CW: This post discusses suicide and suicidal ideation.

I understand why the ethical codes are in place around suicide prevention. I get that counselors are at the front of the line in hearing about suicide from their clients and students. I see why laws are in place around continuing education for suicide prevention and having them as a requirement for license renewal. Also, suicide prevention, while there is ethical stuff around it, is very much not in the realm of ethics for me. While I do love me some ethics, when I have an actively suicidal client sitting in front of me, ethics are not even in the car we’re driving together. If at any point of my career I’m sitting with a client and say, “hmmm, let me consult the ethical codes about your issue,” I will personally give you, reader, $20. Or maybe I won’t because I will need it, because that will also be the day that I will quit being a therapist.

Woo, tangent! ANYWAY.

I don’t have any specific letters about this topic, so I’m just going to talk about it for a little while. It’s that time of year, especially for those of us who work with kids – the school year is settling in, and all of a sudden, people don’t necessarily struggle more, but instead they start to show it more. “But my kid was doing so well over the summer!” I hear it from SO MANY caregivers (and counselors who work with kids). Well, yeah, but they also go three months without having to “put on a face”, so of course they are. As a clinician, if there’s ever a time that I consistently lose sleep over my clients, it’s the stretch between the beginning of the school year and Thanksgiving, and I know I’m not alone in that.

Over the past week, I’ve had two clients go to the emergency room to wait for an inpatient bed. I remember when I was a new counselor, I really struggled with this (and I worked in community mental health, an inherently high-risk population, so I struggled with this a lot more than than I do now). Did I miss something? Was there some kind of something that I could have helped them with that I missed and that’s why they’re in the hospital? The impostor syndrome was strong in this way, and so in my mind, there was ample evidence that when my client was hospitalized, it was because I did something wrong or missed something. Now I think the opposite.

We can safety plan with clients all we want. We can make these neat little plans and say what a client’s triggers are, what their coping skills are, who their supports are that they can reach out to, what their crisis point looks like. We can do all of the suicide assessments we want. All of this is ethically necessary due diligence – I’m definitely not arguing that point. We can ask all of the right questions and utilize that training that we get in suicide prevention. Don’t get me wrong – our training in this area is important and necessary, and there is no more important work that I do than suicide prevention. That being said, the more I do this work, the more I am convinced that absolutely none of it matters if your client doesn’t trust you enough to tell you what’s actually happening. Do you know how easy it is to lie on those assessments? Do you know how easy it is to tell a counselor that you’ll follow a safety plan, do the work to put it together and then throw it in the garbage when you get home? These documents give clinicians such a false sense of safety and control, and the truth is that we have none when it comes to the safety of our clients.

I used to feel this sense of hopelessness about this. There have definitely been times in my career where I have thought to myself, “well then what’s even the point in having a concrete safety plan in writing?” What’s the point, indeed, reader. Safety plan documentation, I become more convinced by the day, exists to make us as clinicians feel safer and helps us build a false sense of trust that these documents will work. There are clinicians who will print out a safety plan and send it home with their clients. “Hang it on your refrigerator or put it somewhere that you can see it every day.” For sure, I used to be one of those therapists and even now, if my client wants a document, we make one. If that will bring them some measure of whatever internal resources they need to summon in order to stay safe, sure. The thing is, and I find this incredibly interesting, the second that I stopped insisting on sending a written safety plan home with my clients, the more candid they became about their safety-related issues and their ability to plan for safety and actually follow through on it. Do I document their safety plan? Of course, but that’s what their chart is for. If they don’t want a copy, that’s ok, but they’re going to talk about their safety plan out loud every time I meet with them, because what good is any kind of plan if you don’t know what that plan actually is?

Now, when I hear that a client is in the ER, you know what I do? I breathe the biggest sigh of relief that I could possibly breathe. My client is safe. My client is in an environment where they don’t have access to means to hurt themselves. Is it stressful to hear “yes” when you’re asking some pretty scary yes-or-no questions? Of course it is. But the thing that I have to remember is this: not only is this situation WAY more stressful for my client than it is for me, those conversations about their safety got through. Those conversations of how they’ll know when it’s time to go to the ER, and who they would tell, and why their life is important, something got through. Will I ever know what that is? Probably not, and I’m ok with that. It doesn’t matter to me what got through – it only matters that what my client internalized was enough to keep them safe and alive and to be able to trust themselves to work within their will to live.

Dear Ryan,

I am running into a huge issue with one of my clients. I can’t connect with them, and every session is excruciating. I dread our time together. The other day they called and cancelled their session and I instantly felt lighter and my day felt much more manageable. I’ve never run into this before, and I don’t know what to do because I just can’t even get behind the idea of liking this person in any capacity whatsoever, never mind trying to. I don’t think they’re picking up on my dislike, but that doesn’t mean that I don’t want to address it – I know that I need to, I just don’t know where to start. How can I summon any kind of positive feelings for this person?

Sincerely,

A Perfectly Normal Counselor Running into a Perfectly Normal Situation

Dear Normal,

Let’s clear something up right here and right now. Your client is picking up on your negative feelings about them, sure as I’m sitting here. You may not think that they are, but they are looking for those signs 100% of the time. Unless they have no social capacity whatsoever, they’re picking up on it, even if they can’t identify the “it”. They’re looking for whether or not you’re judging them. They’re looking for whether or not you’re connected and listening. If you’re not, they know. They are making themselves vulnerable and taking a risk by even coming into the session with you, and so they are going to try to find reasons to reduce that vulnerability (because it’s super uncomfortable) every chance they get, and if they can pick up on any of your signals that you’re not attuned, there’s their out.

That said, it’s normal to not like your clients sometimes. It’s happened to me a few times. There are times I have client leave my office and say to myself, “WOW is that person a buttface.” If I can’t get rid of that feeling or find some kind of compassion in myself or something likeable about them to hang my hat on, then I’m the one that needs to do that work, not them. Are they triggering something inside of you? Do they remind you of someone in your life with whom you have an unpleasant relationship? Do they reflect qualities of you that you don’t like about yourself? Dig. Explore that reaction. If you don’t, it’s going to come up again and again and again. Moreover, if you don’t, then your capacity to build empathy is compromised. And, if you dislike someone so much that you can’t have empathy for them, you are actively doing them harm and should transition them off of your caseload.

But, before you ever consider that, get curious with them about the relationship between the two of you. You may find yourself surprised by the answer. “How are things going between us?” “Do you feel comfortable?” “Is there anything I could be doing that I’m not?” “Is there anything that I am doing that I should not be?” When I ask these questions of my clients (and I ask all of them at various points to every client), almost without fail, I get a surprising amount of vulnerability. Plus, it gives them an opportunity to give honest feedback and if they don’t, you’ve at least communicated that you’re open to hearing it if they ever want to.

Also, let’s talk about values differences. Is there a values difference between the two of you? Is there something in your belief system that you need to bracket before you meet with them again? If there’s a values difference, then this is ethically tricky, because according to ACA ethics codes, you can’t terminate with them over it. You have to be able to manage it unless you’re actively doing harm. If it’s such a huge values difference that it’s doing you harm, I encourage you to explore that. If the values difference is one that could cause harm to others, there’s explorable territory there. What fuels their beliefs? Are they aware of the impact that it’s having on other people? Is there opportunity to make them aware of the impact that it’s having on you without you getting too defensive or putting yourself on the offensive? There’s lots of grist for the therapy mill here, as well as grist for the supervision mill. I encourage you to explore it!

Dear Ryan,

I am a new clinician working toward licensure. The other day, I went into clinical supervision and my supervisor gave me a pound of coffee and said, “I thought of you when I saw this at the grocery store the other day,” and gave it to me. Ryan, I don’t drink coffee! I don’t like it, and I don’t do caffeine. I accepted it from them to be nice, but now I feel weird about it. I asked my colleagues, and none of them received anything from this person around the same time, which makes me feel even weirder about it. I’m thinking I might want to give it back, but I don’t want to appear mean. What should I do?

Sincerely,

Confused Clinician

What a wise choice you’ve made to come to me, Confused, because my two favorite fighting words are “power differential”. Never is it more apparent in any counseling relationship than in the supervisor-supervisee relationship, particularly when you’re a new clinician working toward licensure with someone who will hold your ability to get said mental health license in their supervisory little hands. I can understand why, just based on the power differential alone, that you’d feel icky about it, but also, you don’t drink coffee, and your relationship with your supervisor is so new that they don’t know that! That just adds another layer of weird.

One of my old professors, also one of my favorite people on the whole planet, shared some wisdom with me once that sticks with me to this day – people at the top of the power differential are the least aware of its impact. What this supervisor has done is that they have abused the power differential. Does that sound a little like I’m being shrill? Maybe. But that doesn’t make it any less true. Supervisors have to be so careful about the power differential. We could make an off-hand comment that could be super offensive to someone over whom we have power and they would never tell us because of said power differential. We could also consciously and intentionally do something super egregious and the people over whom we have power would never say anything, also because of the power differential.

Still think I’m being shrill over something that seems inconsequential? Whenever I consult with other clinicians or counselors about something like this, my encouragement is consistently this: Play the tape to the end and play out worst case scenario. What if your supervisor gave you this pound of coffee that’s going to sit on your counter staring at you until you do something with it, and then later, because they didn’t know that you don’t drink coffee and you accepted it without saying anything (which they think gives them implied permission to keep abusing the power differential!), they ask you for a favor? Tell me about what’s going on with this coworker. Tell me about what you hear around the water cooler. Go to that group supervision to which clinical supervisors are not invited and tell me everything that goes on in that meeting. They washed your back by giving you a gift – now it’s your turn to wash theirs. And it all started with a pound of coffee.

What is also egregious about this is that your supervisor has tried to place some of the onus on you to state your discomfort and risk at least some kind of rupture to the relationship, and has potentially caused you to feel uncomfortable bringing it up due to this fear. This person holds your future licensure in their hands, and now you are the one responsible for fixing the problem and repairing the relationship. If you don’t say anything, it’s a slippery slope. If you do say something and give the coffee back, then you might be afraid that there’s going to be a weirdness between the two of you and you might feel like you caused it. (You didn’t. They did.) As the person at the top of the power differential, your supervisor is the one responsible for fixing the weirdness.

So, Confused, you have choices here. If it were me, I’d give the coffee back with a healthy dose of “please don’t do that again because it made me really uncomfortable” and let them repair the relationship from there. If you have a good supervisor, they’ll get it and respond accordingly. If you don’t and they don’t respond appropriately, you’ll know that too and you’ll have more choices from there.

Dear Ryan,

I have been working in the field for several years, and I am finding that I am running into an issue. If my client tells me that they can’t afford their copay that week, I simply waive it. I believe in making sure care is accessible for my clients, and if I know that someone can’t afford it, I don’t want their copay being the barrier to care. Is this problematic? Other colleagues that I have consulted with have either said no, or they have told me that it might be but haven’t really told me why.

Sincerely,

Compassionate Copay Waiver

Dear Compassionate,

Insurance copays and insurance reimbursements are such sticky areas to talk about, and they get even stickier when our clients’ finances come into play. The way I see it, you have a potential ethical issue, and a potential legal one. First, let’s talk about the legal one. If you work with a client who is using insurance in order to consume your services, you are contractually and legally obligated to collect co-insurance, whether that’s a deductible or a co-pay. Waiving copays and deductibles routinely is illegal. It’s a felony, and it violates both the Anti-Kickback Statute and the False Claims Act. The exception, it looks like, is if a client is going through a financial crisis of some kind, and then you might have precedent to waive copays until they get back on their feet. However (and this is a BIG however) – how do we determine what a financial crisis is? The law is the opposite of clear in what this determination means, and so if we can’t even get together on a definition of what a financial crisis is, how are we to determine whether or not our client is in one? And, there’s this whole concept of universality – if you would do it for this one client, are you going to use the same standard for all of your clients? If someone is going through a financial crisis and you waive copays, what if you have a client living in poverty but still owes a copay, or has a spend-down or a deductible that they have to meet? In other words, what if you have a client perpetually living in financial crisis? Legal precedent says that you can’t continually waive their copays, so what are you to do? It’s a slippery slope that, in my opinion, is best avoided.

This is a nice segue into the ethical precedent. There’s the whole universality of it all, but also, money is a part of the counseling relationship, unless you have a client who has no co-pay or deductible. Even if that was the case, if a client has a problem with their insurance, money comes into the equation REAL quick. That someone would come in and not be expected to pay a co-pay when their insurance requires one speaks to value in the context of the counseling relationship; either they are undervaluing you, or you are undervaluing yourself. Either way, you’re being devalued.

ANYWAY. The ACA Ethical Code that I’m referring to directly is A.10.c, Establishing Fees. You have to be able to legally do so if you’re going to adjust someone’s fees. If you are under an insurance contract, which is a legally binding document, you generally can’t not accept copays or deductibles.

The bigger ethical issue here, in my opinion, is the relationship. There’s a big ol’ boundary issue at play here, primarily. (“Boundary” is my third favorite fighting word.) Our clients always test how permeable our boundaries are, and it’s up to us in the power-up position (as much as I hate to admit it too, we are!) to maintain those boundaries appropriately. Moreover, you reinforce the power differential by putting yourself in the position of being the decider of whether or not a copay or deductible should be collected. (I know. You’re thinking, “What? How’d you get there?” Bear with me as I explain my point.) If you decide to waive copays, you are inadvertently saying to your client, “I am the one who determines whether or not you spend this money on this service.” In all reality, if you are getting reimbursed by insurance, the decision is actually out of your hands. (If you are a private pay clinician, that’s another determination entirely.) And! And and and! If we are private pay clinicians, we say that we want the determination of how much a client pays for services to be collaborative, but it’s not. If a client has to financially undress for you in order to get a lower rate for services, you’re not on equal footing even more than before finances overtly came into the relationship.

Surely, payment for services is a nuanced idea, whether we’re contracted with insurance companies or not. It’s a complicated issue, to be sure, and one that I’m sure will be revisited.

Thanks for making your way to my blog! I’m super excited about this endeavor, and I hope to help many with my perspective and witty writing style. (Who said writing about ethics couldn’t be fun? I shall overpower them with my nerdiness!)

Let’s go over a couple of housekeeping items before we get started, shall we?

1. If I have a question, how do I contact you? Please send your inquiry to ryan.aquilina.lcmhc@protonmail.com . All inquirers will have their names or any identifying details changed in order to protect anonymity.
2. Who the heck are you and why do you think you’re an ethical authority? I’m definitely not an ethical authority, reader! I just have lots of different experiences from my time as a counselor and supervisor that give me a unique perspective. I also feel that I am nerdy enough about ethics to be able to share them. There are many perspectives out there, all valid, and I’m just adding my voice. I consult with people all the time, and ethics in counseling is something I’m SUPER passionate about. That being said…
3. Please, please, please do not let this blog be your only ethical consultation if you find yourself in need of it. The viewpoint that I express is mine and mine alone. (I may have other people guest-post for me every once in a while, but that’s Later Ryan’s decision. Starting a private practice is HARD, y’all.) Any good consulting about ethical issues deserves WAY more than one viewpoint. There are tons of great resources, like your licensure board, colleagues, liability insurance, overall governing bodies (like the American Counseling Association or American Mental Health Counseling Association, both of which have ethics hotlines), and so many more – use them!
4. I am not responsible for any negative implications that come from decisions you make after reading this blog. In other words, please don’t sue me.
5. We are all counselors here. Please de-identify information to the best of your ability. Even if you do, I’ll still do it for you anyway, too. Please don’t use names or expressed genders whenever possible if you submit a question. I tend toward gender-neutral pronouns when I write, and I’m going to de-identify your information as well so that it can’t be traced back to you.
6. I am a mandated reporter in the states of New Hampshire, Massachusetts, New York, Pennsylvania, and Florida. Please know that if you give me information that is reportable, I will report it. I really like my freedom, I really like being a licensed clinician, I really like not paying thousands of dollars in fines, and I really, really hate subpoenas.
7. If it doesn’t become glaringly obvious to you from the get-go, I’ll just come right out and say that I’m not by any stretch of the imagination a legal expert. Will we talk about legal issues? Of course. How can we not, when ethics and laws around counseling intersect so much? I will say things, but definitely consult your liability insurance provider, too. They’ll have way more answers and authority on what to do than I ever, ever will (or should, for that matter).
8. There is no ethical territory too uncomfortable for me to address. We all get into spicy situations that we don’t know how to handle – from sexual attraction to clients or supervisees, to boundary issues that are difficult to navigate, to having to violate confidentiality for legal reasons. Bring it on! I want to hear all of it!