Tag: EthicsForReal

Introducing Diligent Page Publications

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Introducing Diligent Page Publications

So, if you’ve read the blog for awhile, you know I can get ranty about some stuff in our field. And nothing gets me on a soapbox faster than talking about how EXPENSIVE therapy is and how much that prohibits so many people from accessing good resources.  

I love therapists. I am a therapist. It’s not that I don’t want us to make a fair wage and maybe even have nice things. I do. 

(Side note: Here’s a little experiment for you to try. First, go to the bank and get $150 in one dollar bills. Then, find a therapist-colleague. Set a timer for 60 seconds. Now, every time the time goes off, give them three $1 bills. Or have them do it to you, or both. Do it for the WHOLE 50 minutes. Just notice what that’s like for you. And discuss.) 

So, I’ve been channeling that rage-energy that gets worked up in me sometimes (usually when someone at my office says something like, “But can’t they pay the full rate?” or “We’re increasing everyone’s rate by $5”) into writing. So, I started Diligent Page Publications as a place to publish low cost, super high quality, empirically-supported resources for clients. (It’s just in its baby stages; don’t get TOO excited.)

My favorite piece of this is a little ebook that teaches clients how to do therapy efficiently, saving them time and money and making more space for new clients, while not reducing therapist rates! 

And then I have a few guided journals that I made for clients and decided could be a useful resource for people who are doing life transitions (instead of therapy or as an adjunct to help therapy go faster/less expensively), because it turns out there really aren’t good, inner-world-focused books for people doing life transitions! 

I have a few other projects in the works, and of course I’ll post about them when they’re ready. But I want to share Diligent Page with you, because there’s a chance as a continued reader of this blog, you might share some of this desire with me!  

 

 

 

 

 

 

Supplements are a thing

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Supplements Are A Thing

And it’s worth knowing about, because your clients might bring it up.

ETHICS NOTE: Don’t recommend them! That’s outside our boundaries of competence!! If you want to help clients in other areas, become a teacher of how to recognize credible sources and read the scholarly literature!

Here I’ll give you some research about mental-health related supplements that have happened to come up from my clients recently (links attached, of course!!). Probably this will end up being a series, but who knows? 

 

Comment below: Any supplements your clients are talking about, that you’ve looked into? Share your info! Anything you’d like me to look into for a future post?  

 

 

 

Book Announcement

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So… I did a thing…

Here’s a book! I wrote it. 

ROUTLEDGE published it, and the level of fanciness I feel saying that is not measurable. 

It’s a lot like this blog, only you can get it in paper and you have to pay for it. Oh, and it has no pictures. 🙂

Actually, it’s much more comprehensive and better structured than the blog, though the writing style is a lot the same and the idea is the same – let’s BE BETTER THERAPISTS. Let’s use theory and research and our colleagues to help us do that. 

Therapists, in general, I think will really like it and get a lot out of it. So will advanced practicum students and interns. 

At any rate, I’m supposed to tell important people. So, there you go! 

It is available at Routledge and through Amazon! Oh, and if you go to the new Book page on the blog, there’s a coupon code! 

 

 

Best Quick Tips Ever (Vol 1)

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Best Quick Tips Ever

 

There are a bunch of super effective, super-fast, super-easy techniques for stress reduction, emotion regulation, and more that therapists just aren’t teaching clients! Why?! I think it might be because people don’t know about them? Here’s a list of a few of my favorites, each with a little video. Well, except for the really self-explanatory ones. For those, I’m attaching some research because it’s hard to imagine these commonplace little tactics are actually effective! 

(Ethics moment – definitely don’t use these if the underlying theory isn’t already part of your clinical repertoire, please!)

 

  • The Dive Reflex – If you’re a mammal (and you are), and you’re stressed, put your face into cold water for 30 seconds. Instant changes in the stress response, thus calming anxiety and other dysregulated emotions. 
  • The Physiological Sigh – You do this, unwittingly. It’s that sobbing sort of thing you sometimes do in the middle or near the end of a big cry, or you at least do it in your sleep! It’s like taking 2.5 inhales and then a long exhale, repeat 3-5x. The end. Really good for quick emotional calming. (Side note: In real life, when your body does this naturally, it’s more like 1.5 inhales, but when I’ve taught it in therapy, clients are usually breathing very shallowly, and teaching them to do this consciously, 2.5 seems to work better – the first inhale to baseline, the second to what feels like “capacity” or a “deep breath,” and then that last little bit that “overinflates.”)
  • List 3 Things You’re Grateful For – Lots of research about this, but here’s a fun study about how gratitude reduces Repetitive Negative Thinking and thus reduces depression and anxiety. Even a single, small intervention, like listing 3 things you’re grateful for in the moment can change perspective and improve mood. 
  • If you already do EMDR, consider the Flash Technique – it’s like a quickie version of reducing SUDS, without processing the actual trauma (but has some limitations, of course). Remind me one day to do a post on what actually makes EMDR work (which isn’t bilateral stimulation).
  • Call a Thought a Thought – the simplest  of cognitive defusion strategies. Notice you’re thinking thoughts. Then say it to yourself, “I’m noticing I’m thinking XYZ,” or even “That’s just a thought.” Crazy powerful, quick, and accessible anytime. 
  • Controversial but interesting…. Take a Tylenol – Acetaminophen (paracetamol) reduces the pain of social rejection and of making tough decisions. Careful, though – it may also increase risk taking, reduce empathy, and decrease the intensity of positive experiences, as well. (And, of course, mind the risk of overdose!) 

Comment below: Share your favorite, research-based “quick tips” for clients!  

 

 

 

First, do no harm.

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First, do no harm. 

Despite the DoDo bird’s insistence, not all therapies are created equal. 

This won’t be a post explaining evidence based practice, or common factors, or how diagnostics should impact our therapy plans, or how psychodynamic therapy gets an undeserved reputation just because CBT is easier to manualize. (All possibilities for another day!) For today, I think it’s worthwhile to talk about how sometimes we had really interesting ideas and they turned out to be wrong. Some therapies have evidence demonstrating not just that they don’t work as well as other therapies, but that they don’t work at all or they actively damage clients! YIKES! 

Examples that might surprise you?

  • Critical Incident Stress Debriefing for PTSD
  • Grief counseling for normal bereavement
  • Relaxation treatments for panic disorder

Check this article by Scott Lilienfeld out here. 

 

Comment below if there’s one of those other topics you’d like me to write about, or if you have ever gotten training in any of these harmful therapies, or (heaven forbid!) you know someone who uses them. 

 

 

 

Not About Pedicures

Ellis1 Comment

It’s Not About Pedicures

I’m quite alarmed by the way that we treat self care, both for ourselves as mental health professionals, but also for our clients. We think about self care the way we think about hunger or sleep – we let ourselves get way overstressed and then we thinking that dropping off the plane in a withdrawal state or going on a self-indulgent binge is the way to somehow repair this.

(Without dismissing the importance of the basic physical health aspects – hydration, good nutrition, regular exercise, adequate sleep…) I’d like to propose a way of thinking about self care that is largely grounded in Csikszentmihalyi’s concept of Flow. The short explanation of Flow, if you’re not familiar with it, is that “zone” we get into when we’re involved in an activity that is just the right balance of challenge with our skills. It’s a balance, because if we’re engaged in things that are too easy, we get bored. If we’re engaged in things that are too difficult, we get stressed/anxious. If you’ve been in that zone, you know what I mean. In that zone, you don’t really run out of energy – the energy just seems to self-replenish.

 

 

I believe in our clinical work, we often get ourselves (or find ourselves) out of balance.

 

We take on too much – too many clients, too long of days, clients who are legitimately outside our boundaries of competence but we don’t want to admit it, expecting to have the same therapy-stamina as the most productive person in the office.

 

Or we take on too little – get into a therapeutic rut and don’t challenge ourselves to build new skills, we are in an overly systematized job and function as automatons rather than clinicians.

 

Sometimes, it’s that we feel we have no control – we’ve given up our autonomy to a harsh internship director for the sake of getting hours (oh, how you’ll regret this!), we’re so burdened by rules and paperwork that our actual clinical work is only a handful of minutes per hour or day.

 
And sometimes, it’s that we know the work isn’t meaningful – we can see that clients aren’t improving, our setting won’t allow for the care clients need, etc.

 

Real talk: if you are exhausted at the end of a perfect clinical day – engaging, moderately challenging clients with a diversity of experiences and concerns who you can have some degree of independence in working with – this might not be your calling. But I’d say that’s probably not most of us. And once you become aware of the ways your clinical work is pulling you out of Flow, you can begin to correct it!

 

Comment, please: Which way do you find yourself leaning out of Flow? How can you see this also working in clients’ lives?

 

 

 

 

Rule of Three

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Rule of Three

I want to talk about the idea of false dichotomy, because they’re both so easy and so destructive.

The tendency to falsely dichotomize (AKA splitting, black-and-white thinking) has been a central issue in psychotherapy since Freud, Kernberg, and Klein. You’ve got two hands and two eyes and two brain hemispheres. There are “two sides to every story.” It so often seems like there is yes-and-no, for-or-against, right-or-wrong. Worse…. Conservative-liberal, masculine-feminine, us-them.

And that’s probably because our brains – beautiful, complex systems that they are – often use dichotomization to help us live faster in the world. (More on this in a future post.)

This happens often, and to our detriment. (Serious statisticians seem to be the only people who really know this!) Clients limit their own options, we constrain our therapeutic directions, and we stifle our diagnostics and conceptualizations.

And the trick to not falsely dichotomizing is oh-so-simple. Just make the rule of three. All questions have at least 3 answers. Don’t do an ethical decision making model without at least 3 choices of possible actions to evaluate. Put at least 3 empty bullet points on your treatment plan template. Make a deal with your consultation partner – not just playing devil’s advocate (which is a great role for them), but playing the role of horizon-broadener. When you create counterthoughts in cognitive work, make at least three. Prep all of your clinical worksheets to match. When you evaluate the “B” in the REBT method, identify at least 3 possible beliefs. When you delineate clients’ values in ACT, make 3 the minimum magic number for actions-in-pursuit-of-values. When you and a client are interpreting a dream, include at least 3 hypotheses.

Don’t worry… you won’t end up limited to just 3 and end up unwittingly stuck again. Three gets you out of falsely dichotomizing and things really open up from there.

 

Comment: When have you noticed false dichotomies in session?

 

 

 

Blank may be better…

Ellis2 Comments

Blank may be better…

I know there’s some kind of marketing value in having lots of “letters” behind your name and on your business card. 

But please, let’s stop the madness. 

Paying $59.99 to be a “Certified Life Coach” does not actually add anything to your practice. Becoming a “Certified XYZ Therapist” for a few hours of training that doesn’t help you do anger therapy any better than basic counseling training is a bit shameful. Mediation and anger and wellness, oh my! I’m sort of willing to go the distance on this and say that these kinds of credentials are actually unethical and misleading (APA Ethics Code 5.01 & ACA Ethics Code C.4)

Not convinced? Read this article about how a middle schooler can become a “Certified Clinical Trauma Professional” and then come back. Here’s the tl;dr…

Mental health professionals typically represent their competencies by earning a diploma and obtaining a state license to practice. Some practitioners choose to further represent their expertise by acquiring specialty certifications. We review the broader landscape of these certifications and provide a case study of a program that illustrates current problems with specialty certifications. Specifically, we demonstrate that an 8th grader with no prior mental health education or training can pass a test intended to assess expert levels of knowledge obtained from a workshop. Implications of these findings on the validity of specialty credentials and the public’s trust in them are considered.

Rosen, G. M., Washburn, J. J., & Lilienfeld, S. O. (2020). Specialty certifications for mental health practitioners: A cautionary case study. Professional Psychology: Research and Practice. Advance online publication. https://doi.org/10.1037/pro0000324

 

Let’s not chase the appearance of expertise. We don’t need to compete with 8th graders. Own your real credentials; clients will respond to your actual expertise. 

 

 

Before burnout begins

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Before burnout begins…

How do I know when my client load is getting too high?

 

First, let’s define “client load.” Number of clients is part of it, certainly. Number of clients divided by number of available sessions and days at work is also a part of it. (Having 16 clients in 16 session spots over two days is way different than having 16 clients in 35 session spots over 5 days!) But clients aren’t all created equal. So, a lot has to do with combinations of clients, your own feelings of effectiveness and meaningful work, diagnoses and personality types you work with best, if you’re one of those clinicians who gets energy from couples/families vs. finds them to be energy vampires. So, how many clients we have often has very little to do with if our client load is too high.

I think we’ve been trained to notice when it’s already too late. You know the signs of burnout, right? You have trouble getting out of bed for work, you’re “phoning it in” with clients, you can tell you should care but you don’t, you are isolating from colleagues, you’re catastrophically behind in your documentation and yet not making headway, you’re emotionally numb or nonreactive.

And before burnout comes overstress. That’s when you wake up anxious before work, “bring clients home” with you mentally, begin dropping behind on documentation and feel pressured to catch up, having trouble shutting your mind off, are cranky or a bit emotionally reactive even at home.

It’s also quite good to notice this before you really get all the way to overstress and/or burnout, because if it gets that far, and you need to reduce your load, that can be another additional stressor.

I’d like to share a few ways I notice when I’m reaching my effective client load limit.

  • I’m not learning something new for a client
    • There’s never a time when I have a case load that is so low or clients who I know so well or I’m so “knowledgeable and competent” that I don’t have something to be learning outside of session. Sometimes, that’s psychotherapy theory or skills related; sometimes, it’s learning about something that’s relevant in a client’s world (e.g., the path to professional soccer, the pokemon universe, and Japanese cultural mores around drug use have been things I’ve learned about recently). If I don’t have the mental space and time outside of session to be learning something for a client, it’s a sign to me that I’m needing to use all of my non-client time for family and self-care. That means the next thing that will slip will be client care!
  • I’m bored or distracted in session (with a client I’m not usually bored or distracted with)
    • Some clients are boring, and that’s good clinical information. Some clients are distractible, because it’s part of their diagnosis. And I get distracted in a way that’s normal for me, that’s session related. But when I get bored with a not-boring client, or distracted (especially by thinking about other clients during one client’s session), that struggle to “stay present” is an early sign to me that client load, in the mental capacity way, is getting too high.
  • It’s takes more than 20 minutes at the end of the day to finish notes
    • For me, I almost never take notes in session after the intake. Also, I’m quite bad at letting clients out at the :50. So, I usually end up with about 3-6 minutes to write notes, read last week’s notes on my next client, and maybe do one other thing (this is either run to the restroom, refill my coffee, or do a super quick meditation or centering exercise). My notes include two main parts – a summary of the important session material (so I can read it next time before session), and “the boring stuff” – client name, date, session #, MSE check boxes, treatment plan updates, etc. So, I write the summary in my 3 minutes along with the client’s name right after session and then I leave the “boring stuff” for the end of the day. It’s no problem to finish the final note and 6 “boring stuffs” in 20 minutes. If I’m not able to, it’s because I mismanaged myself during the day, and that’s usually because my client load is too high. I’m keeping clients extra long and then running behind, I’m not taking time for centering, or I’ve struggled to summarize.

Noticing is one thing. Committing to doing something about it is another. Ask your favorite colleague, your best non-work friend, and the person you share a budget with (if you have one) to all help you commit to delivering excellent care by acting when you’ve noticed you’re approaching your limit, not past it!

Comment below with the ways you notice you’re approaching your limit!