addiction counselor, I walk away from a lot of my sessions not feeling all that great because in addiction treatment, it is more common for clients to relapse or leave therapy against medical advice than for them to complete treatment and go on to celebrate 10 years of sobriety. At times, it does cross my mind, “What am I doing wrong? How can I fix it?” In these moments, I need to meditate and remind myself that I am no one’s savior, and I am there to help clients when they are ready to do their own work to make change. I have to constantly remind myself not to assume this role of savior because it’s easy to feel pressure to “fix” people and think you are responsible for their success. 

Another way to determine if you are saving or helping is to think about how you respond when a client thanks you for helping them. Do you remain humble and appreciative and then remind them of all the work they have done for the success they have earned? Having clients thank me for the support I show them is always a wonderful part of my job, but every time a client thanks me, I remind them of my motto, “This is credit I have earned, don’t give my credit away.” Within a week of working with me, my clients can easily repeat that motto, which helps them realize they are the ones who deserve the credit because they are the ones doing the work. 

I also do not want to diminish the work that counselors put into their sessions. Our work is hard and a labor of love. We watch every day as people grow, change, regress, learn, experience heartbreak and so much more, so it takes a lot of our own strength to do what we do. We deserve credit for our part as well, but clients should not be the ones to pay us that credit. It is essential clients build their own credit when working with us. Our validation should come from our loved ones, supervisors and bosses, so we can focus on helping our clients and not make the session about us, which is unethical. We cross boundaries when we look to clients to validate us, and this is another reason to wholeheartedly allow clients to have the credit for their own growth, which is 100% theirs.

Early on in my counseling journey, I had many clinicians who assumed the role of the savior, and it led me down a path of believing that I needed others to save me. It wasn’t until several years later when I had a clinician point out that I earned the credit myself that I was able to take the first step toward the empowered road I now walk. I am able to accept and ask for help when I need it, but I am also empowered to save myself and know how worthy I am as a person. Knowing my worth each and every day is the best gift I have ever allowed myself to receive, and every client out there deserves the same. As a counselor, I am now in a position where I can pass that message on to my clients and show them their credit is theirs to keep. It is a great honor to work in a helping profession, and it is important to always remember that we are helpers not saviors.

 

****

Caitlin C. Regan is a 35-year-old mental health and addiction counselor in Juno Beach, Florida. She has been living with a mental health diagnosis since she was a teenager, and through electroconvulsive therapy and daily self-care, she has been successfully living with it for over eight years. As a teacher and counselor, she has over 13 years of experience helping those with mental health and addictions. Her passions include helping others, mental health, seeking social justice, and spending time with her friends, family and two dogs. Follow her on Instagram and Pinterest @caitlins_counseling_corner or on her YouTube channel at Caitlin’s Counseling Corner. Contact her at caitlinscounselingcorner@gmail.com.

 

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.

****

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.

Incorporating clients’ faith in counseling

By Lisa R. Rhodes November 2, 2022

A South Asian Muslim woman in her 20s lives at home with her Muslim family and has been struggling in her relationship with her parents. She feels they interfere with her ability to make decisions for herself and treat her like a child.

The woman decides to go to therapy. After listening to the client talk about the issue, the counselor says, “If you move out, this will no longer be an issue.” But this advice was not helpful, and this woman sought out a different clinician, which led her to Nadia A. Aziz, a licensed professional counselor (LPC) at the Empowerment Therapy Center in Manassas, Virginia.

“The client felt the counselor wasn’t informed on how to deal with issues in a culturally informed manner,” Aziz recalls. “The counselor failed the client by not incorporating [her] values” into treatment.

In South Asian cultures, which embrace the spiritual teachings of Islam, Hinduism, Sikhism and Buddhism, it is expected that adults live at home with their families until they either get married or move away for work or college, explains Aziz, who is South Asian and Muslim.

“A counselor suggesting moving out of a family’s home would be insensitive to the [client’s] cultural and religious needs because the client was not able to move out and it wasn’t a realistic expectation,” she says. 

 Aziz, a member of the American Counseling Association, worked with the young woman in therapy to set healthy boundaries and develop assertive communication skills so she could express her feelings and needs to her parents in a way that was respectful of her family’s cultural and religious beliefs.

An evolving practice

This scenario is an example of what many clinicians fear — not knowing how to respond to the religious and spiritual needs of a client. J. Scott Young, a licensed clinical mental health counselor and professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro, says his research on religion and spirituality in counseling, which includes conducting counselor surveys, shows that many mental health professionals feel anxious and uncertain about incorporating a client’s faith into therapy.

“They don’t want to do anything unethical,” Young explains. “They’re worried that they don’t know what to do to help people with [these] issues.”

The uneasiness counselors feel stems from a long history of prohibiting the intersection of religion and spirituality in the therapeutic process. In the third edition of Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice (published by ACA), Young and Craig S. Cashwell point out that “religion has long been a highly controversial topic in the mental health disciplines.” They also note that Sigmund Freud and B.F. Skinner, two pioneers of psychology, considered religious and spiritual belief systems to be frivolous.

However, the counselors interviewed for this article all agree the counseling profession, and the mental health field in general, has evolved over the years to regard religion and spirituality as important additions to counseling education and practice. And they stress that with the proper education, training, and focused introspection into their own religious and spiritual beliefs, counselors can effectively bring a client’s faith into the therapeutic process, if that is the client’s desire for treatment. 

In 2009, the Association for Spiritual, Ethical and Religious Values in Counseling (ASERVIC), a division of ACA, developed the Competencies for Addressing Spiritual and Religious Issues in Counseling to serve as a guideline for counselors seeking to incorporate a client’s religion and spirituality into practice. The competencies work in tandem with the ACA Code of Ethics.

Jesse Fox, an ACA member and the current president of ASERVIC, says evidence-based research into the importance and efficacy of religion and spirituality have made them topics for therapeutic exploration. 

“The evidence base for interrelationships between spirituality, religion and mental health has grown exponentially,” says Fox, an associate professor of counselor education at Stetson University. “In the most recent systematic review in 2012 produced by Harold Koenig at Duke University Medical School, there were over 3,000 published peer-reviewed studies documenting the connection between spirituality, religion and health. In fact, the number of studies grows exponentially every year.”

This empirical work has mapped out how these domains — religion, spirituality and health — of human experience function psychologically, he explains. 

“The net effect is that mainstream mental health models have recognized that spirituality needs to be considered alongside of other dimensions of wellness like emotional health or physical health, as well as intersectional models of identity like race and sexuality,” Fox says.

Religion and spirituality continue to be important to many in the United States. According to a 2022 Gallup Poll, 81% of U.S. adults believe in God. Statistics such as this, Fox says, suggest that religion or spiritual matters will likely be “an aspect of a client’s identity” in counseling.

Young, an ACA member, says research has shown that people who have a faith or religious commitment that supports them tend to experience less anxiety and depression, more stability in their primary relationship, and more stability and commitment in their work and career. This commitment “seems to be sort of a buffer against some of the stressors that they might otherwise face,” he explains. “And if that’s that case, [it] sort of helps to support their mental health as well.”

People often use spirituality or religion to make meaning of their lives, notes Young, who treats clients at Triad Counseling and Clinical Services PLLC, which has offices in High Point and Greensboro, North Carolina. “In counseling, we talk to people about their childhood, their parents, their family drama … [and] their sex life — all these are very personal things for people,” he says. “At times counselors are hesitant to discuss spirituality or religion for fear that it is too personal or that they may misstep.” 

Know thyself, know the client 

The counselors interviewed for this article say that before attempting to bring a client’s faith into therapy, counselors should thoroughly explore their own religious and spiritual beliefs, or the lack thereof.

“If counselors have not taken the time, or realized the importance of taking the time, to know themselves — their values, their beliefs, their own spirituality and religious preferences — then that’s not going to be a good match for clients who have needs in that area,” says Amy Evans, a licensed professional clinical counselor in Minnesota. 

“The challenge is making sure we do not push our own values, worldview and perspectives on our client,” Evans stresses, which is something both the ACA Code of Ethics and ASERVIC competencies make clear counselors should not do. “To make sure we’re not doing that, we have to know ourselves,” she adds. 

Aziz says she was able to explore her religious and spiritual identity in undergraduate and graduate school, where she took courses in multicultural counseling and faith-based counseling, as well as other classes that encouraged self-discovery, self-awareness, and exploring one’s own values and biases in the realm of religion and spirituality.

Justin K. Hughes, a LPC in Dallas who offers religious/spiritual integration, most commonly for Christians, says he learned important tools for bringing a client’s faith into treatment from his own experience receiving counseling as an undergraduate student and from the counselors he worked with during his Christian seminary training and clinical internship. 

Hughes, owner of Dallas Counseling PLLC, says these mental health professionals set the model for him by being respectful and humble and always asking questions to assess his needs and learn more about his religious and spiritual experiences. He says he now mirrors these traits in his own practice. 

Faith and self-disclosure

While it is important for counselors to feel comfortable with their own faith and belief systems, the counselors interviewed for this article agree that it is not necessary for clinicians to share this part of their lives with clients. If clients do inquire about their faith, they advise clinicians to be thoughtful in how they respond. 

Young, a past president of ASERVIC, says he doesn’t discuss his spiritual views in session unless the client brings up the topic, and even then, he is careful not to divulge too many details. 

“I have, on occasion, had a client who really wanted to know how I see these things, so I always preference [my response] with ‘We’re here for you,’” Young explains, noting that he will then try to explore what salience religion and spirituality holds for the client and what the client may be trying to learn by asking about his beliefs. 

Lemonsoup14/Shutterstock.com

 “I do not try to deflect or redirect if they are truly curious,” Young says, “but I do want to understand why it is important for them to know my beliefs.”

Aziz says her faith is evident in the photograph she posts on Psychology Today’s directory of mental health providers and her practice’s website. “I wear the head scarf, the hijab, [so] it’s kind of hard to miss,” she says. “A lot of times I do get contacted through those avenues, so I am implicitly disclosing that I am Muslim, and they are looking for a Muslim therapist.”

If clients inquire to know the specifics about her faith, Aziz says she always brings the discussion back to what the client is looking for and what they need in treatment. Although a discussion of Aziz’s faith may sometimes be helpful in building rapport with a client, she is mindful that it is not relevant to the therapeutic process. 

“A lot of times it is [about] setting boundaries with them,” she says, “and making sure they understand that the counseling session is not about me, it’s about [them], keeping the focus on them.”

Hughes, who specializes in treating obsessive-compulsive disorder (OCD), anxiety and related disorders, is a member of the International OCD Foundation, which has been examining the role of religion and spirituality in the treatment of OCD during the past couple of years. 

Hughes says he is “usually fairly open about being a Christian” with clients if they bring it up. For example, some of his clients have asked, “Are you a Christian?” “Would you be willing to pray with me?” and “I’m not very religious. Are you OK with that?” He only provides specific information if he feels it will be a therapeutic benefit for the client, which he notes varies case by case.

Counselors do not have to share the same religious or spiritual beliefs as their clients to be effective in therapy, yet for some clients, having a match in faith may matter to the client. Evans, an associate professor and program director of the master’s in counseling program at Bethel University in St. Paul, Minnesota, says research shows that what matters in practice is the quality of the therapeutic relationship and the counselor’s responsiveness to the client. 

“If a counselor is trained well and really considers the client’s worldview, culture and values — then that can be helpful to the [therapeutic] relationship,” says Evans, an ACA member. A counselor’s training and ability to modify therapeutic techniques to meet the client’s needs is what is most helpful in practice, she stresses, not the counselor’s faith.

Young acknowledges that a counselor’s faith may be important for some clients. If there’s not a match in faith, it may be barrier for some clients who may not feel as safe in the relationship as they should, he explains. But “as long as the counselor is open and meeting the client where they are [and] they’re not anti-religious or struggle with it themselves,” Young says, “it really shouldn’t make much of a difference.”

Broaching the topic

Counselors must first determine a client’s therapeutic needs to find out if they would like to include their faith in counseling. The counselors interviewed for this article suggest bringing up the topic of religion and spirituality in the first session and including it on intake forms. 

“One of the most important things is to … broach the topic,” Evans says. “If we don’t let clients know it’s OK to talk about it [religion and spirituality], they may not know it is acceptable to bring it up.”

Evans says counselors should also inquire about a client’s faith on the intake form. Then during the first session, they can ask open-ended questions in response to what clients have shared on the form. Evans provides a few examples of things counselors can say to initiate this conversation: 

  • It sounds like your spirituality/religion is important to you. 
  • How might you envision bringing your spirituality/religion into the therapeutic work we are doing?
  • You mentioned that spirituality/religion is an important part of your life. How might it relate to the therapeutic goals we have agreed to focus on?

Evans says partnering with the client to agree on goals, including goals surrounding the client’s faith, helps builds the therapeutic relationship so it can be effective and have positive outcomes for the client.

Aziz also brings up the client’s faith during the intake process. “I ask [clients] if there is anything they want me to know about their cultural or religious beliefs and if they are looking for faith-based counseling,” she says. 

Aziz notes that about 70% of her clients are South Asian and follow the teachings of Islam, Hinduism, Sikhism or Buddhism, and about 30% are from a different cultural background or faith. So she first works with clients to help them identify their own values. “That gives me a better understanding of what they’re looking for in session, and I tend to take the counseling sessions in those directions,” she says. 

Blending faith and counseling

Once counselors assess the religious or spiritual needs of the client, or the lack thereof, they can work with the client in treatment to resolve any issues or explore new insights. Young says bringing a client’s religion or spirituality into practice should be a collaborative process that is not one size fits all. 

One approach, he continues, is to ask open-ended questions that explore the client’s thoughts and feelings around their religious or spiritual practices and traditions. For example, he says counselors could ask:

  • When or where do you feel most connected to the larger whole?
  • What brings you the greatest sense of peace in your life?
  • What rituals, if any, do you practice that bring you comfort (prayer, meditation, walks in nature, etc.)?
  • Have you thought about using these rituals or practices to help resolve problems?
  • Do you have an understanding about a higher power? How is this helpful to you?

Evans co-authored, along with Jennifer Koenig Nelson, an article exploring adapting counseling to clients’ spirituality and religion, which was published in Religions in 2021. In it, Evans and Nelson argue that using the therapeutic approach of cultural humility to incorporate a client’s religion or spirituality into practice can result in positive outcomes for the therapeutic relationship and the client’s treatment goals. Citing Joshua Hook and colleagues’ 2013 article published in the Journal of Counseling Psychology, they define cultural humility as “having an interpersonal stance that is other-oriented in relation to another individual’s cultural background and experience, marked by respect for and lack of superiority toward another individual’s cultural background and experience.”

Cultural humility “relates to positive outcomes and reduces power dynamics in the [therapeutic] relationship,” Evans says. “The openness allows the counselor to step back and have the client determine what is most salient to them, rather than the counselor pushing for the client to focus on certain parts of their identity.” 

The counselor operating from a stance of cultural humility “allows for the client to determine if spirituality/religion is something important to them [or] salient to the work they are doing in counseling,” Evans continues. The client can then decide if they want their faith brought into counseling.

In their article, Evans and Nelson suggested an adaptation to Hook and colleagues’ guidelines for integrating cultural humility into therapy that focuses on religion and spirituality. Their revised guidelines are:

  • Remain humble when engaging with clients around spirituality and religion.
  • Do not assume you understand the client’s spirituality and religion based on prior training, knowledge or experiences.
  • Explore spirituality and religion with the client to determine what is positive and what might be detrimental in relation to their beliefs.
  • Remain curious about the spirituality and religion of the client as it relates to the presenting issues and ask questions when appropriate.

Aziz finds creative ways to incorporate the client’s faith into session when appropriate. If a client is having a hard time controlling their anger, for example, she may integrate the client’s religion into a breathing and mindfulness exercise to help them learn to respond to stressful situations in a healthy way. 

In this scenario, Aziz would first ask the client to come up with a word or phrase that is connected to their faith and has a calming effect. The client must be able to repeat the word or phrase with ease. A client may choose the word “patience” as their mantra for breath exercises, for example, because it reminds them of the Islamic scripture “God is with those who are patient,” Aziz says. 

She would ask the client to relax and clear their mind of any thoughts. Once the client is settled, she would ask them to take four deep breaths in through the nose, hold for a count of six and then breathe out through the mouth for a count of six. While engaging in this breathing exercise, they would focus on repeating their mantra in their mind. This exercise is a helpful way for clients to calm their body and mind and focus on inner peace, Aziz notes. 

Asking clients to select a mantra that resonates with them makes it more likely that they will follow through with the practice on their own, Aziz says, because it helps to make the practice personal to them. And that approach works with clients whether they are religious or nonreligious, she adds. 

“If the client requested faith-based counseling, they usually gravitate toward phrases that have religious significance” to them, she says, noting that she may also talk to the client about why the phrase is important to them.

The guided imagery “wise being” exercise (see lifepluswork.com/guided-imagery-wise-being) is another technique that counselors can adapt to incorporate a client’s religion/spirituality, Aziz says. This technique, she explains, allows clients to tap into their own faith and values.

Aziz begins the exercise by asking the client to imagine a safe space where they would feel comfortable having a personal conversation with someone they view as a wise being. The purpose of the conversation is to allow the client to discuss their problem or issue with the wise being without judgment and to receive guidance from the wise being on how to resolve or approach the problem, Aziz says.

“A lot of times people might pick a spiritual guide based on their faith,” Aziz says. For example, a Muslim client may select the Prophet Muhammad, a Christian client may select Jesus Christ or a Buddhist client may select Buddha.

After the client selects their wise being, Aziz asks them to imagine the guide walking toward them to begin the conversation. “It is almost a spiritual moment for them to have this conversation,” she notes. They “may have felt the presence of their spirit guide” during this exercise. And the exercise often provides clients with clarity or helps lead them to what they want to discuss in counseling, she adds. 

Aziz leaves the decision to share the details of this conversation with her up to client. Sometimes, it takes clients a few sessions before they are ready to share what they felt or experienced in that moment, she says. 

If a client chooses to discuss the exercise with her, Aziz often asks, “Why do you think [the] wise being said what they said?” Then together they process the client’s feelings about the wise being’s message and its meaning. She asks, “How are you going to incorporate [the wise being’s advice] into your life?” 

Overcoming challenges

Integrating a client’s faith into session may not be easy for some clinicians. Young reminds counselors that they don’t have to be an expert on a client’s religious or spiritual beliefs to be effective.

“Counselors don’t have to have the answers for [a] client’s faith questions,” he says. “It is an important part of faith development for people to struggle with questions that do not have clear answers.”

Young advises counselors to remember that staying present for the client, being curious about their experience and not projecting their own values onto the client can help to navigate the ups and downs of practice if they are focusing on a client’s faith or another area of the client’s life. 

Hughes says counselors must be willing to meet challenges and make reasonable mistakes when bringing a client’s faith into practice, and they must be willing to use compassion to correct themselves. But when counselors deal with religious and spiritual sensitivities, they don’t feel they have any space for errors.

Counselors don’t want to violate the code of ethics, Hughes says, but even if they’re doing therapy competently, they may sometimes ask irrelevant questions or make a human gaff. For example, he once worked with a Jewish client who often brought details about her faith into therapy. But when he attempted to define the Hebrew word “shalom” in reference to the client’s therapeutic goals, the attempt “fell flat,” he recalls.

“I have studied some of the original Hebrew and knew what I was talking about technically,” Hughes explains. But the client “corrected me from her personal understanding, and because I am neither Jewish nor living her life, she had the right to define what the word meant to her in relation to her goals.” This exchange highlights the need for communication and questions as well as the importance of never taking things for granted, he adds.

Fox, executive director of the Episcopal Counseling Center in DeLand, Florida, says navigating a client’s faith can be challenging for counselors when they realize the diversity of religious and spiritual perspectives. 

“You encounter a myriad of worldviews, practices, frameworks of meaning, [and] it can be daunting about where to start,” Fox says. It can be hard for counselors to “discern when a client’s religious or spiritual life has become unhealthy,” or if the real dangers of imposing their values onto the client have become evident, he adds.

Fox and Aziz recommend counselors find a mentor or supervisor or seek additional training if they have questions or want guidance on discussing faith with clients. “I think there’s a lot of benefit to talking to colleagues and supervisors [to get] a different opinion or view of things,” Aziz says.

Be curious

The counselors interviewed for the article agree that clinicians should take advantage of opportunities through professional channels and in their community to learn more about the diversity of religious and spiritual traditions of their clients.

“We learn best by engaging with individuals who are different from us,” Evans says. “Get out there, get to know people, … and be curious.”

She suggests attending different religious services and reaching out to local religious leaders who are open to sharing information about specific religious and spiritual practices.

“[Do] what makes sense clinically,” Evans says. “Start exploring things. … Take the time to be curious and investigate and interact with people outside [your] regular circle.” 

Most professional trainings about religion and spirituality are Christian in nature, Aziz notes, so counselors who are seeking guidance about other religious or spiritual traditions should consider reading books or researching multicultural blogs. 

Evans, Fox and Young recommend counselors take advantage of the resources offered by ASERVIC, including Counseling and Values (their official publication and one of the oldest peer-reviewed journals on the topic of spirituality and religion), their annual conference and webinars. 

Fox serves as co-investigator of the Spiritual and Religious Competency Project (srcproject.org), an initiative funded by the John Templeton Foundation, which aims to provide mental health professionals with basic competencies to address the spiritual and religious aspects of their clients’ lives. His team of researchers are “testing methods of training mental health professionals in spiritual and religious competence” and are tracking how mental health professionals may utilize this training nationwide. They are also “using implementation science to discover the best ways to make this type of training more likely to happen in mental health care in the future,” he says.

The project’s early research has found that more mental health training programs are open to including religious and spiritual studies, but staff lack the training to confidently teach and supervise students, Fox explains.

“Over the next five to 10 years, we are hoping that through our efforts we see this gap close so that every client who brings religion and spirituality into their counselor’s office will be met with competent help,” he says. 

Young is also hopeful about what the future holds for the integration of religion and spirituality within counseling. He says the more research that is done in this area and the more conversations that takes place among counselors, the more possibilities there are to expand the reach of religion and spirituality in clinical practice for the benefit of clients.

 

****

Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.

****

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.

Confidentiality comes first: Navigating parent involvement with minor clients

By Bethany Bray October 28, 2022

What is said between a counselor and an individual client is confidential, even when the client is a minor. But parents often want to be kept in the loop about their child’s progress in therapy. This can put the counselor in a tricky situation, especially when the parents want to control or influence the counseling process.

The only scenario in which counselor-client confidentiality can be broken is in situations that necessitate protecting the client or others “from serious and foreseeable harm,” such as suicidal intent. (For more on this, see Standard B.2.a. of the 2014 ACA Code of Ethics.)

Marcy Adams Sznewajs, a licensed professional counselor (LPC) who often works with teenage and young adult clients at her group therapy practice in Beverly Hills, Michigan, says she empathizes with parents who ask about what she’s covering in counseling sessions with their child. However, she finds it helpful — and necessary — to offer a firm explanation of counselor-client confidentiality whenever she begins counseling a young client.

Sznewajs says that she emphasizes to parents that she will let them know if their child discloses anything that will put the child in danger. She also makes it clear to both parties that she will only invite parents into the counseling sessions if the young client grants permission.

This conversation is often not what the parents want to hear, Sznewajs admits, but it is important because it spells out the boundaries of what the counselor is obligated to tell the parents and reassures the client that their privacy will be respected.

Sznewajs stresses to families that they all must trust the process for her work to be effective.

“It’s important for the teenager to trust an adult with these difficult thoughts and feelings, and legally and ethically I have to keep it confidential,” says Sznewajs. “I’d be doing my client a huge disservice [if I disclosed session details to the parents]. That’s not only unethical, it’s damaging — and what does it teach the kid? That this person that you’re supposed to trust, you can’t.”

The feelings behind the questions

Parents’ concerns and questions about the work their child is doing in therapy are often rooted in fear, says Martina Moore, a licensed professional clinical counselor supervisor with a mediation and counseling practice in Euclid, Ohio. Not only do parents worry that the challenging behaviors that caused their child to seek counseling, such as rule breaking, isolation, defiance or problems at school, will have negative long-term outcomes in the child’s life, but they might also feel these issues are a reflection of their parenting abilities.

“Parents sometimes have such anxiety about their children it’s [gotten] to the point where they are increasing their child’s anxiety,” notes Moore, president of the International Association of Marriage and Family Counselors, a division of the American Counseling Association.

Although Moore makes a point to validate these fears with parents, she also emphasizes that it’s good for the child to grow and build autonomy through counseling on their own. She applauds parents for seeking help while explaining that she needs the freedom to work with the child alone for the counseling process to work.

“I also spend time with parents to dig into what their fear is. They’ve come to counseling [with their child], so they must believe that there is benefit in this process,” Moore says. She emphasizes to parents that they need to trust the process. “I spend a lot of time with parents getting their buy-in,” she notes.

In addition to fear, parents may also struggle with strong feelings of shame for having a child who is engaging in risky behavior and failing to thrive.

Le’Ann Solmonson, an LPC in Texas who has extensive experience working with children and adolescents, says she makes a point to acknowledge and normalize parents’ feelings of vulnerability and worry. If appropriate, Solmonson says she will sometimes disclose that she’s experienced similar feelings when her adult children sought therapy.

“No parent is perfect, and you worry over feeling like they are talking [in therapy] about what you’ve done wrong,” says Solmonson, the immediate past president of the Association for Child and Adolescent Counseling, a division of ACA. “It’s a very vulnerable thing to have your child go to counseling. You can’t help but feel that it’s a reflection on you as a parent and feeds into fears that you’re ‘screwing your kids up.’”

Navigating the balance

Counselors often need to get creative and act diplomatically to keep parents in the loop while maintaining young clients’ confidentiality and trust.

When parents insist on being involved in their child’s counseling, Moore negotiates with both the parents and client to find a plan that they all agree on while staying within ethical boundaries.

This was the case for a teenage client Moore once counseled who had substance use disorder. The parents were worried about their child and wanted to be involved in the counseling process. Moore facilitated a discussion and, eventually, they all came to an agreement that Moore would work with the teen alone but would let the parents know whenever the client had a relapse or break in recovery, she says.

Keeping lines of communication open and having regular check-ins with parents is beneficial to the counseling process with young clients, Solmonson notes. She often prompts child or adolescent clients to identify one small thing they are comfortable sharing with their parents at the conclusion of each counseling session, such a breathing technique they learned or new words they discovered to describe their emotions. This keeps the parents in the loop while ensuring that the client maintains control over the process.

When parents are left completely in the dark about their child’s work in counseling, it can exacerbate worry, cause them to “fear the worst” and catastrophize about what the child might be saying, Solmonson adds.

Sznewajs notes that talking with young clients about keeping their parents updated also provides the opportunity to check in with the client and ask what they feel is going well. She sometimes begins by asking the client how they feel things are going in counseling and transitions to what (or if) they would want her to share with their parents about their progress.

Disclosure of life-threatening behavior

When a young client is engaging in risk-taking behaviors that are life threatening (i.e., suicidal actions, self-harm), ethically, parents need to be brought into the conversation, says Hayle Fisher, a licensed professional clinical counselor and director of adolescent services at a behavioral mental health provider in Mentor, Ohio. While this is crucial to do, it can also impair the therapeutic relationship with the teen, she adds.

Fisher finds the vignettes in the 2016 British Journal of Psychiatry article “‘Shhh! Please don’t tell…’ Confidentiality in child and adolescent mental health” particularly helpful for examples on navigating these conversations. She keeps the following notes for herself, drawn from that article, for situations when she must disclose a young client’s harmful behavior:

  • Tell the client what you (the counselor) are planning on disclosing to the parents, with an emphasis on the full context of why you need to. Ask for their feedback on how they might like to edit what you plan to say.
  • Talk through the potential benefits and costs of disclosing to the parents. Ask the client how they feel about the disclosure and consider their views as you move forward.
  • Validate any fears the client may have about the disclosure, such as losing access to resources and freedoms, feeling blamed or ashamed, or being concerned that the police or social services will become involved.

To maintain trust and a therapeutic alliance with young clients, Fisher emphasizes that it’s important for a counselor to give the client as much control as possible over how this communication will occur. If the disclosure happens during an in-person session and the parents are nearby, she gives the client the choice to either stay in the room or step out and wait in the lobby when she invites the parent(s) in to tell them.

Fisher also gives young clients the option to tell their parents before she does. However, this is only appropriate if the client’s risk of harm is not imminent, Fisher stresses. In this scenario, she tells the client that she will call at a certain time the following day to speak with their parents, check in and provide support for the parents and client.

“This option is especially powerful,” Fisher explains, because it “reinforces the adolescent taking accountability for their actions, increases communication skills and fosters independence in the situation so they are not dependent on the counselor for navigating conflicts with their parents.”

Sznewajs also takes a collaborative approach when it’s necessary to break confidentiality to inform a client’s parent or guardian about harmful behavior or intent. She says she tries to take the client’s feelings into consideration while modeling firm boundaries.

Although not having the conversation with the parents isn’t an option, client can choose how and when it happens, Sznewajs explains. She offers to involve the parents in person, call them on the phone, do a video chat during the counseling session or wait until after the session ends.

Sznewajs says she explains to young clients: “I want to make sure you stay safe, so we have to bring your parents into this conversation.” She adds that she tries to “do it in a collaborative way, even when it [the situation] is dire.”

 

****

SeventyFour/Shutterstock.com

*****

Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

****

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.