Above all, Do no Harm!

No one becomes a therapist, especially a couple and family therapist, to hurt their clients! Most anyone who goes through all the work and expense of becoming a therapist, and the ADDED expense and extensive time it takes in training to become a good couple and family therapist, is not out to hurt their clients!

We got into this field to do good, to help individuals, couples and families, and to make a difference in some kind of way for the betterment of the world. By and large in our field we work very hard to be the best we can be and to really help others. It's in our natures to want good things for others, it's part of who we are, and it's part of what drives us to be in the helping profession.

Yet, we all know of horror stories where sexual boundaries are crossed, inappropriate behaviors on the part of therapists happen, and reports of things that just seem so unbelievable to us that happened between a client and a therapist. How do therapists, who start out with this true desire in their hearts to help, end up hurting their clients? Can it just be that "they" (the "bad" therapists) were flawed, perhaps "predators" from the beginning and somehow and therefore are different than "us" (the "good" therapists) that would never be unethical and harm our clients?

One of the biggest mistakes clinicians can make in ethical thinking is to start the "them" and "us" game. When we don't "own our stories, our stories own us" as vulnerability and shame researcher Brene' Brown, so eloquently describes. While there may be a tiny portion of therapists with malintent, the majority of therapists who have violated this sacred law to do no harm, are just ordinary therapists like us without any evil or ill-willed intentions. Yet, our intentions are often not what is taken into consideration--we are responsible for our actions or inactions, whether we are aware and informed or not. It is our sworn duty to become informed and to make ethical decisions to protect our clients from harm.

The difficult and sad truth of this is, we can find ourselves in a situation that calls our ethical behavior into question if we reject our humanness and fail to own and honor our own stories that make us vulnerable to harming others. When we fail to see our own humanness, we are at risk to unawareness and thus not doing the things that would make a difference.

In this blog we will discuss this foundational principle and what happens when it is neglected, the slippery slope toward that place, and how to avoid going down that path to where we are creating harm.

Non-Maleficence

Unlike medical doctors, psychologists and counselors do not raise their hand to the square and take the "hippocratic oath" when they graduate from their programs and hang their
"shingle" to see clients. Nevertheless, this "do no harm" oath is a very real, core part of our ethical code and has been since the late 1800's beginning with Sigmund Freud.  It is the foundation from which all other ethical concepts emerge, and it this this very principle that gives us legitimacy as a profession, embus us with the power to make a difference in people's lives, and garner the trust from our clients that allows us to make a difference. However, when we are not aware, not attuned or honoring the sacred nature of our profession, if we get too comfortable, distracted or even indolent about our work and take for granted the trust that is put in us to uphold this oath in all aspects of our work with clients, we are primed to take the first step onto the "slippery slope" to harming others.

Whether you are new in the field of behavioral health, or are veteran to the process of therapy you may find this information to be rather redundant and boring. Maybe you've been preached at in your graduate program, maybe even had the "scared straight" discussions putting you on edge or overwhelming you. As a veteran clinician you may have been to so many ethical trainings over the years that it's boring to hear yet again this information. So why am I blogging about it?

Having had some of my own ethical challenges over the years, the reality of it all has hit hard and I realized how close to the edge of that slippery slope I could have been when a client suicided a couple of years ago. Fortunately I was not negligent, not sued, and after much soul searching realized I had truly done all I could do to help my client. 

However, that experience has done more to awaken me from my day in and day out at the office after nearly 20 years of practice than anything else. It has put me on fire to help others be more prepared and if at all possible, help my colleagues who are faced with similar situations.  We know that statistically about 25% of all clinicians will eventually have a client suicide. We want to do our best to keep our clients alive and to protect ourselves from the fall-out that inevitably comes when a client takes their own life. Let's take a very real situation and examine what happened for this clinician.

Dr. McDougall, in his early 60's, had been in practice as a clinical psychologist for 35 years. He owned his own office and continued to see patience 3 days a week as he was slowing down a little to prepare for retirement in the next few years. He often worked with older gentlemen and was well-known in the community as a geriatric specialist. When Mr. Anderson brought his elderly father in his mid 80's in for depression treatment, Dr McDougall knew the profile well. He asked his client about suicidal ideation, if there was a plan, and if there were guns in the house. This was routine and part of Dr. McDougall's standard assessment questions. Mr. Anderson Sr. denied there was any real plan or an available gun. Yet he was not willing to engage in treatment after five sessions to make any progress against his depression, and kept saying he was tired of life and just didn't want to be here any more. The day of a scheduled appointment with his elderly client, Dr. McDougall received a call from Mr. Anderson's angry son who told him that his father had hung himself with his tie in his closet the night before, and was going to sue Dr. McDougall for malpractice. 

What happened for this well-respected and known geriatric psychologist? Was Dr. McDougall negligent? Were there more appropriate measures he could have and should have taken to intervene? Did his client's son have a case for malpractice?

Let's look at the situation a little closer. Dr. McDougall was having some of his own health issues that were distracting him. He was being treated for prostate cancer, and though was cleared by his doctor to continue working, his health issues occupied much of his time in-between and after sessions. He also had a full caseload, even though he had moved to just 3 days a week, and was struggling to keep up with the paperwork. He was use to working on his own and though he had an office mate, he didn't take time to slow down and consult with him very often. He certainly didn't bother to consult regarding this rather "routine" client. We can see the "slippery slope" that he was on. He was busy, preoccupied, he saw his client without the lens of alertness, and didn't give much time or extra thought to what his client needed. He was on "automatic" and going through the motions, and had no checks or balances with colleagues or consults to call his attention to the danger of this situation.

Dr. McDougall is not too unlike many of us. He was good at his craft, well trained and knew the right things to do and say. Yet he missed something. In this case, he missed something very crucial that might have made all the difference. Calling the son, making a psychiatric referral, and/or making a referral to a hospital might have taken time out of the Dr.'s busy schedule.  He was already feeling overwhelmed with as he was managing his own life. This is where he failed in his due diligence to protect and do no harm, and where a court could potentially rule against him.

It is vital to become acutely awake and aware of our own vulnerabilities and what could potentially set us up to miss things we might ordinarily not miss. Some situations require us to be immediately mobilized and if we're struggling with something of our own in the moment we might not be at our best to deal with.

Lets face it, as therapists we are human and subject to all the things that our clients struggle with. We can have a bad night of sleep, a fight with our partner, concerns about our children, about the finances, about our physical, emotional and mental health and well-being. We're not talking about things that would be overtly obvious to keep us from working, but just those life things that do impact us and can have an effect on our work. The things of our lives that might prevent us from being fully present and on board to meet our client's needs and act appropriately. 

So what can we do to help us avoid some of the mistakes that can happen when we are having our own struggles?

Tune in, Reach out, Engage

1.  Reach out to a trusted colleague. If we have to speak up, if we have to tell a colleague about our concerns for our client, we can often hear and be heard about what we might need to do differently. Sometimes just saying it outloud can give us the wake up call, sometimes our colleague's feedback to us can help us hear and see things a little clearer. Having a regular and consistent pre-arrangement with a colleague that we can turn to for support is really vital if we are in private practice by ourselves. 

2. Create or attend a regular consult group. Hearing other colleagues battling with similar issues can help break the silence we can get caught in if we are in private practice as well. We can hear and respond differently if we have a group of like-minded colleagues working on solutions and calling us to accountability.

3. Tune into yourself and your gut senses--be Mindful. Mindfulness has become a major movement in the world of therapy today. There's a really good reason for it! Slowing down, taking time to process and become aware of our own senses, vulnerabilities, and needs is a major step toward awareness of what we might be missing with our clients. Check out Dr. Daniel Siegel's book the Mindful Therapist.

Had Dr. McDougall had a regular consult group, and/or a regular meeting time with his colleague and office mate to discuss clients, if he had a regular mindful practice, the story might have ended differently for both he and his client. We will never know. But it would be a good guess that Dr. McDougall would not be second guessing himself about what happened, and spending a lot of time worried about his license and the future of his practice, or preparing himself for a lawsuit. 

If you've found this article to be of help to you in anyway, please respond and let me know your thoughts!