Ontario Psychological Association 24 February 2007

ACHIEVING PERSONAL & PROFESSIONAL BALANCE: EASIER SAID THAN DONE

Gary R. Schoener* INTRODUCTION There are many different frameworks people use to address this sort of topic. One area is distress in practitioners. An early book in the mid-1980s was Professionals in Distress: Issues, Syndromes, and Solutions in Psychology (Vandenbos, Nathan, & Thoreson, 1986). Another is the concept of the impaired practitioner that is when a professional is not only in distress of some sort but unable to perform duties at their usual level. The APAs Advisory Committee on the Distressed Psychologist, became on the Impaired Psychologist, and evolved into Colleague Assistance. There is a long history of interest in and research on practitioner burn out which has spun off in several directions. There is a great deal of research on burn out in various types of institutions and settings which often focuses on identifying institutional stressors and seeking solutions in terms of institutional structure. A variant on this was created by William White in his classic work Incest in the Organizational Family which more recently has been replace by his excellent work The Incestuous Workplace: Stress and Distress in the Organizational Family. (White, 1997) As work with trauma victims grew in the 1980s, another line of investigation and discussion emerged in parallel with the work on burn out. This examined vicarious traumatization and took a focus which was very much aimed at the individual practitioner. It was not that institutional issues were not considered just that they were not the center of focus. But there are other frameworks to consider. From the other side of the coin, one can focus on health and wellness and their maintenance. The concept of stress resistance was applied to practitioners, having already proved its mettle in studies of the invulnerable child and in the application of public health principles to the prevention of disease.

My framework will incorporate a number of these viewpoints and issues, but will be very focused on special challenges in clinical work challenges of clients, boundary maintenance, and difficult tasks and duties which psychologists have. The hope is that you will in fact raise both some of the problems and issues and that we will be able to discuss things which might help prevent problems or assist in dealing with them when they arise. Challenges and pressures from ones personal life, career issues, and those presented by certain clients are fair game
* The presenter is a Licensed Psychologist (M.Eq.) & Executive Director, Walk-In Counseling Center, 2421 Chicago Avenue S., Minneapolis, Minn. 55404 (612) 870-0565 Fax (612) 870-4169 website: www.walkin.org Personal Email: grschoener@aol.com This material is not intended as professional advice for any given circumstance local consultation is always best for that. This handout may be reproduced to share with colleagues without additional authorization.
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DIFFERENT FRAMEWORKS, DIFFERENT ROLES Overall, our field of Psychology is not known for teamwork or being a club. By contrast, in medicine if there is a death in the family there are resources which can be brought to bear on the situation to help. In medical settings and dental settings, there is some tradition of providing coverage during emergencies and/or when someone goes off to war. Psychology is not known among the professions for protecting its own. How real this perception is remains to be seen. This is also subject to change if a local group decides to do so. YOURSELF & YOUR FAMILY o Dealing with your own familys problems, o Dealing with your personal needs and problems, o Obtaining behavioral health assistance, marital counseling, help for your child in a situation where your personal privacy is limited because of your work COLLEAGUES WITH WHOM YOU WORK with all you have a duty to intervene or to communicate about the management or leadership concerning impairment; in terms of your humanistic concerns, failure to do so may take its toll on you too. How will you create an open door to permit you to discuss concerns with them, or to hear theirs about you? o Co-workers keeping good communication and a good standard of the provision of honest feedback is key here o Students you have special duties o Supervisees you have special duties o Supervisors & Administrators this is the great challenge providing feedback to someone who is above you in the hierarchy COLLEAGUES YOU KNOW your friends in the profession or in other professions. o Depending on the nature of the relationship, and whether you know their family, situations may arise where you provide feedback, or provide support o Depends on whether they come to you for help one of the challenges is to be careful about the nature of your interaction with them is it friendship or a professional service? COLLEAGUES TO WHOM YOU HAVE A PROFESSIONAL DUTY beyond any humanistic concerns, it is important to differentiate duties to each: o Supervisees If you use the term supervision you have professional and legal liability for their work, whether or not you have actually supervised a case. You also have a duty to intervene with impairment or practice problems. You have a duty to be aware as to whether their psychological functioning might be impacting their practice negatively. o Consultees Case consultation is the voluntary sharing of information in hopes of getting advice and input. The case consultant (unless mistakenly called a supervisor) cannot enforce their recommendations. Can be individual, or a consultation group.
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Note that poorly functioning or distressed colleagues can undermine public faith in the field itself and be a personal or professional embarrassment. Likewise, if your life becomes a mess you undermine your own credibility with clients, potential clients, and peers. YOUR COHORT Studies which look at the age of a practitioner, or even the number of years in the field, can miss the point that it may be far more significant what your cohort is. That is, which group of practitioners did you train with, work with, transition through the field with? What generation are you a part of? This can relate to: (1) (2) (3) (4) General belief systems & values; The role of the psychologists; Setting rural vs. small town vs. suburban vs. urban; University setting vs. general community.

These things also help define your personal life and some of the professional challenges which impact: (1) (2) (3) (4) Are you married or single? Are you in a committed relationship? Is it straight (heterosexual) or gay/lesbian/bi-sexual? Do you have children? Childrens behavior can be quite visible; they can also provide potential interface with clients; they may need professional services? (5) Are the children in school, or grown up? The younger children connect you with the world of the schools; older ones can be out on their own and establishing their own reputation, good or bad. (6) Do your children live near you, or far away? Are they part of the local community? Again, potential boundary issues abound. (7) Have you had previous committed relationships from which you are now divorced? (8) Is your ex-spouse or lover in the local community? In the field? (9) What about aging family members? They may need care, may be in the public eye; may require special attention. (10) How much of your career has been in the locality? This may impact on the degree to which you encounter former clients, for example. One Size does not fit all of us. There are countless areas of special challenges as well as potential supports depending on these personal characteristics. AGING THE ONE THING WE ALL HAVE IN COMMON The ending of ones career, unless there is some sort of accident, is a long term process. James Guy and colleagues have researched aging in psychologists and found that most have no specific plans for retirement, and that most are not even thinking about declining faculties. In one study the vast majority expected to get client feedback when their work was not adequate.
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One question is the degree to which you feel you have met your goals vs. not met them professionally. A related one has to do with the financial realities of your situation. Some of the challenges: Declining faculties hearing, attention, energy Reduced knowledge acquisition this runs in the fact of the information explosion and newer technologies for knowledge acquisition Can have a sense of confidence due to position in the field but is it a false sense of confidence? Motivation can be an issue being tired of the burden, disenchanted with the field or with society; if you dont acquire new knowledge you can end up in a rut

A few questions: How to decide when to quit? If you are in an administrative, consultative, or advisory role, how to assist in the decision-making? If you are thinking of some grand swan song for your exit to the field, how does one choose it? THE IMPACT OF PERSONAL CRISES Well deal with professional practice related crisis later. It is instructive that the Chinese character for crisis, consists of two characters: Wei (danger) and Ji (opportunity). The Chinese character for adversity if actually a depiction of a person rowing against the current. While we have traditionally focused on Post-traumatic stress (and will be discussing this later in professional situations) there is a growing interest in Post Traumatic Growth (PTG). Ted Tedeschi & Lawrence Calhoun have worked on this concept for two decades and in 2006 came out with the Post Traumatic Grown Inventory. It is posted on the APAs Help Center on the internet. You can take it on line at http://www.apahelpcenter.org/ptgi/ The issue is not the crisis alone, but how you choose to handle it. Do you follow the advice you would give your clients? With myself, with my supervisees, and with my colleagues this is always a fair question. This is a reverberating circuit personal crises can impact the practitioner and then have impact on their own adjustment which in turn impacts on practice. The practice impacts can complicate the personal situation (e.g. you go into crisis, then your client does). PERSONAL CRISES THAT ARENT SO OBVIOUS It is easy to underestimate the impact of various events on your personal life and adjustment. The various studies, for example, of the impact of the terrorist attack on the World Trade Center in New York on Sept. 11, 2001 have shown that it had impact on a great many people who viewed it on TV but who were not in New York. While clients may be affected by such situations, so are we. It is important to note that many such events are classified as situations involving ambiguous loss. The next page provides an overview of ambiguous loss from one of the foremost writers on the topic, Pauline Boss.
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PERSONAL DISTRESS THE BROADER PICTURE Attached to this handout are copies of two articles related to a study done in Minnesota some years ago which was designed to assess local psychologists self-rating of their distress and/or impairment, and that of their colleagues. The articles are: Brodie, Jane & Robinson, Bean (July 1991). MPA Distressed/Impaired Psychologists Survey: Overview and Results. Minnesota Psychologist, July 1991, pp. 7 10 Asha Mukherjee (July 1991). MPA Distressed/Impaired Psychologists Survey: Summary of Responses to Open-Ended Questions. Minnesota Psychologisst, July 1991, pp. 10 12.

The data is consistent with the literature in general which shows that a substantial percentage of psychologists report that they and their colleagues have experienced significant problems. For example: Depression 47% acknowledged, and 84% had observed in colleagues Burnt Out/Overwork 60% acknowledged, 81% had observed in colleagues Relationship problems 49% had experienced, and 78% had observed in colleagues Anxiety disorder 44%, and 67% had seen it in colleagues Some things were observed in others, but most denied they had such a problem: Suicidal Attempts or Ideation only 10% acknowledged, but 29% had seen it in their colleagues Physical Health/Disabilities (hearing loss, cancer, memory loss) 7% acknowledged this had impacted them, but 39% had seen it in colleagues Alcohol/Chemical Use 7% acknowledged this as a problem, but 52% reported seeing it in colleagues Personality Disorder only one (1%) psychologist acknowledged this, but 54% reported it in colleagues

When asked about practice-related problems, they reported: Dual Relationship/Poor Boundaries 15% acknowledged this themselves, and 76% had observed this in colleagues Mishandled Countertransference 43% acknowledge this problem, and 68% had observed this in colleagues Practicing Beyond Ones Competence While only 8% acknowledged doing this themselves, 53% had observed it in colleagues Sexual Contacts (with clients, students, supervisees, research subjects) 2 (1%) admitted this, but 53% had seen colleagues do it Questionable Business Practices 3 (2%) admitted this, but 52% said they had seen colleagues who engaged in them Being Abusive/Aggressive to Clients None admitted this, but 36% had seen colleagues do this

To put this in a broader context, the next page comes from Jeanette Milgroms Boundaries in Professional Relationships. It is a diagram done by William White.
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Perhaps the most common early warning sign of trouble in almost any setting Or role, from the clinic to the university, is when someone is falling behind on paperwork. This often precedes absenteeism which is the second most important sign of impairment or breakdown.
VICARIOUS TRAUMATIZATION One framework related to practitioner burn out is the concept of Vicarious Traumatization. This concept was developed in connection with work with trauma victims, but actually is now applied to any sort of difficult clinical work which may lead to practitioner stress. Some of the challenges for the practitioner include: Finding the traumatic experiences one hears quite troubling in and of themselves; Trauma survivors dont trust easily most therapists like to be trusted and see themselves as trustworthy. This causes a conflict; In the therapy business, you cant take it home. You cannot share fully what happened during your work day. (e.g. Dear, would you like to see some really terrible traumatic drawings a patient did today?) Many trauma victims have chronic suicidal thinking and engage in self-harming behaviors this is difficult to take session after session Many victims are re-victimized, and some feel that this leads to enactments where the therapist can slip into a role of victim, victimizer, or bystander Hearing about the cruelty these people have experienced can cause one to expect to see it in everyday life Affect tolerance can be challenged, and some workers find themselves, for example, overreacting with anger Your partner at home experiences some consequences but doesnt know why In your private life you can tend to take on others problems and function as a therapist without a formal role Increase anxiety about your family members safety hyper-awareness of dangers in the world Unless you have a good collegial support base, you can end up quite isolated You may develop a pervasive sense of cynicism about people and the world Recommendations by Experts in VT (1) Determine what you can do yourself in terms of your professional life (2) Look at what your organization or clinic can do to assist (3) Examine options and tools for your personal life PERSONAL THERAPY It goes without saying that personal therapy might be a useful aid to assisting a practitioner in dealing with personal problems, stress, etc. Various studies over the years have found that from 72 75% of therapists themselves have some therapy at some point in their training or career. This varies with specialty from a low of 53% of
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behavior therapists to a high of 98% for psychoanalysts. This compares to 25 27% of those in ordinary American households. (Norcross & Guy, 2005, p. 166). When one examines the post-training period, about half of therapists return for some therapy. Various studies have found that 55 65% of therapists in various groups have some psychotherapy after they have earned their terminal degree. One study of psychoanalysts found that 55% had additional treatment after their training analysis. While 38% had additional psychoanalytic treatment, 43% had some other treatment (group therapy, couples therapy, or marital therapy were most common). (Norcross & Guy, 2005, p. 167) Marital and couples therapy can be very helpful in cases of marriage problems, and family therapy may be helpful in the same situations. Just as there are special challenges in doing individual therapy on practitioners, marital and family therapy can be challenging because family members may perceive a bias created by shared professional identity. (Aponte, 2005) Another challenge is created by situations in which another family member is receiving therapy since there may be concerns about confidentiality and/or boundary issues. This is especially the case when ones child is receiving some sort of service and one is in a client role as the parent. What Challenges Are There for You to Seek Therapy Or for a Family Member to Seek Therapy? DUTIES TO REPORT OTHER PROFESSIONALS There is a duty to internally report complaints or concerns about professional conduct within a facility or clinic. Once a staff member knows of a problem, the organization is on notice. Your informed consent statement given to clients should include this exception to privacy. As regards professional codes of ethics, there has always been some ambiguity about reporting duties to professional ethics committees. The Canadian Code of Ethics for Psychologists carries some duties for the psychologist as regards handling violations by others: II.40 Act to stop or offset the consequences of seriously harmful activities being carried out by another psychologist or member of another discipline, when there is objective information about the activities and the harm, and when these activities have come to their attention outside of a confidential client relationship between themselves and the psychologist or member of another discipline. This may include reporting to the appropriate regulatory body, authority, or committee for action, depending on the psychologists judgment about the person(s) or body(ies) best suited to stop or offset the harm, and depending upon regulatory requirements and definitions of misconduct. II.41 Act also to stop or offset the consequences of harmful activities carried out by another psychologist or member of another discipline, when the harm is not serious or the activities appear to be primarily a lack of sensitivity, knowledge, or experience, and when the activities have come to their attention outside of a confidential client relationship between themselves and the psychologist and member of another discipline. This may include talking informally with the psychologist or member of another discipline, obtaining objective information and, if possible and relevant, the assurance that the harm
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will discontinue and be corrected. If in a vulnerable position (.e.g., employee, trainee) with respect to the other psychologist or member of the other discipline, it may include asking persons in less vulnerable positions to participate in the meeting(s). In Ontario all regulated health professionals have a duty to report sexual misconduct by any other regulated health professional. This does require that one know the identity of the professional in question and there are situations where the client withholds that information. Note: Sometimes a client declines to complain or authorize you to do so, but when re-contacted at a later date with additional information, decides to go ahead with a complaint.

What stress or problems have you experienced as regards the mandate to report sexual misconduct by other professionals?*
* Richard Brigham (1989) in an unpublished doctoral dissertation reported on a study in Wisconsin of stressors on practitioners. One of the highest pressures equivalent to having a suicidal client which is an item that usually tops the scales in most studies of stress on clinicians was knowledge of an incident of therapist-client sex. One of the lowest was the duty to report. This was seen as a remedy for the stress of the guilty knowledge. Reporting colleagues is normally stressful, but so is having the knowledge of misconduct and not being able to do anything with this knowledge.

SUPERVISORY ROLES THE NARROW LINE BETWEEN CONCERN & MIXING ROLES With any supervision, but especially with clinical supervision, there is a need for the supervisor to be mindful of the personal adjustment and functioning of the supervisee. Problems in this area may require intervention for administrative or other purposes. A caring supervisor opens the door for the supervisee who is having problems and needs help. But, it is important to avoid shifting from supervision to doing some sort of supportive therapy with a supervisee. Having some understanding as to how their personal adjustment is affecting their work, or that it may dictate some change in duties, is important. But it must not be allowed to drift into provision of direct help or any undermining of administrative or supervisory duties. Likewise a psychotherapist who is treating someone else in the field may from time to time find themselves discussing the handling of a given client. But again, it is important to avoid drifting into provision of consultation or supervision. ASSESSMENT OF THE SUPERVISEE: THE DESIGN OF A SUPERVISION PLAN Supervision, like other professional duties and tasks, requires an assessment and game plan. One has the duty to gather background on the supervisee -- from them, from their training program, from former supervisors at the same facility -- so as to do a preliminary assessment as to their strengths, weaknesses, and supervision needs.
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If the supervisee has had past difficulties, you may need to obtain outside information or background data to be able to fully assess current difficulties. At times one must obtain a release to permit a review of their situation with a past supervisor, employer, or even their therapist. It is your job to make every effort to know the needs and the strengths and weaknesses of your supervisee. If the supervisee is on any sort of probation or the supervision is a requirement of continued employment or licensure status, then the supervisor must obtain any and all data about the background of the situation so as to know precisely what the original practice problems were and precisely what the Board, employer, or other party expects the supervision to accomplish. It is your job to require disclosure so as to be fully prepared for what you are dealing with. SUPERVISING THE PRACTITIONER UNDER DISCIPLINARY ORDER In an article entitled Transference and countertransference in the psychotherapy of therapists charged with sexual misconduct authored by Glen Gabbard, MD, in the February 1995 issue of Psychiatric Annals, the author describes the boundaries challenges by one of the practitioners he has treated: Dr. A came to his first session of psychotherapy after being referred by a state licensing board. He began the session by asking me if it would be okay if he called me by my first name. I suggested to him that because he was seeing me in a professional relationship, it would probably be more appropriate for him to call me Dr. Gabbard. He acceded to my request, but went on several times in the session to use my first name, only to apologize afterwards. As the therapy went on, he told me he had heard that I had written a book on this subject and asked if he could borrow the book from me to read up on the kind of problems he had. He assured me he would return it in a couple of weeks. I told him that while I really had no doubts about his returning the book, I nevertheless felt it was not a good idea for me to loan him books because it was another variant of the professional boundary problem that had gotten him into difficulty in the first place. He then asked if I could buy one of the books at the author's discount price and he would reimburse me. Again, I told him that I thought that the financial transgressions between us should only be related to the fee. During another therapy session, while he was describing how he had fallen in love with a patient, he told me that he was aware that all therapists became sexually excited by certain patients, and he asked me if that ever happened to me. I stressed to him that the focus of psychotherapy was on him and his countertransference difficulties rather than on mine. Late in therapy, Dr. A told me he thought he was getting better and wondered if we could switch from psychotherapy to supervision. I responded that I felt he needed me as a psychotherapist and that there were other people available as supervisors. (Gabbard, 1995, p. 102) The challenges of doing therapy on practitioners who have crossed boundaries have parallels in the supervision of the same people. Using some of the issues discussed by Gabbard, there are the problems inherent in: Supervisor as Cop: To the degree that the supervisor is an extension of the college, licensure board
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or the discipline of an employer, the supervisor can drift into the role of a disciplinarian and watchdog. Supervisor as Rescuer and Absolver: Many disciplined professionals come for supervision in a traumatized state. Supervision may be seen as a place for confession and absolution. Seeing the supervisee as a victim, at least in part, is an easy step, as are rescue fantasies. Supervisor as Authoritarian Parent: Many professionals who violate boundaries have a longstanding resentment of authority and a rebellious streak which is easily triggered in some settings. In supervision they can bring about an authoritarian response from the supervisor. Those with a history of self-destructive and masochistic relationships may pity themselves sufficiently to bring on frustration in the supervisor eventually leading to some punitive interaction. Supervisor as Corruptible Object: Practitioners who have trouble managing boundaries in general will challenge the supervisory boundaries. To the degree that they can undermine these boundaries they may show that even the supervisor has problems with boundaries. Transference and countertransference may occur in any supervisory relationship, but are especially likely in situations where the practitioner is forced into some sort of remedial supervision. These may parallel developments in the practitioner's therapeutic work with his/her client, or may be unique to the supervisory relationship. There may be a "parallel process," but this is not always the case. SELF CARE STRATEGIES In his book The Resilient Practitioner Tom Skovolt (2006, p. 210) lists poor self care strategies: POOR SELF-CARE DEADLY DOZEN

1) 2) 3) 4)

Toxic supervisor and colleague support Little fun (e.g. playfulness, humor, laughing) in life or work Only a fuzzy and unarticulated understanding of ones own needs No professional development process that turns experience into more competence and less anxiety 5) No energy giving personal life 6) An inability to say no to unreasonable requests 7) Vicarious traumatization that takes an accumulated toll 8) Personal relationships that are predominantly one-way caring relationships with self as giver 9) Constant perfectionism in work tasks 10) Continual unresolved ambiguous professional losses 11) A strong need to be needed 12) Professional success defined solely by client, student, or patient positive change or appreciation

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Top Ten Helpful Activities [from Pearlman, 1995] Taking vacation Social activities Emotional Support from Colleagues Pleasure Reading Seeking consultation on difficult cases Reading relevant professional literature Taking breaks during the workday Emotional support from friends or family Spending time with children Listening to music

Well-Functioning Psychologists Top 10 Activities Contributing to their Well-Functioning Coster & Schwebel, 1997 Self-awareness and self-monitoring Personal Values Preserving balance between personal and professional lives Relationship with spouse, partner, or family Personal therapy Relationship with friends Vacations Professional identity Informal peer support Mentor
Themes From Interviews With Well-Functioning Psychologists Coster & Schwebel, 1997)

Peer Support Stable Personal Relationships Supervision A Balanced Life Affiliation With a Graduate Training Program Personal Psychotherapy Family of Origin as a Source of Personal Values Continuing Education Negative Costs of Professional Impairment Positive Coping Mechanisms (vacations, rest, relaxation, exercise, evening with friends, spirituality Psychologist Kate Hays notes that exercise has an excellent track record in
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dealing with anxiety and with depression. It has been show to decrease both state and trait anxiety. Problem solving is helped by increasing exercise time or shower time. Psychologist Ellen Baker emphasizes self-regulation. She has workshop attendees write a note or letter to themselves regarding goals for improving professional well-being or personal well-being. These are then put in an envelope and given to the workshop leader (or a friend). The letters are then mailed to the participants on New Years. It is critical to spend time constructing goals and committing yourself to some changes: change in number of clients, change in work habits, etc. One can also commit to improving some element(s) in ones professional work or environment. For example: Improving the furniture, decorations, lighting in ones office Improving the waiting room furniture, music, etc. Finding a new office or work setting which is more comfortable or more convenient Setting up a plan for continuing education and building it into schedule Changing ones case load or client mix, or mix of activities Improving office procedures, record-keeping or storage Setting up consultation & other professional supports Setting up collegial contacts reconnecting with old friends Improving ones technology; taking a course or having training in how to better utilize technological tools
MONEY AND PRACTICE CONDITIONS

Coping with reimbursement issues Developing a better mix of work Attempting to affiliate with physicians Relationships with businesses personnel evaluations The reality of the health care cost spiral and our relatively powerless position in that world Reducing your operating costs of your practice Being creative about use of ones skills (i.e. my colleague Ellen Luepker, LICSW, does interviews with people and creates a videotape memoir www.livingportraits.com )
SELECTED PRACTICE CHALLENGES
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AVOIDING TROUBLE TERMINATION OF THE RELATIONSHIP WITH THE CLIENT The Canadian Code of Ethics for Psychologists includes the following sections: II.32 Provide a client, if appropriate and if desired by the client, with reasonable assistance to find a way to receive needed services in the event that third party payments are exhausted and the client cannot afford the fees involved. II.33 Maintain appropriate contact, support, and responsibility for caring until a colleague or other professional begins services, if referring a client to a colleague or other professional. II.34 Give reasonable notice and be reasonably assured that discontinuation will cause no harm to the client, before discontinuing service.

What is Client Abandonment? What conflicts have you had with this issue?
POST-TERMINATION RELATIONSHIPS WITH CLIENTS Many professionals have no concept of the degree to which the power may shift and they may be at risk for relationships which began within the service context. They also are not aware that it takes very little for someone to argue that a professional relationship is continuing. See the handout Personal Relationships With Former Clients. In small towns and rural areas, of course, contact with former clients is commonplace. This is also the case when one is treating a student or health care professional. Anderson and Kitchener (1998) have written a fine article on decisionmaking concern non-sexual post-therapy relationships. A HIGH RISK SITUATION: THE SUICIDAL CLIENT Studies of stressors on clinicians usually rate suicidal clients as among the top three stressors on practicing clinicians. Some areas for consideration related to your own practice, your supervisory duties, or even provision of consultation to a therapist dealing with a suicidal client are as follows: (1) Competence to Assess Risk, and access to appropriate consultation in a timely fashion (there is an ethical duty and practice challenge to have this in place beforehand); (2) Competence to provide appropriate management for the chronically suicidal client (the ethical duty is to have appropriate training and any tools available); (3) When to breach confidentiality in order to prevent an imminent suicide (this has always been an option, but unlike the "duty to warn or protect" there are generally no standards in rule or law for when one takes this step); (4) Self care for the practitioner after a suicide attempt or completion;
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(5)

Reconsideration of practice parameters after a death of a client: (a) (b) Psychological autopsy consideration of its impact on future practice

(6)

Providing support or intervention for other clients who may be impacted THE HIGH RISK SITUATION: CLIENTS WHO ARE DANGEROUS TO OTHERS See the handout Dealing With Dangerous Clients and the Threat of Violence. WHEN YOU OR YOUR COLLEAGUES ARE THE TARGET OF STALKING OR HARRASSMENT BY A CLIENT OR A RELATIVE OF A CLIENT

A random sample of university counseling center in the U.S. found that 64% of the staff had experienced harassment from a current or former client. This included 5.6% who had been stalked, 8% where a family member had been stalked, and 10% who had supervised someone who had been stalked (Romans, Hays & White, 1996). Other studies have found high numbers of professionals who have been threatened or attacked, with physical assaults more likely in hospitals and clinics than in individual private practices. An archival study of former hospital inpatients who engage in post-discharge stalking found that the duration was short-term, generally only a few weeks. Such patients were more likely to have a history of fear-inducing or assaultive behavior pre-admission, and were more likely to have personality disorders or a paranoid disorder with erotomanic features. They are more likely male. (Sandberg, McNeil Binder, 1998) There are some excellent resources on the internet, and I would highly recommend Mullen, Pathe, & Purcell (2000) -- Stalkers and Their Victims. Another useful book is Stalking: Perspectives on Victims and Perpetrators (Davis, Frieze, & Maiuro, 2002). Unfortunately, when mental health professionals become victims of stalking or harassment they do not tend to talk about it. The research shows that while 100% of those who talk to the police felt it was helpful, Only 60% felt it was helpful to talk with colleagues. Why is this the case? REFERENCES Anderson, S.K. & Kitchener, K.S. (1998). Nonsexual posttherapy relationships: A conceptual framework to assess ethical risks. Professional Psychology: Research & Practice, v.29, pp. 91-99. Aponte, Harry J. (2005). Conducting marital and family therapy with therapists. In Jesse D. Geller, John C. Norcross, & David E. Orlinsky (Eds.) The Psychotherapists Own Psychotherapy, pp. 297306, New York, NY: Oxford University Press. Barnett, J.E. (1998). Should psychotherapists self-disclose? Clinical and ethical considerations. In L. Vandecreek, S. Knapp, S., & T.L. Jackson (Eds.), Innovations in Clinical Practice: A Sourcebook, Vol. 16, pp. 419 - 428, Sarasota, FL: Professional Resource Press. Barnett, J.E., Behnke, S.H., Rosenthal, S.L., & Koocher, G.P. (2007). In case of ethical dilemma, break glass: Commentary on ethical decision making in practice. Professional Psychology: Rsearch
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& Practice, v. 38, pp. 7 -12. Barnett, J.E., MacGlashan, S.G., & Clarke, A.J. (2000). Risk management and ethical issues regarding termination and abandonment. In L. Vandecreek & T.L. Jackson (Eds.). Innovations in Clinical Practice: A Sourcebook, Vol. 18, pp. 231 - 245. Sarasota, FL: Professional Resource Press. Boss, Pauline (1999). Ambiguous Loss. Cambridge, MA: Harvard University Press. Boss, Pauline ((2002). Family Stress Management. Newbury Park, CA: Sage. Brigham, Richard (1989). Psychotherapy Stressors and Sexual Misconduct: A Factor Analytic Study of the Experience of Non-offending and Offending Psychologists in Wisconsin. Unpublished doctoral dissertation, Wisconsin School of Professional Psychology, Milwaukee, WI Brownlee, K. (1996). The ethics of non-sexual dual relationships: A dilemma for the rural mental health professional. Community Mental Health Journal, v. 32, pp. 497-503. Campbell, C.D. & Gordon, M.C. (2003). Acknowledging the inevitable: Understanding multiple relationships in rural practice. Professional Psychology: Research & Practice, v. 34, pp. 430-434. Catalano. S. (1997). The challenges of clinical practice in small or rural communities: Case studies in managing dual relationships in and outside of therapy. Journal of Contemporary Psychotherapy, v. 27, pp. 23-35. Caudill, O.B. (1997). Can therapists be vicariously liable for sexual misconduct? In L.E. Hedges, R. Hilton, V.W. Hilton, & O.B. Caudill, Therapists At Risk: Perils of the Intimacy of the Therapeutic Relationship, pp. 269-273, Northvale, NJ: Jason Aronson. Chamberlain, J. (2004 November). No desire to fully retire. Monitor on Psychology, v. 35, pp. 8283. Charles, Sara & Frisch, Paul (2005). Adverse Events, Stress and Litigation. New York, NY: Oxford University Press. Coster, J.J. & Schwebel, M. (1997). Professional Psychology: Research & Practice, v. 28, pp. 513 Coyle, B.R. (1999). Practical tools for rural psychiatric practice. Bulletin of the Menninger Clinic, v. 63, pp. 202-222. Davis, K.E., Frieze, I.H., & Maiuro, R.D. (Eds.) (2002). Stalking: Perspectives on Victims and Perpetrators. New York, NY: Springer. Dobia, Debra C. & Pipes, Randolph B. (2002). Mandated supervision: An intervention for disciplined professionals. Journal of Counseling & Development, v.80, pp. 140-144. Epstein, Lawrence & Feiner, Arthur. (1993). Countertransference: The Therapists Contribution to the Therapeutic Situation. Northvale, NJ: Jason Aronson. Epstein, R. (1994). Keeping Boundaries: Maintaining Safety and Integrity in the
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Psychotherapeutic Process. Washington, DC: American Psychiatric Press. Forrest, L., Elman, N., Gizara, S., & Vacha-Hasse, T. (1999). Trainee impairment: A review of identification, remediation, dismissal, & legal issues. The Counseling Psychologist, v.27, pp. 627686. Gabbard, G. & Lester, E. (1995). Boundaries & Boundary Violations in Psychoanalysis. New York: Basic Books Galloway, V.A. & Brodsky, S.A. (2003). Caring less, doing more: The role of therapeutic detachment with volatile and unmotivated clients. American Journal of Psychotherapy, v. 57, pp. 32-38. Geller, Jesse, Norcross, John, & Orlinsky, David (Eds.) (2005). The Psychotherapists Own Psychotherapy: Patient and Clinician Perspectives. New York, NY: Oxford University Press. Gerson. B. (Ed.) (1996). The therapist as a person: Life crises, life choices, life experiences and their effects on treatment. Hillsdale, NJ: The Analytic Press. Gold, J. H. & Nemiah, L.C. (Eds.) (1993). Beyond Transference: When the therapist's real life intrudes. Washington, DC: American Psychiatry Press. Gutheil, T.G. & Gabbard, G.O. (1998). Misuses and misunderstandings of boundary theory in clinical and regulatory settings. American Journal of Psychiatry, v. 155, pp. 409-414. Hargrove, D.S. (1995). Ethical issues in rural mental health practice. In D.N. Bersoff (Ed.), Ethical Conflicts in Psychology, pp. 338-342, Washington, DC: American Psychological Assn. Harper, K. & Steadman, J. (2003). Therapeutic boundary issues in working with childhood sexualabuse survivors. American Journal of Psychotherapy, v. 57, pp. 64-79. Hays, K.F. (1999a, August). Nutrition and exercise: Key components of taking care of yourself. In L.T. Pantano (Chair), Taking care of yourself: The continuing quest. Symposium conducted at the annual convention of the American Psychological Assn., Boston, MA Hays, K.F. (1999b). Working it Out: Using Exercise in Psychotherapy. American Psychological Assn. Washington, DC:

Heath, Sheldon (1991). Dealing With the Therapists Vulnerability to Depression. Northvale, NY: Jason Aronson. Hedges, L.E. (1997). In praise of the dual relationship. In L.E. Hedges, R. Hilton, V.W. Hilton, & O.B. Caudill, Therapists at Risk: Perils of the Intimacy of the Therapeutic Relationship, pp. 221250, Northvale, N.J.: Jason Aronson. Horst, E.A. (1989). Dual relationships between psychologists and clients in rural and urban areas. Journal of Rural Community Psychology, v. 10, pp. 15 - 24. Irons, Richard & Schneider, Jennifer (1999). The Wounded Healer. Northvale, NJ: Jason Aronson. Jenaro, Cristina; Fores, Noelia; & Arias, Benito. (2007). Burnout and coping in human service practitioners. Professional Psychology: Research & Practice, v. 38, pp. 80-87.
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Kilburg, N., Nathan, P., & Thoreson, R. (Eds.) (1986) Professionals In Distress: Issues, Syndromes, and Solutions in Psychology. Washington, DC: American Psychological Assn. Knapp, Samuel & VandeCreek, Leon (1997). Treating Patients With Memories of Abuse: Legal Risk Management. Washington, DC: American Psychological Association. Koocher, G.P. (2003). Ethical & legal issues in professional practice transitions. Psychology: Research & Practice, v. 34, pp. 383-387. Professional

Kroll, Jerome (2001). Boundary violations: A culture - bound syndrome. Journal of the American Academy of Psychiatry and the Law. v. 29, pp. 274-283. Lamb, D. (1999). Addressing impairment and its relationship to professional boundary issues: A response to Forrest, Elman, Gizara, & Vacha-Haase, The Counseling Psychologist, v. 27, pp. 702711. Lamb, D. & Catanzaro, S. (1998). Sexual and nonsexual boundary violations involving psychologists, clients, supervisees, and students: Implications for professional practice. Professional Psychology: Research & Practice, v. 29, pp. 498-503. Luepker, E.T. (2003). Record Keeping in Psychotherapy and Counseling. NY, NY: BrunnerRoutledge. McGee, T.F. (2003). Observations on the retirement of professional psychologists. Professional Psychology: Research & Practice, v. 34, pp. 388 - 395. Manosevitz, M. & Hays, K.F. (2003). Relocating your psychotherapy practice: Packing and unpacking. Professional Psychology: Research & Practice, v. 34, pp. 375-382. Minnes, P.M. (1987). Ethical issues in supervision. Canadian Psychology/Psychologie Canadienne, v. 28, pp. 385-390. Mullen, Paul, Pathe, Michele, & Purcell, Rosemary (2000). Stalkers and Their Victims. Cambridge, UK: Cambridge University Press. Norcross, John C. & Guy, James D. (2005) The prevalence and parameters of personal therapy in the United States. In Jesse D. Geller, John C. Norcross, & David E. Orlinsky (Eds). The Psychotherapists Own Psychotherapy, pp. 165-176, New York, NY: Oxford University Press. Pearlman, L.A. & MacIan, P.S. (1995). Vicarious traumatization: An empirical study of the effects of trauma work on trauma therapists. Professional Psychology: Research & Practice, v. 26, pp. 558565. Peterson, Marilyn (1992). At Personal Risk: Boundary Violations in Professional-Client Relationships. New York, NY: W.W. Norton & Co. Pope, K.S. Ken has tons of useful material posted on his website: www.kspope.com Pope, K.S., Sonne, J. , & Green, B. (2006). What Therapists Dont Talk About and Why.
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Washington, DC: American Psychological Association. Pope, K.S. & Vasquez, Melba (2005) How to Survive and Thrive as a Therapist. Washington, DC: American Psychological Assn. Ramos-Sanchez, Lucila, Ensil, Edna, Riggs, Shelley, Wright, Laura, Goodwin, Alan, Touster, Lisa, Ratanasiripong, Paul & Rodolfa, Emil. (2002). Negative supervisory events: Effects on supervision, satisfaction and supervisory alliance. Professional Psychology: Research & Practice, v. 33, pp. 197-202. Ritterban, L.M., Gonder-Frederick, L.A., Cox, D.J., Clifton, A.D., West, R.W., & Borowitz, S.M. (2003). Internet interventions: In review, in use, and into the future. Professional Psychology: Research & Practice, v. 34, pp. 527-534. Romans, John; Hays, Joni; & White, Tamiko. (1996). Stalking and related behaviors experienced by counseling center staff members from current or former clients. Professional Psychology: Research & Practice, v. 27, pp. 595-599. Rupert, Patricia & Kent, Jamie (2007). Gender and work setting differences in Career-sustaining behaviors and burnout among professional psychologists. Professional Psychology: Research & Practice, v. 38, pp. 88-96. Sandberg, David; McNiel, Dale; & Binder, Renee. (1998). Characteristics of psychiatric inpatients who stalk, threaten, or harass hospital staff after discharge. American Journal of Psychiatry, v. 155, pp. 1102-1105. Schank, J.A. & Skovholt, T. M. (1997). Dual relationship dilemmas of rural and small-community psycyhologists. Professional Psychology: Research & Practice, v. 38, pp. 44-49. Schank, J.A. & Skovholt, T.M. (2006). Ethical Practice in Small Communities. Washington, DC: American Psychological Association. Schoener, G.R. (1999). Practicing what we preach. The Counseling Psychologist, v. 27, pp. 693701. Schoener, G.R. (2005). Treating impaired psychotherapists and wounded healers. In Jesse Geller, John Norcross, & David Orlinsky (Eds.), pp. 323-341, New York, NY: Oxford University Press. Schoener, G., Milgrom, J., Gonsiorek, J., Luepker, E., & Conroe, R. (1989). Psychotherapists' Sexual Involvement With Clients: Intervention and Prevention. Minneapolis, Minn.: Walk-In Counseling Center Schwebel, M., Skorina, J.K., Schoener, G. (1994). Assisting Impaired Psychologists, Revised Edition. Washington, DC: APA Board of Professional Affairs, American Psychological Association. Shapiro, E.L. & Ginzberg, R. (2003). The accept or not to accept: Referrals and the maintenance of boundaries. Professional Psychology: Research and Practice, v. 34, pp. 258-263. Shuman. D.W. & Greenberg, S.A. (2003). The expert witness, the adversary system, and the voice of reason: Reconciling impartiality and advocacy. Professional Psychology: Research and Pracitce, v.
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34, pp. 219-224. Simon. R.I. & Williams, I.C. (1999). Maintaining treatment boundaries in small communities and rural areas. Psychiatric Services, v. 50,pp. 1440-1446. Skovholt, Thomas M. (2001). The Resilient Practitioner. Needham Heights, MA: Allyn & Bacon. Smith, R.C., Mead, D.E., & Kinsella, J.A. (1998). Direct supervision: Adding computer-assisted feedback and data capture to live supervision. Journal of Marital and Family Therapy, v. 24, pp. 113-125. Stamm, B. H. (Ed.) (1995). Secondary Traumatic Stress: Self-care Issues for Clinicians, Researchers, & Educators. Lutherville, MD: Sidran Press. Susman, Michael B. (Ed.) (1995). A Perilous Calling: The Hazards of Psychotherapy Practice. New York, NY: John Wiley & Sons. Waldman, J. (2003). New Mother/Old Therapist: Transference and countertransference challenges in the return to work. American Journal of Psychotherapy, v. 57, pp. 52 - 63. White, William L. (1997) The Incestuous Workplace: Stress and Distress in the Organizational Family. Center City, Minn.: Hazelden ATTACHMENT I APPROACHES TO PROFESSIONAL DECISION-MAKING Tying difficult decisions to ethical principles can reduce anxiety and also provide a grounding. The Code of Ethics of the Canadian Psychological Assn. provides four basic principles and lists them in order according to the weight each should be given if they conflict: I: II: III. IV. Respect for the Dignity of Persons; Responsible Caring; Integrity in Relationships; Responsibility to Society

I am going to focus on five ethical principles which are somewhat different and will present them in an order which is irrelevant. I have found these more useful in terms of providing a frame for action: (1) BENEFICENCE: likelihood that it will help, or do good for the client (2) NON-MALEFICENCE: likelihood that it will not harm the client (3) AUTONOMY: likelihood that it will foster the client's autonomy (4) FIDELITY: the degree to which it is true to what was promised (5) JUSTICE: balancing the needs or rights of one versus another -- for example the issue of a duty to warn third parties of danger from our clients, involves the competing principles of Justice vs. Autonomy. Another example is the responsibility to consider the wise use of resources and to be able to justify differences in levels of service provided to different people based on some rationale. The issue in most complex situations is not what is ethical -- it is the comparable ethicality of the various options for action. How might a given course of action fulfill each of the five ethical
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principles above? In each situation the analysis of how each of these principles would be met may produce a different pattern of positive vs. negative outcomes. A DECISION-MAKING APPROACH Another way to examine this is via a decision-making chart or table. With complicated decisions I find it is necessary to actually write down the anticipated outcomes in order to be able to decide on a course of action. I make a chart of likely positive and likely negative outcomes for each option. There could in fact be far more alternatives. Getting consultation from colleagues normally produces additional ones. Likely Positive Outcomes Option A Likely Negative Outcomes

Option B

To illustrate this approach, let's take a case where you are providing services to a single mother with a child. Let us presume that you have decided that what is going on meets the statutory test for a mandatory report (e.g. without a release) of child abuse or neglect. Whether to report is not the issue -legally or ethically. The question is: Will you tell the mother before you report? (Obviously, we could also make options such as tell the mother before you report, when you report, immediately after you report, etc. But we are going to stick with (1) tell before; (2) don't tell. possible Positive Outcomes Tell mother that you are going to report 1. increase trust 2. helps working relationship 3. you can explain what's next 4. clarifies your concerns possible Negative Outcomes 1. decreased trust 2. gets in the way of working rel. 3. parent punishes child 4. parent kidnaps child

Don't tell mother

1. Since they are in counseling 1. Shock if CPS contacts parent CPS may not even contact them 2. Greater feeling of betrayal 2. Avoid panic, overreaction 3. May not be able to explain if the 3. Avoid distractions family drops out of care etc.

CASE:

You are treating a 18 yr. old college student who is having problems with
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emancipating from family and is also depressed. She has been doing better, but he misses an appointment and you get a phone message that sounds very depressed. You are worried she may be suicidal based on some recent events where she failed a course, and also had a close friend kill himself. You try to phone her but her roommate says she's left for her parent's home for the Spring break -- a six hour drive. You have talked with her parents when the therapy began so they know who you are. What do you do?

ATTACHMENT II: PROFESSIONAL BOUNDARIES EXERCISE List off characteristics of a relationship which might contrast personal and professional relationships. The issue is not that there are clear personal vs. professional lines (except for sex) but that these are all continua. The problem comes in when you begin to drift, usually along several parameters, from the professional side to what is more commonly the personal side. Also, note that depending on the service you offer, where you sit on each line will vary. For example, in home family therapy, takes you out of the office and into the clients home. PERSONAL versus PROFESSIONAL

Some examples of items which come up during this exercise: (1) Fees & payment: professional relationships involve fees or some form of payment; (2) Time: Longevity of the Relationship: Personal relationships can last forever -- professional ones are always time-limited. They end if you change jobs, move away, or if the client is transferred or referred, changes health plans, joins a new church, etc. (3) Time: The Time involved in an interaction. Interactions in personal relationships can be any length of time -- you can even go on a trip or spend a weekend with a friend or family member. A professional relationship involves "sessions," hospital stays, a "fifty minute" hour, and other units of time which may even be legally defined. (4) Site or Location: You can get together with family or friends anywhere you choose. A professional encounter is at a particular site -- office, church, clinic, etc. Even when services
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are delivered in the client's home, they occur at a set time during which time the home is the professional setting. (5) Goals: The professional relationship has formal goals -- that is generally not true of personal relationships. You don't think of "goals" of a friendship for example. (6) Notes/Records: The professional relationship requires record-keeping. Although some people keep diaries about their personal life and relationships, that is their choice. While there are some legal records in personal relationships such as marriage agreements, for the most part they are not required. They are with professional relationships. (7) Licenses and Regulation: The professional needs to be licensed or approved by the state in many circumstances. Although Minnesota psychologist David Lykken has suggested that parents should be licensed, that isn't required. Likewise, friends do not need certification. However, there may be legal agreements between friends, such as when one buys a house, or gets married. (8) Self-disclosure: In a personal relationship it is two-way (although admittedly this may vary from time to time -- one time you cry on your friend's shoulder and the next day they do so). In a professional relationship it is largely one-way with the client doing most of the disclosing, although again, professionals do engage in some self-disclosure. (9) Power Differential: In a personal relationship one aims at equal power, although admittedly that may vary over time, or relationship to relationship. The professional is more powerful than the client or student or parishioner (although if the professional engages in misconduct, this power may shift if the client realizes that he/she can make a complaint). (10) Physical Contact: In a personal relationship physical contact is based on what adults agree to and is generally limited only by a desire to avoid harm or pain. In a professional relationship physical contact is limited to treatment - related contact, which in some relationships means only a handshake. (11) Sexual involvement: Exclusively limited to a personal relationship. But while the touching of the professional's sexual areas is always forbidden, in some physical procedures a professional may be expected to touch the private parts of the client (e.g. a physician performing a pelvic examination). (12) Privacy & Confidentiality: In personal relationships these are guided by understandings between the parties, personal discretion, and other informal arrangements. Both parties in a personal relationship are typically bound by the same understanding and have the same duties. In a professional relationship it is the professional who has the duties. In professional relationships these are defined by codes of ethics, rules, and laws and the professional is obligated to maintain them, with certain well-defined exceptions.

ATTACHMENT III: IS THERE A "SLIPPERY SLOPE" AND HOW DANGEROUS IS IT?

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Kroll (2001) and others have questioned the concept of the "slippery slope" -- namely that the crossing of particular boundaries really leads, inevitably, to significant problems in the treatment relationship or harm to the client. Assuming that there is not an organization rule which is being broken can one clearly define a slippery slope. For example, if there is not a rule against accepting gifts as there is for example in a number of facilities, how does one make the decision as to whether to accept a gift? Gutheil & Gabbard (1998) have also written about misuses and misunderstandings about the concept of boundaries in both clinical and regulatory settings. Many times a complaint letter lists a great many boundary crossings, but that in no way clarifies how and why those boundaries were crossed. NOTE: One must consider the context, appearance to others (other clients, others in the community), overall situations regarding boundaries, how the client might perceive it, etc. THE "DUAL" OR "MULTIPLE" RELATIONSHIP CONCEPT While firmly established in the psychology and social work ethics codes for many years, during the past decade the dual or multiple relationship concept has come under attack from a number of perspectives -- usually that it is vague or that it does not apply well in rural areas or within small groups such as cultural or ethnic minorities, gay/lesbian communities, small religious denominations or groups, etc. The study Crossing the Boundaries done by a Special Task Force of the College of Physicians and Surgeons of British Columbia found that both the public and physicians felt that standards for personal relationships between doctors and their former patients might vary when comparing rural to urban areas in this province. The Canadian Code of Ethics for Psychologists addresses potential dual relationships several places: III.33 Avoid dual or multiple relationships (e.g. with clients, research participants, employees, supervisees, students, or trainees) and other situations that might present a conflict of interest or that might reduce their ability to be objective and unbiased in their determinations of what might be in the best interest of others. III.34 Manage dual or multiple relationships that are unavoidable due to cultural norms or other circumstances in such a manner that bias, lack of objectivity, and risk of exploitation are minimized. This might include obtaining ongoing supervision or consultation for the duration of the dual or multiple relationship, or involving a third party in obtaining consent (e.g., approaching a client or employee about becoming a research participant). One can have an (1) encounter with a client or former client outside the office; or (2) one can have some overlap in your lives on a more ongoing basis; or (3) true multiple or dual relationship where a conflict of interest is likely or a high risk. Living or working in small towns, rural areas, or being part of small ethnic, cultural, religious, or other minority groups make the likelihood of all three very great.. The concept that you could somehow go through life with minimal interaction with clients seems to apply only to a very large city. An fine book on this topic is Ethical Practice in Small Communities (Schank & Skovholt, 2006).

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