It is important to note that all LinkedIn profiles are public. In this way, they are similar to Facebook business pages. However, unlike a Facebook business page, engagement via LinkedIn is a two-way street. In the LinkedIn world “connection requests” can be sent. If accepted, then a “connection” is made.
Depending on the interpretation of this online relationship, this could be construed as establishing a business relationship. There are two different sorts of culture within LinkedIn. The first are called LIONs (LinkedIn Open Networkers). LIONs believe that the more connections they have, the better. Their networking philosophy is to cast a wide net and get lots of exposure. The second culture is more exclusive. These people will only connect to those they know personally, and tend to have far fewer connections than LIONs. Therefore, when using LinkedIn, be cautious about approving connection requests from current or former clients, as a dual relationship could be inferred as defined by the ACA ethics codes. Even if you are a LION, clients may not understand what this means. And, just as with the Facebook business page, it is recommended not to initiate connections with past or current clients.

Lastly, updates may be posted to LinkedIn, which will be viewed by all of your connections. As mentioned previously, take care to post only relevant, accurate and carefully worded opinion, as each time you post you are contributing to your electronic footprint. And electronic footprints are forever.

Yours in the Joy of Knowledge,

Barbara LoFrisco

Personal Profiles

On a personal profile, interested people send a “friend” request, which has to be approved by the owner of the page. If approved, a “friend” relationship is established. Even by adjusting the privacy settings, this means potential and current clients would have access to personal information, including status updates. Clearly, this is problematic. The other issue is that all “friends” of a page owner can see each other, leading to a possible confidentiality breach. For these reasons, therapists should never “friend” past or current clients on their personal profile. They should also take care to consistently distinguish between their personal and business identities. So that means don’t post business information on your personal profile. Otherwise, clients could be enticed to “friend” you, thinking this is your business page as well. Then you will be placed in the somewhat awkward position of having to explain to clients why you couldn’t “friend” them. Which, by the way, should be spelled out in your informed consent.

Business Pages

However, with a business page you do not connect with people in the same way. Business pages are public, and anyone can “like” them, unlike personal profiles, where the owner has to approve them. When a person “likes” a business page, the posts generated from that page appear in that person’s newsfeed. Depending on how the business page is set up, people might be able to post something on the wall, and comment on items posted by the owner. Those are the limits of engagement. You do not have an established “friend” relationship. You cannot tag each other in posts or pictures. Facebook does not reveal the identity of the people who have “liked” your business page to other people. Again, you must take care to consistently separate your two identities. Personal information should never be shared on your business page.

Rules of Engagement

1. Do not invite any clients to “like” your business page. This could be considered initiating a “non-professional interaction,” which is discouraged unless it benefits the client according to the ACA ethics code.
2. Never reveal any client information, even if the client volunteers it. This would violate confidentiality. This includes not responding to anything personal that clients post. Your response could be considered an affirmation of client information, which is a confidentiality breach.
3. Do not state or imply expertise you do not have, either through the “About” section or in a post. This would consist of operating outside the “boundaries of competence” as indicated by the ACA ethics codes.

When used properly, considered and ethical use of Facebook can be a wonderful way to engage the public. Insights into human behavior, suggestions for better relationships, inspirational posters, and links to relevant articles are examples of valuable content that can help educate and engage the public.

Yours in the Joy of Knowledge,

Barbara LoFrisco

Boundary Crossing and Confidentiality Issues

The main drawback of social media use, particularly for therapists, is the opportunity it creates for both boundary crossing and confidentiality issues. This is the reason most therapists refuse to use social media. Therapists get into trouble because they don’t understand how social media works, not because social media is inherently problematic. By becoming educated in social media and behaving ethically just as you would when not on a social platform, these problems can be avoided. Because these types of issues differ slightly by platform, I will cover them in more detail in the next few weeks.

Time

Another major drawback is time. Due to its addictive nature, if you aren’t disciplined and don’t have a social media plan you can easily lose hours of your day with little or no benefit. Even with specific goals, proper use of social media is time consuming. Each site must be kept current, which means adding new information regularly; a dead social media site is worse than no social media site at all. Although there are productivity tools that can be utilized to save time, be careful about duplicating messages across social media platforms. First, social platforms really encourage the use of original content. Second, there are varying etiquette considerations across the platforms that cannot be accommodated without tailoring engagement for each platform. For example, it is perfectly acceptable, even expected, to have multiple Twitter updates per day. Try that on your Facebook page and your audience will quickly become aggravated. Making matters worse, ROI (return on investment) is difficult, if not impossible, to measure. All of these elements can add up to a huge waste of your valuable time. Therefore, you need to create a plan, limit your time, and stick to your plan. You may want to focus your efforts on just a few sites instead of trying to use all of the platforms.

The Inhibition Factor

Because social media is immediate and anonymous, it may be tempting to post things without thinking them through. Bad idea. Therapists must be careful about what they post. Not only are posts public, but content will remain indefinitely. Therefore, therapists should treat every social media post as if it is the headline in tomorrow’s newspaper. Obviously, this would include any kind of personal information. In general, therapists should separate personal information from professional information whenever possible.

Profile Pictures

Lastly, please keep in mind that profile pictures are generally publically available, even when privacy options exist. For example, even if you set your Facebook personal profile to “private,” your profile picture is still visible to the public. Do you really want the world to see you in jeans drinking a beer? Therefore, a professional headshot is the best way to go, even for your Facebook personal profile page.

Yours in the Joy of Knowledge,

Barbara LoFrisco

Affordable and Accessible

As mental health counselors, one of our main tasks is to improve society by helping individuals and families to improve their lives. But not all people have access to mental health services. Although community agencies are often affordable, there is usually a cost for attendance and a long wait list. Then there’s the issue of transportation. Social media, on the other hand, is free and available anytime, anywhere to anyone with a computer or smart phone. And smart phone ownership is growing. According to one source, 49% of people currently own a smart phone with 57% projected for 2013 and 67% projected for 2017. Although social media use will never be a replacement for in-person counseling, it is a practical way to disseminate valuable information. In sum, social media use in counseling is a grass roots movement, which has positive implications for social justice.

Community Building

It also builds community. For example, by blogging to the public about general mental health topics, you have the opportunity to start a conversation. As future counselors, you will be experts in human issues and human behavior and have much relevant information and knowledge to share. There are problems that are common to all of humanity, and it can be a relief for people to see that that they are not alone. A conversation or even just a small post on social media can accomplish this. (Note, however, that it is never appropriate to counsel people or to address specific therapeutic issues through this medium, since it is public).

Networking

Lastly, by participating actively on social media you are seen as relevant, particularly by the younger generation, who were raised with cell phones in their hands. Younger clientele are going to have a difficult time relating to you if you can’t be bothered to enter their world. This means you need to go social! A wide presence on social media can also expose you to a variety of professionals, which can mean valuable connections for you. For example, if you are working in an agency that treats substance abuse, it might be really helpful to know a grief counselor or an anxiety counselor to whom you can refer clients.

Yours in the Joy of Knowledge,

Barbara LoFrisco

A good crisis counselor follows direction. Crisis counseling is non-intrusive and also practical. A crisis counselor must be able to walk into a room and determine who needs help the most. People who are very angry and may act out need to be helped first, because if they become violent they may upset the person who is crying. Another high priority would be someone who appears to be mentally ill. If someone is already being comforted, leave them alone.

In a crisis situation, people often feel that they have lost control. This terrible thing has happened to them and they could not stop it. Therefore, crisis counselors can be helpful by offering the clients choices: Would you like me to sit here or there? Would it be OK if I called you tomorrow? Another way to help someone in crisis is to prepare them as to what will happen next, ie. when you walk outside you will see a lot of police, etc.

Crisis management is about receiving information, if the client wants to tell us what they saw, etc. In fact, it is a good idea to gather some basic information, like where they live or whether they are military so that they can be connected with the appropriate services. Crisis counselors generally do not give information, unless it’s just a card or brochure to a resource. Dissemination of any information at a more detailed level will generally not be effective, since the person is usually in a state of shock. As the person recovers, they will discover the brochure or card that you gave them and at least remember it was important. At that point, they can make a call if they want to get more information on the resource.

De-escalation is very important in crisis counseling. If you are unable to de-escalate people, they may start to become violent. Some specific suggestions:

• Remain calm. Speak softly and calmly. The person’s anger is not about you, and if you become angry in return it will just make the situation worse. And never argue with someone who is intoxicated.
• Validate. You don’t have to agree with the facts as the person is stating them, but you can acknowledge their feelings and show that you are listening by paraphrasing to them what they have told you. It is especially helpful to listen for feeling, and reflect it. i.e. “Wow, you must be really angry that…..”
• Don’t defend yourself by attacking back. This is likely to just make the person more angry.
• Keep your personal space. The closer you get to someone, the more they may feel threatened.
• If the person wants to escape the situation, allow them to. Do not block them or try to get them to stay. In fact, the more you can get people away from the trigger to the trauma, the better.

Yours in the Joy of Knowledge,

Barbara LoFrisco

*Source: Presentation by Dr. Amy Menna, University of South Florida, 4/16/13

In crisis counseling the role of the counselor is not to affect change. The role is very practical, like getting them a glass of water. When people are in crisis, their needs are lower on Maslow’s hierarchy, and so you are dealing with more basic issues such as safety. If safety and food needs are met, a crisis counselor may provide information, but they would not do psychotherapy.

In regular counseling, we assume the client is deficient, but in crisis counseling we assume that the person has resources. Therefore, the role of a crisis counselor is to be the bridge between the client and resources. Most individuals do not develop psychopathology from a crisis situation, but may need some type of basic comfort in the moment.

Furthermore, you cannot talk to a person in crisis the same way as you would a person not in crisis, this is just like speaking Chinese. For example, you would not tell a person in crisis that “it is going to be OK.” Not only is it unhelpful, it is very frustrating to the person. A person in crisis is in their limbic system, their “body brain.” They do not have access to their neocortex, which means they really can’t process things on a cognitive level.

Individuals vary widely on both what constitutes a crisis and the reactions they have to the event. Anything can be a crisis; you have to look at the meaning individuals construct behind the event. Stress reactions range in all kinds of different directions. Everything from laughing and smiling to crying on the floor.

MET is both directive and client-centered, which is one of it’s great advantages. It is directive because the counselor chooses what to respond to, but it also has elements of Rogerian therapy, which also make it client-centered. According to MET, each client has within themselves the capacity for change. The counselor’s role is to help them get in touch with their motivation. MET values client autonomy in that the client is seen as expert and makes the choices, this is what makes MET client centered.

MET is good for issues that have a behavioral component such as alcoholism or uncontrollable gambling, or when a client presents with significant ambivalence (conflicting feelings and thoughts). MET is also good for court ordered clients, which are common in agencies or when working with EAPs. However, MET therapy is not effective for clients who want the therapist to be the authority.

Philosophy

MET is based upon the following research findings:

• Change occurs naturally
• Even very brief interventions can trigger change
• Interpersonal interactions can affect change
• The majority of client change happens within the first few sessions
• A good counselor/client match is essential
• An empathic counseling style facilitates change
• What people say about change is important

According to MET philosophy, humiliation, shame, and negative emotions in general are not the causes of change. Rather, these emotions can inhibit change. Instead, it is validation and understanding that help promote change. As such, the goal of MET is to get people to see the problems associated with their behavior by working with them in a non-threatening and supportive way. The more people are coerced and forced, the more they will rebel. Therefore, MET is about “rolling with resistance;” redirecting people’s natural energy instead of fighting about it.

In sum, MET values collaboration over confrontation, evocation over education, and client autonomy over counselor authority.

Four Main Principles

1. Empathy: the client must get the sense that you understand them.
2. Develop Discrepancy: highlight the conflicting thoughts, ie. “You like to smoke pot, you think it’s great; but on the other hand you are tired of looking over your shoulder so you don’t get arrested.”
3. Rolling with Resistance, ie. if a client is very defensive, don’t argue with them, just say something like “Hey, I don’t know anything about that, why don’t you tell me what is going on.” According to MET, if a client is resistant, then the problem is that there is a mismatch between the counselor’s intervention and the client. So, it is up to the counselor to change the intervention rather than to force the client to do something different.
4. Self-efficacy: counselors emphasize the ability of client so help themselves.

In order to utilize MET effectively, counselors must discipline themselves not to impose their own opinions or expert knowledge on the client.

Yours in the Joy of Knowledge,

Barbara LoFrisco

*Source: Aaron Norton, LMHC, presentation at University of South Florida on 4/16/13

A Bit of History

Back in the 1950s a mathematician by the name of Weiner got together with a therapist by the name of Bateson and came up with the concept of systems theory. That is, that families and couples can be considered as systems, with many parts that all interrelate. The major concepts behind family therapy originate from systems theory.

Around the same time a very interesting thing happened. Also in the 1950s, Bateson began to notice problematic family dynamics in the families that would come visit the people with schizophrenia in the mental hospital. What he noticed was a double bind, that the verbals and non-verbals of the family members didn’t match. For example, the mother might say she loves the patient, but when the patient goes to hug her she remains stiff. Bateson thought this might be enough to make the patients crazy. Of course, it has since been discovered that problematic family dynamics do not cause schizophrenia, but attention was drawn to family dynamics, contributing to the development of this theory.

Major Concepts

• Homeostasis. Systems have a tendency to maintain the status-quo. That is, they abhor change. Systems will do anything they can to keep things static.
• Feedback loops. In order to maintain homeostasis, systems use feedback loops. Each part of the system provides information to the other parts of the system, which then adjust themselves accordingly. How does this manifest in a couple or family? Members of the system will influence each other with their behavior. Assuming the system was healthy to begin with, it becomes dysfunctional when homeostasis cannot be maintained.
• Circular causality. In a system, it doesn’t matter where the problem started. Causality is not linear in that sense. Each part affects the other in a loop, so it doesn’t matter where you begin to examine the problem. You can start anywhere and still cover all of the bases.

Interventions

After examining the system, family therapists will know where and how to intervene. Depending on your theoretical orientation (there are several for this type of therapy), a family therapist could intervene in a number of different ways. Here are some examples:

• Once a dysfunctional feedback loop has been identified, and the family agrees with its conceptualization, the therapist will work with the members to identify a) what behaviors they would like others to change; b) what behaviors they are willing to change; and c) what other members can do to facilitate their behavior changes.
• The identified patient may not be the problem. In an attempt to maintain homeostasis, children may act out. More specifically, if Mom and Dad are always fighting, but stop when little Susie pitches a fit, guess what little Susie is going to do? Because she doesn’t like it when Mom and Dad argue, she will act out. Therefore, although the child is the “presenting problem,” often it is the parents that really need the help.

Yours in the Joy of Knowledge,

Barbara LoFrisco

Background

Reality therapy was created by William Glasser and Robert Wubbolding in the 1950s and 1960s and is based on Choice Theory. That is, that people are in control of their behavior, and their lives are a result of all of the choices that they have made. People have the capability of choosing their behavior freely. Feelings and thoughts are a result of the chosen behaviors. Therefore, clients are responsible for their lives.

How People Get into Trouble

People get into trouble when they mistakenly choose behaviors they think are going to get their needs met. Either people don’t know what they really want, they don’t understand what their options are, or they simply use bad judgement. People will use behavior as a way to manipulate and modify their perceptions of the world so that it fits what they really want. The problem is, this doesn’t really work because it doesn’t really get people what they want. Therapists can help by helping people plan for and adapt more appropriate and effective behaviors.

How a Reality Therapist Can Help

The first step in the process is to understand what the client wants. According to the tenants of Reality Therapy, we all have fundamental needs for belonging, freedom, power, fun and survival (physiological needs). What the client wants is going to be a combination of all of these. The second step is to evaluate what the client is currently doing in an attempt to meet those needs. Then, a reality therapists helps the client evaluate if what they are doing is really meeting those needs. In the words of Dr. Phil (never thought I would quote him): “How is that working for you?” Lastly, the reality therapist helps the client plan for behaviors that will better meet those needs.

Drawbacks

Although the theory sounds simple, it is not necessarily simple to implement. Reality Therapy does not provide for specific interventions, for example. In addition, it may not be sufficiently clear to some therapists where the boundaries are. Meaning, there are many opportunities for therapists to insert their own judgement where they shouldn’t. For example, a therapist may discourage a client from pursuing an open relationship due to the therapist’s own bias against such types of relationships. It doesn’t really matter what the therapist wants. All of the decisions should lie with the client- what they want and what behaviors they are comfortable doing to get what they want.

Because reality therapists think that people choose all aspects of their lives, they believe that people choose to be mentally ill. Therefore, a reality therapist will say that a depressed person is “depressing.” Meaning, they are choosing to be depressed. And, just as they are choosing to be depressed, they can chose to not be depressed.

Many therapists take issue with this position. If it is true that people are choosing depression or other mental illnesses, why does medication works? Why is it that for some mental illnesses, such as schizophrenia. medication is the primary, if not only, mode of treatment? Therefore, one major drawback to this theory is that it discounts biological processes.

Yours in the Joy of Knowledge,

Barbara LoFrisco

* source: Current Psychotherapies by Raymond J. Corsini and Danny Wedding

However, if individual sessions are to be done by the same therapist that is doing the couples therapy, special consideration must be given to confidentiality. Specifically, how should a couples therapist handle a secret? What if one partner tells the therapist something in confidence during the individual session? Does the therapist hold the secret or must it be revealed to the partner? Every couples therapist has to decide what his or her policy is and communicate it from the very beginning of therapy.

The therapist has four basic choices. They can opt for full, partial, or no confidentiality for the individual sessions, or they can opt not to do individual sessions.

1. Full confidentiality. Some couples therapists believe in full confidentiality for the individual sessions. There are both benefits and drawbacks to this position. Some therapists believe that the only way clients will be completely honest with you is if they are guaranteed full privacy. And the more useful information the client is able to provide, the easier it is to help them.

   On the other hand, if people know they aren’t going to be held accountable for what they say in their individual sessions, doesn’t that create a situation in which they would be more tempted to attempt to manipulate the therapist? On the other hand, by telling both partners up front that anything they share in an individual session that affects the relationship is fodder for future couples sessions, they know they will be held accountable. So, perhaps the benefit is not really a benefit after all.

   The drawbacks? With the assurance of complete confidentiality, a client may reveal something he or she doesn’t want is partner to know. If this occurs, then of course the therapist must keep this information secret. Which now means the therapist is keeping a secret to benefit one partner but possibly to the detriment of the other. Power is also unbalanced, because now both the therapist and one partner know this information, but the other partner does not. It is very possible that the partner left in the dark will perceive an alliance between the therapist and the other partner, which is very detrimental for couples therapy. Couples therapists have allegiance to the couple. Not any individual. It is the couple that has sought help, not the individual.

2. Partial confidentiality. The therapist may choose to keep some secrets, but reveal others. Usually, things that don’t directly affect the couples’ relationship, or that would serve no benefit to the partner, are not revealed. Things that affect he couples’ relationship, or could influence the partner on whether to stay or go, are revealed. An example of a confidential item would be details of past sexual abuse. An example of an non-confidential item would be an affair. This position allows for some of the benefits of confidentiality without most of the drawbacks.
3. No confidentiality. With this position, the therapist does individual sessions but does not guarantee any confidentiality. The risk of this position is that the partner may be unwilling to share certain details, such as an affair, so the individual session may not be as effective and informative as it should. The partner may also be unwilling to discuss a personal issue in depth if they think all of the details will be revealed to their partner. The other problem is if a partner does reveal a secret (despite you making your policy very clear up front) that they want you to keep. Your choice then is to either break confidentiality or end the couples therapy. Neither option is optimum. The benefit, however, is that the therapist does not risk alienating a partner by keeping a secret.
4. No individual sessions. Here, the therapist never has to worry about what to keep secret, since all meetings are done with the couple. However, since no space is created separate from the partner there is the risk that the therapist will not get all of the information he or she needs. A good example of this is when there is domestic violence. In the presence of the abusing partner, the abused may not feel safe telling the therapist about the abuse. Yet, this is vital information for the therapist.

Yours in the Joy of Knowledge,

Barbara LoFrisco