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Does Professionalism Trump the Golden Rule?
By Kevin Geraghty, MSW, LCSW

I accepted the challenge of this title and asked myself what I would like to experience during a counseling session. First, I’d like to be seen as competent despite my request for help. The counselor seeing me would take time to learn a bit about my competencies.
I like to think that I have wisdom and abilities that will get me through periods of difficulty, so the professional would not presume to give me unsolicited advice.

I’d like to be able to name the problem myself, so the counselor would not translate my words into professional terms or jargon that I may not relate to.

I’d like to know what the counselor records about me so that I could disagree or add information to the file that supposedly represents me. I’d like to be viewed as an expert about myself and asked what I think about any conclusions, theories, or perspectives about me that the counselor is considering.

I’d like to talk about any choices in the context of my values so the professional would spend some time learning about how my values inform my decisions. I’d like to decide how often I come to counseling and when to stop coming. In short, I’d like to engage in a process that helps me think rather than one that tells me what to think or how. The counselor and I would collaborate.

Although I’d like to practice like the professional I’ve described above, I have faced numerous constraints in providing counseling or psychotherapy services that would be recognized as collaborative.

In private practice and agency-based work, I have asked health insurance companies to pay me for the treatment of an illness. I join with them in viewing counseling as a medical procedure with a diagnosis and a procedure code. In those cases, the insurance company seems reasonable in asking me to document the illness and to explain the treatment. Within this dynamic, any professional can easily feel compelled to identify and focus attention on problems. As professionals, we may be tempted to see problems as even more important than the person in the room with us (Zimmerman & Dickerson, 1996). After all, insurance companies are no more interested in a person’s competencies than they are in knowing about a leg that isn’t broken.

Old Habits Die Hard
After coming to work in the employee assistance program (EAP) field, I found a little less pressure to think and talk in traditional diagnostic ways (Geraghty, 2010). Since employers pay for EAP services directly, there is no billing to insurance companies. But even after knowing that an EAP offered a bit more freedom from medical ways of thinking, I remained tied to problem-focused thinking. It reminded me of stories about wild animals that become so accustomed to their cage that they do not flee it when the door is wide open.

My former ideas about professionalism held me to the same standards that an insurance company requires. That is, we should be talking about our work and documenting it in ways that support the empirical scientific views of modern medicine. Traditional ideas about professionalism promote the notion that a counselor’s job is to provide the best insight, perspective, or knowledge to help people resolve problems. This way of working tends to promote a more passive role for the person who is seeking help. Many people object to seeking help on this basis: “I don’t need anyone to tell me how to understand my life.”

I don’t want to sound like I am opposed to scientific medicine. In fact, I want that kind of help for a collapsed lung or a bone fracture. In that medical process, little is lost if the picture of my rich, complicated life is narrowed down so the focus is on a single bone. However, in a counseling setting, I would much prefer to be understood as a rich, complicated person who is more than the problems with which I am struggling (White, 2007). 

A psychiatric diagnostic label can have very different effects on the life of the labeled person compared with a diagnostic label related to a bone fracture.  Identity can even be stolen by the problems that come into a persons’ life (White & Epston, 1990): “She’s a hysteric; he’s bipolar; they’re alcoholics.” If we intend to be more collaborative and respectful of our clients’ skills and abilities, as counselors, we may have to rethink some of our notions of professionalism.

From within a collaborative model, ideas about professionalism can have some nontraditional implications. Drawing from the work of Bill Madsen (2007), we see the following options:

• It is unprofessional to inquire about difficulties without establishing a foundation of competence, connection, and hope.

• It is unprofessional to not actively elicit the wisdom that clients have about their situation.

• It is unprofessional to use objectifying language (labels) in clinical discussions without considering how clients might experience it or how it could shape our thinking about clients.

• It is unprofessional to not routinely solicit and make use of client feedback about our work with them.  

Madsen’s work indicates these are ideas that can clash with old habits of thinking and talking that are strongly supported by many professional and cultural discourses.

A New Look at Clinical Forms
While trying to think in a more collaborative way in my current EAP position, it became clear that our clinical forms were pushing in a different direction. They were an invisible barrier to providing collaborative counseling. As professionals, we were asking ourselves to describe the presenting problem (as if it were the same thing as the presenting person) and assign a problem category as the first step in helping. We continued to record a psychosocial history. We asked about current symptoms, alcohol and drug issues, previous treatment, and clinical impression.

I’ve learned to ask, “How is this intake form setting the stage for knowing this person? Am I moving toward a position of collaboration or toward medical expert/passive patient? Is there room here for knowing something about the person as a whole aside from the problems? How will using these forms shape the way I think and how the person might think about himself or herself?” Finally, I have asked myself, “If using these forms does not support my intention to know a person in a rich and respectful way, am I more accountable to this person or to the forms?”

I proposed some revisions to the forms and they were approved. The section titled “Presenting Problem” has been replaced with “Clients’ Concerns and Agenda.” This change leaves room for forward-looking goals. While we make note of problems and concerns, they are known in the broader context of a rich life. We make room for learning about the client’s aspirations.

The section titled “Psychosocial History” invites us back into the world of psychiatric thinking, where we might trace and thicken problem stories across time and family lines. Hope is rarely a by-product of a discussion that emphasizes a problem’s power and pervasiveness, with little attention paid to the history of resistance and the times of problem-free living. This section has been retitled “Context and Background Information,” which is more neutral and can include strengths, abilities, experiences, and allies that might prove helpful for the client.

We removed the word “Issues” in several places and replaced it with “Concerns.” Asking about issues allows us to unilaterally decide when someone has one, regardless of his or her own opinion. Only the client can say if something is a concern. Asking about concerns presents an opportunity for the client to voice his or her own opinion and explain it. Professionals still have the opportunity to offer their own concerns into the record.

The section called “Previous Treatment” has been replaced with “A History of Responses to the Presenting Concerns.” While treatment looks only at the help received from a professional, responding to the concerns reminds us that people have already taken action, learned important things, stood up to problems in various ways, and have experiences that can help them find a path forward. These stories of personal action are often excluded from assessments that focus only on problems and progress from the perspective of helpers.

Subcategories under “Responding to the Concerns” include “What Has Helped,” “What Didn’t Help,” and “What Made Things Worse.” Discussing these items can empower a client to make judgments about the relative usefulness of different services and strategies. It promotes the notion that professionals are more accountable to clients than to treatment models or protocols.

The section titled “Clinical Impression” is traditionally the place for diagnostic formulations. It has been replaced by “Organizing Vision and Goals.” An organizing vision is future oriented and can be supplied only by the client—for example, “Where would you like to head in this struggle with depression?” This discourages the professional from assuming a leading role in knowing “what’s best.”

This collaborative model of EAP counseling, and the clinical forms that help promote it, do not claim to offer a “better” way to help. Some professionals and clients may not find it more helpful. However, it offers a choice about how to help. At the end of an hour-long conversation, something will be better known. It can be only the problems, or it can include the client’s abilities, commitments, and dreams.

If you were in the client chair, what would you prefer? In noticing our choices as professionals for helping people, we can be more accountable for the effects that we have in others’ lives. The Golden Rule can still have a legitimate place.

— Kevin Geraghty MSW, LCSW, is a supervisor with the employee assistance program at Saint Alphonsus Health System in Boise, ID, and the former ethics chair for NASW Idaho.

References
Geraghty, K. (2010). A different kind of report—Narrative therapy comes to an employee assistance program.  Explorations: An e-journal of narrative practice, 2, 43-49.

Madsen, W. C. (2007).  Collaborative therapy with multi-stressed families: from old problems to new futures. 2nd ed. New York: Guilford Press.

White, M. (2007).  Maps of narrative practice.  New York: W. W. Norton.

White, M., & Epston, D. (1990).  Narrative means to therapeutic ends.  New York: Guilford.

Zimmerman, J. L. & Dickerson, V. C. (1996). If problems talked: Narrative therapy in action. New York: Guilford.