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| A) | the educational level of a therapist. | ||
| B) | the extent to which a therapist understands all of the cultural and social pressures in his or her clients. | ||
| C) | the extent to which a therapist has the knowledge and skill required to deliver a treatment to the standard needed for it to achieve its expected effects. | ||
| D) | None of the above |
Competency is defined as "the extent to which a therapist has the knowledge and skill required to deliver a treatment to the standard needed for it to achieve its expected effects" [8]. It is the scope of the professional's practice. According to the ethics codes of the APA, the ACA, and the NASW, members are to practice only within their boundaries of competence [3,4,5].
| A) | Every therapeutic relationship is built on a legally binding contract. | ||
| B) | Counselors teach their clients what a healthy relationship is through the compassionate care and limit setting that occurs within the therapeutic context. | ||
| C) | Counselors model acceptable behavior in the office so their clients are equipped to emulate and apply that behavior in the outside world. | ||
| D) | In many cases, counselors are teaching self-regulation to clients who are learning how to control impulses or regulate behavior in order to improve their connection to other people. |
Many situations that occur in the counseling office are not written about in textbooks or taught in a classroom setting. Counselors learn through hands-on experience, intuition, ongoing supervision, and continuing education. One constant is the therapeutic relationship. Every therapeutic relationship is built on trust and rapport. Counselors teach their clients what a healthy relationship is through the compassionate care and limit setting that occurs within the therapeutic context. Counselors model acceptable behavior in the office so their clients are equipped to emulate and apply that behavior in the outside world. In many cases, counselors are teaching self-regulation to clients who are learning how to control impulses or regulate behavior in order to improve their connection to other people.
| A) | Judgment | ||
| B) | Self-response | ||
| C) | Self-observation | ||
| D) | Cultural competence |
Bandura has described self-regulation as a self-governing system that is divided into three major subfunctions [9]:
Self-observation: We monitor our performance and observe ourselves and our behavior. This provides us with the information we need to set performance standards and evaluate our progress toward them.
Judgment: We evaluate our performance against our standards, situational circumstances, and valuation of our activities. In the therapeutic setting, the counselor sets the standard of how to interact by setting limits and upholding professional ethics. The client then compares the counselor's (i.e., "the expert's") modeled behavior with what they already have learned about relationship patterns and dynamics (i.e., referential comparisons).
Self-response: If the client perceives that he or she has done well in comparison to the counselor's standard, the client gives him- or herself a rewarding self-response. The counselor should reinforce this response by delivering positive reinforcement and affirmation for the newly learned behavior. For example, if the client arrives to therapy habitually late and then makes an effort to arrive on time, the counselor can remark, "I notice that you are working hard to arrive on time for session. That is great." The counselor's positive reinforcement and acknowledgment can have a positive impact on the client's self-satisfaction and self-esteem.
| A) | Empathy | ||
| B) | Congruence | ||
| C) | Negative reinforcement | ||
| D) | Unconditional positive regard |
According to Rogers, "individuals have within themselves vast resources for self-understanding and for altering their self-concepts, basic attitudes, and self-directed behavior" [10]. To facilitate a growth-promoting climate for the client, the counselor should accept, care for, and prize the client. This is what Rogers refers to as "unconditional positive regard," and it allows the client to experience whatever immediate feeling is going on (e.g., confusion, resentment, fear, anger, courage) knowing that the professional accepts it unconditionally [10]. In addition to unconditional positive regard, a growth-promoting therapeutic relationship also includes congruence and empathy.
| A) | Repeating back a client's words | ||
| B) | Reflecting only the content of a client's words | ||
| C) | An affinity, association, or relationship between persons wherein whatever affects one similarly affects the other | ||
| D) | Understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another |
There is great power in empathy. It breaks down resistance and allows clients to feel safe and able to explore their feelings and thoughts. It is a potent and positive force for change [10]. Empathy serves our basic desire for connection and emotional joining [12]. Empathy may be defined as the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another. It is a deeper kind of listening in which the counselor senses accurately the feelings and personal meanings that the client is experiencing and communicates this understanding to the client [10]. Empathy is not parroting back the client's words or reflecting only the content of those words. It entails capturing the nuances and implications of what the client is saying, and reflecting this back to the client for their consideration using clear, simply connotative language in as few words as possible [13]. Counselors also can show empathy in nonverbal ways to their clients by, for example, looking concerned, being attentive, leaning forward, and maintaining eye contact [13].
| A) | remain judgmental. | ||
| B) | not respond to feedback. | ||
| C) | keep a distance from the experiences being expressed by the client. | ||
| D) | alter their perspective of the client as they acquire more information. |
Empathy is a multi-level process of relating to others. It encompasses both an emotive experience and a cognitive one. It includes an intellectual component (namely, understanding the cognitive basis for the client's feelings), and it implies the ability to detach oneself from the client's feelings in order to maintain objectivity [14]. While engaged in empathic listening, mental health professionals should remain responsive to feedback and alter their perspective or understanding of the client as they acquire more information [14]. Empathy may be summarized by the ability to [15]:
See the world as others see it.
Be nonjudgmental.
Understand another person's feelings.
Communicate your understanding of that person's feelings.
| A) | Empathy | ||
| B) | Sensitivity | ||
| C) | Nonjudgment | ||
| D) | All of the above |
Compassion-focused therapy is a rapidly growing, evidence-based form of psychotherapy that pursues the alleviation of human suffering through psychological science and engaged action [17]. According to Gilbert, the following are attributes of compassion-focused therapy [18]:
Sensitivity: Responsive to distress and needs; able to recognize and distinguish the feelings and needs of the client.
Sympathy: Being emotionally moved by the feelings and distress of the client. In the therapeutic relationship, the client experiences the counselor as being emotionally engaged with their story as opposed to being emotionally passive or distant.
Distress tolerance: Able to contain, stay with, and tolerate complex and high levels of emotion, rather than avoid, fearfully divert from, close down, contradict, invalidate, or deny them. The client experiences the counselor as able to contain her/his own emotions and the client's emotions.
Empathy: Working to understand the meanings, functions, and origins of another person's inner world so that one can see it from her/his point of view. Empathy takes effort in a way that sympathy does not.
Nonjudgment: Not condemning, criticizing, shaming, or rejecting. It does not mean nonpreference. For example, nonjudgment is important in Buddhist psychology, which emphasizes experiencing the moment "as it is." This does not mean an absence of preferences.
| A) | True | ||
| B) | False |
It also is important to be reflective rather than reactive in words and actions. Use of the mindfulness technique can help counselors to become reflective rather than reactive and can help counselors unhook from any triggering material and maintain appropriate limits and boundaries. Reflection demands a reasonable level of awareness of one's thoughts and feelings and a sound grasp of whether they deviate from good professional behavior. Reflection includes [25]:
A questioning attitude towards one's own feelings and motives
The recognition that we all have blind spots
An understanding that staff are affected by clients
An understanding that clients are affected by staff behavior
A recognition that clients often have strong feelings toward staff
| A) | empathy. | ||
| B) | judgment. | ||
| C) | group therapy. | ||
| D) | vicarious trauma. |
Clients are more accepting of transference interpretations in an environment of empathy. Transference interpretation is most effective when the road has been paved with a series of empathic, validating, and supportive interventions that create a holding environment for the client [26].
| A) | helps to determine what is acceptable. | ||
| B) | delineates the "edge" of appropriate behaviors. | ||
| C) | clearly defines what is appropriate with every client at every time. | ||
| D) | Both A and B |
Generally speaking, a boundary indicates where one area ends and another begins. It indicates what is "out of bounds" and acts to constrain, constrict, and limit. In the therapeutic relationship, a boundary delineates the "edge" of appropriate behaviors and helps to rule in and out what is acceptable, although the same behaviors might be acceptable or even desirable in other relationships [35,36]. Boundaries have important functions in the therapeutic relationship, helping to build trust, empower and protect clients, and protect the professional.
| A) | Is not readily available | ||
| B) | Maintains confidentiality | ||
| C) | Relates to the client as an "expert" | ||
| D) | Reacts strongly to every issue under discussion |
The familiarity, trust, and intensity of the therapeutic relationship create a powerful potential for abuse that underscores the need for careful attention to the ethical aspects of professional care [36]. Trust is the cornerstone of the therapeutic relationship, and counselors have the responsibility to respect and safeguard the client's right to privacy and confidentiality [4]. Clients have expressed what they believe to be essential conditions for the development of trust in the therapeutic relationship. These include that the clinician [37]:
Is perceived as available and accessible
Tries to understand by listening and caring
Behaves in a professional manner (evidenced by attributes such as honesty in all interactions)
Maintains confidentiality
Relates to the client as another adult person rather than as an "expert"
Remains calm and does not over-react to the issue under discussion
| A) | Divorce | ||
| B) | Domestic violence | ||
| C) | Childhood sexual abuse | ||
| D) | Intimate relationship with a previous counselor |
Clients often enter therapy with a history of prior boundary violations (e.g., childhood sexual abuse, domestic violence, inappropriate boundary crossings with another professional) that leave them with persisting feelings and confusion regarding roles and boundaries in subsequent intimate relationships [40]. Consequently, they may test the boundaries as children do. The counselor should recognize these boundary dilemmas and manage them by reiterating the boundaries calmly and clearly [39]. The counselor must also set and maintain boundaries even if the client threatens self-harm or flight from therapy. This can be extremely challenging when faced with a client's primitively motivated, intense demands. However, counselors should recall that one description of the tasks with clients with primitive tendencies is to resist reinforcing primitive strivings and to foster and encourage adult strivings [41]. Winnicott refers to this as a "holding relationship," wherein the counselor acts as a "container" for the strong emotional storms of the client. The act of holding helps reassure the client that the clinician is there to help the client retain control and, if necessary, assume control on his or her behalf [42].
| A) | Crises in one's own life | ||
| B) | Feeling solely responsible for a client's life | ||
| C) | Feeling unable to discuss the case with anyone | ||
| D) | All of the above |
A boundary crossing is a departure from commonly accepted practices that could potentially benefit clients; a boundary violation is a serious breach that results in harm to clients and is therefore unethical [48]. Professional risk factors for boundary violations include [49]:
The professional's own life crises or illness
A tendency to idealize a "special" client, make exceptions for the client, or an inability to set limits with the client
Engaging in early boundary incursions and crossings or feeling provoked to do so
Feeling solely responsible for the client's life
Feeling unable to discuss the case with anyone due to guilt, shame, or the fear of having one's failings acknowledged
Realization that the client has assumed management of his or her own case
| A) | Referrals | ||
| B) | Bartering with clients | ||
| C) | Physical contact with clients | ||
| D) | Sexual relationship with supervisee |
Mental health professionals are forbidden to exploit any person over whom they have supervisory, evaluative, or other similar authority. This includes clients/patients, students, supervisees, research participants, and employees [3,4]. Professional ethics codes outline specific instances of behaviors and actions (some that are expressly prohibited) that have exploitative potential, including [3,4,5]:
Bartering with clients
Sexual relationships with students or supervisees
Sexual intimacies with current or former clients
Sexual intimacies with relatives/significant others of current therapy clients
Therapy with former sexual partners or partners of a romantic relationship
Romantic interactions or relationships with current clients, their romantic partners, or their family members, including electronic interactions or relationships
Physical contact with clients (e.g., cradling or caressing)
| A) | retain clients after a romantic relationship is initiated. | ||
| B) | keep meticulous notes about interactions in the client's record. | ||
| C) | maintain established boundaries and limits indefinitely after therapy ends. | ||
| D) | wait two years before initiating a personal or business relationship with a client. |
The safest course of action is to continue to maintain established boundaries and limits indefinitely after therapy ends. In addition to the noted relevant factors, counselors should keep in mind that the client may return for further treatment. If the counselor has become involved in a business or social relationship with a former client, he or she deprives the client of the opportunity to return for additional treatment. It is vital to be mindful of the potential to exploit the client's vulnerability in a post-termination relationship [54].
| A) | sentimentality. | ||
| B) | the monetary value of the gift. | ||
| C) | your personal need for the gift. | ||
| D) | the effect on the therapeutic relationship. |
As noted in these excerpts, the effect on the therapeutic relationship should be a primary consideration when considering whether to accept a gift. Gifts can mean many things and also can fulfill social functions. The counselor's task is to identify the contextual meaning of the gift and determine when the gift is not merely a gift. To do so, the counselor must draw out from the client information to discern the possibility of a metaphorical or culturally significant meaning for the gift giving [55]. Counselors should consider the client's motivation for gift-giving as well as the status of the therapeutic relationship. Gifts that may seem intended to manipulate the counselor are probably best refused, whereas rejection of a gift intended to convey a client's appreciation may harm the relationship [56].
| A) | The monetary value of the gift | ||
| B) | The client's motivation for giving the gift | ||
| C) | The counselor's motivation for wanting to accept or decline the gift | ||
| D) | All of the above |
Gifts can range from physical objects, to symbols or gestures. As stated, consider the monetary value of the gift, the client's motivation for giving the gift, and the counselor's motivation for wanting to accept or decline the gift [4,5,7]. If there are concerns about any of these factors, it may be best to explore the intent of the gift in session. If a gift is deemed inappropriate, the counselor is advised to decline to accept it. In these cases, counselors should express appreciation for the thought and gesture, explain why they are unable to accept the gift, return it with kindness, and note the encounter in the client's record.
| A) | Gift giving is outside of the usual clinical picture for such clients. | ||
| B) | Gifts from such clients are considered an extension of emotional sharing. | ||
| C) | Generally, these clients exhibit manipulation, poor boundaries, and fixed or rigid patterns of relating. | ||
| D) | Accepting a gift from such a client may contradict patterns of manipulative or self-debasing behaviors that are symptomatic of the problematic levels of functioning. |
Clients with personality disorders present unique challenges regarding the issue of gifts. Generally, these clients exhibit manipulation, poor boundaries, and fixed or rigid patterns of relating, and gift giving can be a feature of the clinical picture for such clients. Accepting a gift from such a client may reinforce patterns of manipulative or self-debasing behaviors that are symptomatic of the problematic levels of functioning. In such instances, counselors should discern which course of action is truly in the client's best interests [55].
| A) | True | ||
| B) | False |
We live in a rapidly changing world, especially where technology is concerned. In the past, therapy was offered only through in-person interaction in an office setting. Then, gradually, some professionals began to offer telephone sessions. Today, counseling is offered through video conferencing and online message boards, and paper client records are being replaced with electronic records. Competent counseling includes maintaining the knowledge and skills required to understand and properly use treatment tools, including technology, while adhering to the ethical code of one's profession.
| A) | True | ||
| B) | False |
The 2014 ACA Code of Ethics also addresses distance counseling, technology, and social media. It states [4]:
Counselors understand that the profession of counseling may no longer be limited to in-person, face-to-face interactions. Counselors actively attempt to understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how such resources may be used to better serve their clients. Counselors strive to become knowledgeable about these resources. Counselors understand the additional concerns related to the use of distance counseling, technology, and social media and make every attempt to protect confidentiality and meet any legal and ethical requirements for the use of such resources.