NCE – Symbolic Experimental Family Therapy

According to Metcalf, (2011) Symbolic Experimental Family Therapy “Focuses on here-and-now experiences, playfulness, humor, intuition, craziness, spontaneity, and personal growth. It is a pragmatic, atheoretical method for treating families. Incorporates growth of the therapist and clients as the ultimate motivation, and focuses on circular, recursive patterns in a family that lead to mutual benefit and interpersonal context” (p147). Another unique aspect about this theory is that it normalizes pathology.  As I see it, this theory focuses on familial cultures, (i.e. shared meanings, beliefs, thoughts, symbols, and perspectives).  Entering in the “family’s symbolic world” (Metcalf, 2011, p. 148) is the goal here since change is conceived to result from the therapeutic process.

Founder – Carl Whitaker

Stages of Therapy

Symbolic Experimental Therapy is focused on the present.  The  first of therapy begins with the clients’ first contact with the therapist.  It is at this stage, that the therapist is “responsible for setting the tone of therapy.” (Metcalf, 2011, p. 149).   Whitaker, describes the therapist as a foster mother/investigator since, at this point, family morale and information gathering are the focus (Metcalf, 2011). Once therapy has been initiated, it is the family’s responsibility to “take charge of their own experiences…[in an] anything goes  [manner]” (Metcalf, 2011, p. 149).  Interestingly, during the early stages, the therapist is a disconnected observer who, while “joined with the family”, (Metcalf, 2011, p. 149), steps back and lets the family play out their own shared reality.  However, as therapy progresses the therapist pushes the family to address the symbols and meaning that underlies their pain.  This allows them to develop a new perspective upon which to understand their shared experience.  During the termination phase, the therapist begins to disengage as the family learns to adapt to new positive shared experiences.

View of the client

This perspective seems to focus on the shared symbolic meanings that underlie shared family dynamics.   Change happens by understanding the symbolic meanings that give rise to these family dynamics.  Change can happen if the client is willing to work with it.  Within each pathological dynamic is an opportunity for growth, therefore it is conceived as evidence of potential and not malady.  Individual human choices can be contextualized within a shared familial reality since it is from here that we develop our beliefs, values, and cultural identity.   “Families should preserve, protect, and maintain a sense of self while understanding how their being/growth influenced by family history (Metcalf, 2011, p. 150).”

Assumption about marriage

  1. “Marriage is a third entity. In therapy, the clients are the husband, wife and the marriage.
  2. Marriage is greater than the sum of its parts.
  3. People choose partners on the basis of set core beliefs and values
  4. Marriage is legally and emotionally binding. A marriage constrains two persons from getting emotionally involved with other people outside the marriage.
  5. Marriage must learn to grow and resolve unexpected and predictable impasses that occur occasionally. (Metcalf, 2011, p. 151)”

How Change Happens.

Change can happen simply by examining how we choose to interpret our shared experiences.  “Failure is one’s only teacher; success allows one’ the courage to fail.  [Change happens through]personal growth, symbol relief, character development, resolution of dependency, ability to experience emotion/anxiety, & increased spontaneity/creativity (Metcalf, 2011, p. 152).

Basic skills of a therapist

  1. “Able to tolerate pain, anxiety, etc in his own life
  2. Understructure of caring
  3. Able to listen to personal intuition
  4. Ability to become family’s foster parenting and balance nurturing with toughness during therapy
  5. Belief in continuous personal growth…
  6. Ability to interweave beliefs, assumptions, and biases into therapy.” (Metcalf, 2011, p. 152)

Key Concepts

  1. SYMBOLS:  comprise an unspoken underlying meaning that defines our experience.  It gives the meaning to the pain we experience and the options available to us for change and growth.
  2. CRAZINESS:  “allows a person to not be constrained by socially accepted realities, and be more spontaneous and symbolic.” (Metcalf, 2011, p 156).  There are three types of crazy: (1) driven crazy (2) going crazy & (3) acting crazy.  Driven crazy refers to being repelled from intimacy.  Going crazy refers to an intense and neurotic distress.  Acting crazy is a technique that involves regressing into crazy behavior during periods of heightened stress/anxiety.
  3. SPONTANIETY – “rooted in intuition and the use of craziness. Is an unconscious process. Is a key aspect for any personal interaction in therapy…..” (Metcalf, 2011, p 156)
  4. CONFUSION – “Confusion is a symbolic way to open up the infrastructure of the family and disrupting old patterns.”  (Metcalf, 2011, p 156).
  5. FANTASY –  “a form of play that allows the therapist and family to address their separate symbolic worlds & meanings.”  (Metcalf, 2011, p 156)
  6. GROWTH – “growth is the ultimate motivation of thus approach to family therapy. Growth occurs thru play” (Metcalf, 2011, p. 156).

A working template

Change happens by reshaping the “symbols and language used by the family[this provides a]  corrective experience for the family when discussed openly” (Metcalf, 2011, p. 157).  Essentially, this section of Metcalf’s (2011) discussion provides a reiteration of the therapy stages except in terms of the therapist’s objectives….

  1. PHASE ONE  – Build Rapport by upholding a foster parent role by stepping back and observing while relating “to the family as a peer” (Metcalf,2011, p. 157).
  2. PHASE TWO – Once rapport has been established it is possible to begin investigating the problem.  This happens by interviewing each family member without interruption individually.
  3. PHASE THREE:  The next step involves assessing the family dynamics and their desire for change.  “The goal is to understand the past symbols underlying the family’s pain” (Metcalf, 2011,p. p157)
  4. PHASE FOUR:  Develop familial goals.
  5. PHASE FIVE:  Amplifying change by  “getting into a family and then out as soon as possible is the goal, so you don’t leave any marks of your presence behind.” (Metcalf, 2011,p. p157)
  6. PHASE SIX: Termination.


Linehan, M. (1997). Validation and psychotherapy. (pp. 353-392). American Psychological Association. doi: 10.1037/10226-016
Gilbert, P. (Ed.). (2005). Compassion: Conceptualizations, research and use in psychotherapy. Routledge
McKay, M., Wood, J. C., & Brantley, J. (2007). The dialectical behavior therapy skills ​workbook. Oakland: New Harbinger.
Metcalf, L, (2011). Marriage and family therapy: A practice oriented approach. New York: Springer Publishing Company


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Sofa-Surfing with my husband…

Monday 7/7/17

I’m so Fucking Tired!!!!

It is late Monday night and this is my first day off after a three day stretch of back-to-back 12-hour night shifts.  So I came home and then crashed on the sofa until 1:00 before rushing to my second job for a meeting with a client at 2:30.  Now its late in the evening and I’m attempting to make sense of what I’m reading.  However, my loving husband likes to watch the television.  He is a bit of a remote hog and likes to watch shows about cars.  All the shows are about guys buying old cars and making them into pretty new ones.  Mind you, I have no interest in cars, but my husband enjoys including me in on what is happening on the television.  Every fifteen minutes or so he asks me to stop a minute and look up from what I’m doing to see what’s going on.

I listen attentively, and drop my train of thought completely so I can engage in a conversation with my husband.  I don’t want to be a bad wife….

These conversations are usually brief lasting about 5-10 minutes while I watch this “Fascinating” portion of the particular episode where they reveal something.  Then, once it’s over, I’m able to get back to what I’m doing.  However, after this brief interruption, it is very difficult for me to remember where I was.  Gathering my thoughts, and trying to remember where I was at is nearly impossible.  So therefore, this attempt to study for the NCE exam is not going to go smoothly as I hoped.  I have neither the time, nor ability to devote to trying to understanding the material I’m trying to study.  So I get frustrated and try dividing my attention between my husband and the task at hand.

What I am not able to say

I just left work after a very crappy night.  At one point during the shift I became so overwhelmed by frustration and sadness that the emotions were literally unbearable.  I prayed, in that moment, that if this was supposed to be my life that God just take me home.  I don’t want to do this any more.  I literally can’t….

And what’s so sad is that things aren’t progressing quickly enough.  It will probably be some time before I’m able to quit my second job at the rate thongs are going.  I’m really looking forward to my new career, it but am aware. that it will be a while before I’m able to do so.  In the meantime I will have to accept being tired during the day to the night-shift sleep disorder problem…

Why I’m not able to say it…

I don’t share any of these thoughts about my job, how stressful it is and how I can’t take it anymore. My husband is very invested in the idea “provider role” notion in the sense that I am a barometer of self-worth for him.  Any time I express a feeling that is negative about money or his job, my husband becomes defensive and angry.  This defensive anger is, naturally, a byproduct of hurt.  The communication goes downhill and I end up consoling him and apologizing for being so mean to share my feelings.

And this is the issue.  I really can’t share any of this with my husband and am dealing with it alone.  I don’t feel its his fault and I am not blaming him for my crappy job or my the stressful career transition. Oftentimes what I seek is just for him to listen and be there.  This isn’t something to fix, it is something we just need to work through.

Tuesday 8/8/17

“Same Shit Another Day”…

I’m a mother, I’m a therapist, and a C.N.A.  All of these positions require me to care for others.  At the end of a long day, I just want to sit down and not worry about anything.  Maybe read a book, or blog a bit.  However this isn’t working.  Because my husband joins me and likes to watch t.v. again while I’m on my computer.  About ever 5-10 minutes he asks me to look up from what I’m doing so he can tell me about what’s going on.

So rather than fight it, I’m going to chronicle highlights of our idiotic channel surfing t.v. watching evenings on the sofa in this stupid post….

The Feelings Remain Forever buried….

This issue growing and perpetual frustration about not being able to share my feelings really gets to me at times.  It actually concerns me in light of a recent visit I had with my psychiatrist during a session last week.  He is good about summarizing his observations and insights into questions for me to ponder.  How is it you can be so out of touch with how you’re feeling?  I go through the motions at work.   Shove aside all thoughts and emotions in the moment.  Nobody cares anyway.  You’re there to care for them and cater to their needs, not vice versa.  If my client is impatient and rude, I can’t really honestly tell him how I feel.  If I am frustrated and angry that I have to work on a floor that is so short-staffed this doesn’t matter.  If somebody needs to take a piss, it really doesn’t matter to them that I have over 20+ patients to care for and can’t be two places at once.  So I put up and shut up.  There’s a smile on my face regardless of how tired and frustrated I am….

….When my home life isn’t the respite from this sort of thing as I hope, I can become very angry and frustrated.  It’s too much to take, living a life in which you spend the majority of it not sharing your feelings.

Watching Rattled & “Out-daughtered”.

….It’s Tuesday, at 10:40 p.m.  We just finished watching Rattled and my husband was repeatedly mentioning about how the guys on the show are either idiots or douches.  There’s the guy who is worried about having a second baby and my husband is angry that he can’t be supportive.  And then there’s the other guy who quit his job without finding a new one so he thinks this is irresponsible.  Anyway, we’ve moved on that show Out-Daughtered and we’re watching them taking care of all these kids at the same time and now he’s telling me that he’s tired just watching them.  There’s no way we could survive that without going crazy, he comments….

As I hear this, I continue to try my best and complete this blog post, but I realize it’s impossible. I get angry and frustrated.  “Doesn’t he realize I have a licensure exam to study for??” I think to myself.  However, I don’t feel its a good idea to share what I feel .  After all it will hurt my husbands feelings since it might translate to him feeling like a “bad provider”.  So therefore, I try not to stew inside yet the frustration grows despite my best efforts.  My calm demeanor and smile slowly fade to a distracted anxious that causes my husband to task, “what’s wrong?”   I tell him I’m okay and try to listen to what he’s saying, but find it impossible.  I wonder if he notices that I’m not really paying attention?

Now we’re watching Fantom Works…

It’s now later in the evening and we switch to the show Fantom works.  I’m still trying to write a blog post while watching this show.  For the idly curious here’s the link to the episode we were watching. However, I could be wrong because I’m only pretending to pay attention.  Apparently, they’re fixing up this old mail truck and make it pretty…  I really don’t give a flying fuck about cars, but however I’m trying my best to pay attention….

….As the episode nears the half-way mark, I slam my notebook shut in frustration and lie down on the sofa.  I curl up underneath my favorite fuzzy blanket and stair absent-mindedly at the television set.

 I don’t know how much longer I can take of this…

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When will this fuckin’ hell end!?

I’m at work right now and it’s about 2:30 am; the second of three back-to-back 12-hour shifts. It’s a med-surg floor with 16 patients, three nurses on the floor.

While this doesn’t sound too awful in light of the fact that I’ve had on average, about 20-30 patients by myself.   However, it’s not the staffing ratio or raw census data that make this night so special.  It’s the quality of patients they happen to have on this floor….

…On a night like this I’m always stuck with a lazy nurse who refuses to answer call lights.  Every so often catch her out the corner of my eye playing on her phone I wanna scream: “how about getting off your ass and giving me a hand!?”  However I realize that as an “overpaid” agency tech this is probably not prudent.  I’d never hear the end of it from my boss.

So as I struggle to keep up with call lights and vitals find myself constantly running between 3 rooms.  There 3 confused ladies at opposite ends of the unit with leaky bladders.  As huge fall risks, we have them both on alarms. Naturally, they forget to use the call light so about every 30 minutes that familiar siren rings.  I end up dropping what I’m doing so I can hopefully bolt down the hall quickly enough to catch them before they fall.

However, the real cherry ? on top of this fine sundae are my “special” patients.  There’s the agitated and verbally abusive old man who likes to kick and put you when you change him.  However I must say, there’s a special place in my heart for that old man with a leaky colostomy bag who requires hourly bed changes cause he won’t stop playing with it…

If I’ve offended you with my frankness I do apologize.  I hate for you to get the wrong impression.

Over the course of my 15 years in this profession, I’ve had to learn some survival skills.  FIRST, I work to find a deeper meaning & value in this line of work.  I know I’m making a positive impact on those I care for – this does provide some comfort.  THEN, there’s the advice of Brene Brown who urges us to lean into the discomfort….

As beneficial as these nuggets of advice have been.  I  occasionally find myself at the end of my rope.  Ive been doing this for 15 years & for much of that time spend the majority of my hours caring for others.  I do it at home as a wife & mother.  I do it at work as a C.N.A.  Finally, as a student therapist, I’m trying to launch a new career.

So what’s the problem you ask? (beyond the obvious fact that this job sucks donkey balls)…

  1. I spend the majority of time caring for others & have no time to care for myself.
  2. I spend the majority of my time tending to others’ need but nobody tends to mine. 
  3. Throughout my day, there’s rarely a time or place for me to just share how I feel with somebody who is willing and/or able to listen.  
  4. So I adapt in the best dissociative manner possible.  

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What is WHODAS???

How to Administer it…

What is in the WHODAS?

How To score it?

WHODAS Scoring Tutorial from Dr. Anthony J Hill on Vimeo.

Finally A Copy of The WHODAS 2 Assessment

Here is a copy of the self-administerd 36-Item WHODAS-2

Here are instructions for the self-administered 36-item WHODAS-2

Here is a copy of the self-administered 12-Item WHODAS-2

here is how u score self-administered 12-item

Here is a copy of 12-item interiewer-Administered WHODAS-2


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Nature & Limits of Confidentiality…

Confidential: Ethical & Legal Issues

“B.1.b. Respect for Privacy Counselors respect the privacy of prospective and current clients. Counselors request private information from clients only when it is beneficial to the counseling process…B.1.c. Respect for Confidentiality Counselors protect the confidential information of prospective and current clients. Counselors disclose information only with appropriate consent or with sound legal or ethical justification. B.1.d. Explanation of Limitations At initiation and throughout the counseling process, counselors inform clients of the limitations of confidentiality and seek to identify situations in which confidentiality must be breached.” (ACA, 2014 p. 6-7)

During the informed consent process, clients should be explained how privileged communication and documentation will be utilized, and what measures are taken to protect their privacy.  Corey, et al, (2011) note that confidential is both an essential right for clients and necessary for effective therapy (p. 210).  Additionally, “as a general rule, psychotherapists are prohibited from disclusing confidential communication to any third part unless mandated by law to do so” (Corey, et al, 2011, p. 211).  However, certain legal limitations exist regarding a therapist’s ability to protect a client’s information.  They must be warned of this in advance…

Defining Key Terms…

  1. Privileged Communication: “A legal concept that generally bars the disclsure of confidential communication in a legal proceeding…All states have enacted into law some form of psychtherapist-client privilege…when a client-therapist relationship is covered as privileged communication by statue, clinicians may not disclose confidential information” (Corey, et al, 2013).
    1. If the client waves this privilege, the therapist is obligted to “disclose information that is necessary and sufficient when the client requests it” (Corey, et al, 2011, p. 213).
    2. “Generally Speaking,…[this] does not apply to group counseling, couples counseling, family therapy, child and adolescent therapy.” (Corey, et al, 2011, p 214)
  2. “Privacy: as a matter of law refers to the constitutional right of individuals to be left alone and to control their personal information…Practitioners should exercise caution with regard to the privacy of their clients” (Corey, et al, 2011, p. 2015).

Steps to Protect Client Privacy…

  1. “PREPARATION: Before you explain the limits to confidentiality, it is important for you to understand these limtits yourself.  Review the relevant legal and ethical standards and contemplate/define your own moral principles.
  2. BE UP FRONT:  Tell the client the limits imposed to you  legally.  Obtain the client’s consent and have them sign relevant documentation indicating they understand these limts.
  3. OBTAIN INFORMED CONSENT BEFORE DISCLOSURE:  (should not require explanation.  However, sometimes for reasons listed below this is not always possible).
  4. RESPOND ETHICALLY TO LEGAL REQUESTS FOR DISCLOSURE:  if there is a pending legal demand for disclosure, notify the client and limit information so the extent that is legally allowed.
  5. AVOID ‘UNAVOIDABLE’ BREACHES:  monitor your recordkeeping, electronic communication, and note-taking practices to avoid unintentional breach…
  6. TALK ABOUT CONFIDENTIALITY:  Disuss with clients and fellow counselors… “(Corey, et al, 2011 p. 213)

Exceptions to Confidentiality

B.2.a. Serious and Foreseeable Harm and Legal Requirements The general requirement that counselors keep information confidential does not apply when disclosure is required to protect clients or identified others from serious and foreseeable harm or when legal requirements demand that confidential information must be revealed. Counselors consult with other professionals when in doubt as to the validity of an exception. Additional considerations apply when addressing end-of-life issues….B.2.c. Contagious, LifeThreatening Diseases When clients disclose that they have a disease commonly known to be both communicable and life threatening, counselors may be justified in disclosing information to identifiable third parties, if the parties are known to be at serious and foreseeable risk of contracting the disease. Prior to making a disclosure, counselors assess the intent of clients to inform the third parties about their disease or to engage in any behaviors that may be harmful to an identifiable third party. Counselors adhere to relevant state laws concerning disclosure about disease status. B.2.d. Court-Ordered Disclosure When ordered by a court to release confidential or privileged information without a client’s permission, counselors seek to obtain written, informed consent from the client or take steps to prohibit the disclosure or have it limited as narrowly as possible because of potential harm to the client or counseling relationship.” (ACA Code of Ethics, 2014, p. 7).

FIRSTLY: Explain to the client the Four Key Exceptions to Confidentiality….

Essentially it is the counselor’s responsibility to help the client understand that confidentiality is not absolute and there are circumsantes in which client’s must reveal confidential information.  These four key reasons are as follows:

  1. There may be occasions in which I therapist is “subpoena’ed” to testify in court.

  2. If the client expresses an intention to harm his/her self and has a plan in place, I am ethically required ot protect their well-being.

  3. If it is revealed that somebody is abusing the client, I need to inform police.

  4. If the client has a plan to harm somebody else, I must warn that person.

SECONDLY: Also explain that sharing info is essential in order to  provide “competent services” (Corey, et al, 2011, p. 221).

  1. In order to reimbursement disclosure of information may be required.
  2. Clerical assistance may occasional need to handle confidential information.
  3. Occasionally the counselor consults with her supervisor regarding this specific case.
  4. When other mental health professionals request information and client gives consent.
  5. It is also essential to communicate with other individuals involved in the treatment team.
  6. When the client requests information.
  7. Occasionally legally mandated exceptions arise: (i.e civil claim, or complaint filed.

Finally, a quick review of the “Duty to Warn/Protect”

As a result of a series of court rulings, mental health professionals have two seemingly contradictory concerns to contend with.  On the one hand, they must protect the privacy of their clients.  On the other hand, it is essential to protect the safety of the client and/or others if this information is revealed in therapy.  In other words, you have public safety on one hand, and personal privacy on the other.

DUTY TO WARN: (requires disclosure)

“Applies to those circumstances where case law or statue requires the mental health professional to make a reasonable effort to contact the identified victim of a client’s serious threats of harm, or to notify law enforcement of the threat” (Corey, et al, 2011, p. 231).

DUTY TO PROTECT: (provides ways to protect privacy)

“Applies to situations where the metnal health professional has a legal obligation to protect an identified third part who is being threatened; in these cases the professional generally has other options in addition to warning the person of harm”

Failing to warn can result in liability for civil damages

  1. Was there a failure to diagnose and predict dangerousness?
  2. Did the therapist fail to warn a victim of the client’s violent behavior?
  3. Was there a failure to commit?
  4. Was there a premature discharge?

“Client’s must do the following:  (1) identify those clients who are likely to do harm to 3rd parties, (2) protect third parties from those clients… (3) treat those clients who are dangerous.” (Corey, et al, 2011 p. 230).     

  1. Take steps to protect public and minimize liability (Corey, et al, 2011, p. 230).
  2. take careful histories and document thoroughly with those clients who are high-risk.
  3. Continually re-evaluate the potential for high risk behavior & modify TP PRN.
  4. Advise clients of their confidentiality limits.  Examine your informed consent document are terms of forfeiture of confidentiality clear as it pertains to the threat of violence to self and/or others.
  5. Regularly seek consultation (supervisor / attorney).  Know your code of ethics.
  6. Record Steps taken to protect others if necessary…
  7. In cases where client expresses desire to harm someone else, assess for suicidal ideation.
  8. Be familiar of treatment options and resources for managing high-risk clients.

Relevant Cases…

  1. Tarasoff Case – “In August 1969 PRosenjit Poddar was a voluntary outpatient at the student health service at the University of California, Berkeley and was in counseling…Poddar had confided to Moor his intention to kill an unnamed woman…Shortly after [the victim’s] return from Brazil, Poddar killed her…The California Supreme Court ruled in favor of the parents in 1976, holding that a failure to warn an intended victim was professional irresponsible….[the therapist has a} duty to exercise resonable care to protect the foreseeable victim of the serious danger of violence against him or her.” (Corey, et al, 2011, p. 232)…
  2. The Bradley Case: “A second case illustrates the duty not to negligently release a dangerous client…the patient, Wessner, had been voluntarily admitted to a facility for psychiatric care…was upset over his wife’s extramarital affair…He had repeatedly threatened to kill her…He was given an unrestricted weekend pass…met his wife and her lover in the home and shot and killed them…Georgia Supreme Court ruled that a physician had a duty to take reasonable care to prevent a potentially dangerous client from inflicting harm” (Coery, et al, 2011 p. 234).
  3. The Jablonski Case:  “The intended victim’s knowledge of a threat does not relieve therapists of the duty to protect…Melinda Jablonski filed suit for the worngful death of her mother…who was murdered by Philip Jablonski…[who] hjad agreed to a psychiatric examination at a hospital…The physicians determined that there was no emergency and thus no basis for involuntary commitment” (Corey, et al, 2011, p. 234).

HIPAA For Mental Health Professionals…

“The Health Insurance Portability and Accountability Act of 1966 (HIPAA) was passed by congress to promote standardization and efficiency in the health are industry and to give patients more rights and control over their health information…and are required to sign the appropriate forms authorizing the health care provider to provide information to other health care providers” (Corey, et al, 2011, p. 228).  The purpose of this rule is to provide a federally based uniformity to how health care facilities and workers are required to protet client’s confidentiality.  There are four main categories of requirements:

Privacy Requirements

“Practitioners take reasonable precautions in safeguarding patient information. Licensed health care providers are expected to ahve workign knowledge of and guard patients’ rights to privacy in disclosure of information, health care operation, limiting the disclosure of protected information, payment matters, protected health information, psychotherapy notes, and a patient’s medical record and treatment activities” (Corey, et al, 2011, p. 229).

Electronic Transactions

“HIPAA aims at creating one national form of communication or “language” so that health care proiders can communicate with one another electronically in this common language.” (Corey, et al, 2011, p. 229).

Security Requirements

“Minimum requirements are outlined in HIPAA that are designed to safeguard confidential information and prevent unauthorized access to health information of patients.” (Corey, et al, 2011, p. 229).

National Identifier Requirements

“It is essential that covered entities be able to communicate with one another efficiently.  Health care providers and health plans are required to have national identification numbers that identify them when they are conducting standard transactions” (Corey, et al, 2011, p. 229).

Confidentiality & Privacy in the School Setting.

Corey, et al, (2011) state that maintaining confidentiality in a school setting is especially problematic.  While “obliged to respect the privacy of minor clients and maintain confidentiality [this can] conflict with laws regarding parental rights.” (Corey, et al, 2011, p. 217)  In other words, the counselor must weight the parent’s rights to be a guiding force in their child’s lives against their client’s desire and right for privacy.  One way of handling this, is for the counselor to ask for permission of information release before and let them know about the limts to privacy.  “The basic standard of care for school counselors is clear, courts have uniformly held that school personnel have a duty to protect students from foresseable harm.” (Corey, et al, 2011, p. 236).

Considerations for Suicidal Clients

The guidelines and rules discussed here also apply to suicidal clients.  The issue here is knowing when to take the client’s serious.  “Therapists have a legal duty to make assessments from an informed position and carry out their professional obligations in a manner comparable to what other reasonable professionals would do” (Corey, et al 2011, p. 241).

Protecting Children, Elderly & Dependent Adults…

“Privileged communication doesn’t apply in case of child abuse and neglect, nor does it apply in cases of elder and dependent adult abuse…Such matters constitute a situation of reportable abuse…The professional is required to report the situation under penality of fines and imprisonment.  IF adults reveal in a therapy session that they are abusing or have abused their children, the matter must be reported….the goal of reporting is to protect a child or older person who is being abused….National Child Abuse PRevention Treatment Act (PL 93-247).  


ACA Code of Ethics as a resource for an academic work: American Counseling Association (2014). ACA Code of Ethics. Alexandria, VA: Author.
American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, Amended June 1, 2010 and January 1, 2017). Retrieved from
Corey, G, Corey M.S. & Callanan P. (2011). Issues and ethics in the helping professions. 8th Ed.  Belmont CA: Brooks/Cole.

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Informed Consent….

Defining Informed Consent

The American Counseling Association states that clients have the freedom to choose whether they will enter to and/or remain in counseling (ACA, 2014, p. 4).  Therapists are responsible for protecting this client right by providing them with the adequate information to make an informed decision.   The APA (2017) adds the following:

 “(a) When obtaining informed consent to therapy as required in Standard 3.10, Informed Consent, psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of con- dentiality and provide su cient opportunity for the client/ patient to ask questions and receive answers. (See also Stan- dards 4.02, Discussing the Limits of Con dentiality, and 6.04, Fees and Financial Arrangements.)” (Section 10.1)

Essentially, the right of informed consent allows the client to make an independent and knowledgable decision regarding the services we provide.  The first step in protecting this rights for the client includes the review of essential bits of information the client might need in order to make an informed decision (Corey, et al, 2011).  The second step is to have the client read through and sign the informed consent documentation (Corey, et al, 2011).  The important point here, is that the client gives their consent with an understanding of the facts provided.

The Informed Consent Process…

Corey, et al, (2011), state that the informed consent is an educational process which is usefl as a collaborate therpeutic relationship-buildiing process.  Examples of common questions asked include the following:

  1. “What are the goals of the therapeutic endeavor” (Corey, et al, 2011 p. 151).
  2. “What services will the counselor provide?” (Corey, et al, 2011 p. 151).
  3. How much will it cost? (Corey, et al, 2011).
  4. What are the risks? (Corey, et al, 2011).
  5. What are limitations to confidentiality? (Corey, et al, 2011).
  6. What are your qualifications? (Corey, et al, 2011).

What does the client need to know?

 According to the ACA Code ef ethics (2014) and my old course textbook, (Corey, et al, 2011). What follows is a list of information that should be included in the informed consent document.

THE THERAPEUTIC PROCESS:   It is important to help the client understand the nature of the therapy process.  There will be frank discussions and as the client’s level of awareness increases, old anxieties and traumas may resurface.  Also make a point to explain the nature of any procedures & therapy goals

BACKGROUND OF THE THERAPIST:  What kind of training, credentials, licenses does the therapist have?  What types of clients, specialized skills, and/or theoretical orientation is utilized by the therapist?

COSTS INVOLVED:  make the client aware of the costs involved, how payments are received, and methods of payment allowed

LENGTH OF THERAPY / TERMINATION:  In addition informing the clien of the length of therapy, they should be informed that htey have a right ot terminate services at any time

CONSULTATION W/ COLLEAGUES:  Make sure the client understands that it may be necessary to consult with your therapist regarding their case from time to time.

INTERRUPTIONS IN THERAPY:  Who can the client contact in case of emergency?  Who can they see in the event that you need to take time off?

BENEFITS/ RISKS – As stated above, clients shoul dunderstand what the therapy process involves.  “Clients need to know that no promices can be made about specific outcomes, which means that ethical practitioners avoid promising a cure…” (Corey, et al, 2011, p. 169)

ALTERNATIVES TO TRADITIONAL THERAPY:  What alternatives are there to therapy?  Help the client learn aobut various community resources and support systems available to the client (Corey, et al, 2011).

RIGHT TO ACCESS FILES:  “Clients records are kept for the benefit of clients…A profssional writes abot a client in descriptive and nonjudgmental ways.  A clinician who operates in a professional manner should not have to worry if his or her notes were to become public information or be read by a client” (Corey, et al, 2011, p. 170).

RIGHTS PERTAINING TO DIAGNOSTIC CLASSIFCATION:  Therapists frequently need to give clients a diagnostic classifications for insurance purposes.  “Some clients are not informed that they will be so classified…or that the classifications…will be given to insurance companies…Clients also do not have control over who can receive this information…Ethical Practice includes informing clients that a diagnosis can become a permanent part of their life” (Corey, et al, 2011 p. 171). 

LIMITS TO CONFIDENTIALITY Must also be discussed with the client.  I will go into greater detail about the limits of confidential in a later post. 


ACA Code of Ethics as a resource for an academic work: American Counseling Association (2014). ACA Code of Ethics. Alexandria, VA: Author.
American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, Amended June 1, 2010 and January 1, 2017). Retrieved from
Corey, G, Corey M.S. & Callanan P. (2011). Issues and ethics in the helping professions. 8th Ed.  Belmont CA: Brooks/Cole.

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