FLEX Psychology Presents:
Providing Ethical Telepsychology: What are the rules, and is what the news is saying really true?
The following post is the opinion of the author based on his experience in the regulatory, clinical, and telehealth sector. It is not a legal opinion, though it is based on a thorough review of relevant legislation and ethical standards. It is written to inform clinicians on how they can ethically provide care through video, but may have information regarding regulations and privacy that could set some mental health consumers of at ease.
FLEX Psychology has provided clinical services over telehealth systems for well over a decade. This has included support for remote communities and hospitals, transitional support for in-person clients, or simply the provision of accessible care where and when it is needed. I personally have had the opportunity to be an educator and trainer in this area for many years, assisting therapists and organizations to implement an ethical and efficacious telehealth solution into their clinics. Over the last decade I have had the opportunity to try out virtually every video solution available. Some are good. Some are bad. None are perfect. Fortunately, nearly every solution (including every free solution) appears to meet the legal and professional requirements of use in Ontario. In other words, you would have to put forth a concerted effort to break any rules.
Today I want to tackle some of the ethical and legal questions I have been hearing when conversing with peers and clients. For obvious reasons, we have seen a clear push towards the implementation of telehealth solutions. The need to rapidly transition to this medium has forced a lot of professionals who were dragging their feet to suddenly shift their practices online. That has brought with it a lot of anxiety, which several video solution providers have appeared to decide to capitalize on. This has further fostered a range of sensationalistic news articles that are difficult to decipher for the layman and, at their worst, are deliberately misleading.
What Laws and Standards Police Telehealth in Ontario?
There is no specific law targeting telehealth solutions in Ontario, but since these tools are used for the real time implementation of healthcare, they do fall under the purview of the Personal Health Information Protection Act (PHIPA). There are a number of similar information acts that have an application to non-health information that may apply on the periphery (e.g. FIPPA; MFIPPA; PIPEDA), but these acts are substantially similar to PHIPA, and PHIPA tends to supersede those acts given the nature of the information we manage within the profession.
So, what does PHIPA have to say about telehealth?
You are welcome to say that again along to War by The Temptations.
Canadian laws tend to be designed in a manner that is technology (and thus time) agnostic. To be more specific, PHIPA has no reference to encryption, technology, means of service, or location of service.
That leads to the question of how a piece of software can be listed as "PHIPA compliant" if there are essentially no actual prescribed routes to compliance. Realistically, it appears that "PHIPA compliant" is nothing but a nonsense marketing technique. Vendors are likely borrowing the marketing term from "HIPPA compliant", which relates only to practitioners in the United States. HIPPA compliance is an actual thing, but relates primarily to a liability agreement that is signed between a vendor and the health practitioner end user. Those agreements are required by law in the US, but are not accessible to Canadian providers. In many cases, upgrading to "compliant" software provides you no additional protections at all. Zoom Cloud Meetings, for instance, provides identical encryption techniques across both their free and professional accounts. While the pro and healthcare versions do provide some additional features (e.g. unrestricted group meetings), the level of encryption is the same across all versions of the platform.
Given the lack of any actual prescribed compliance standards, I like to remind those I speak to that my cat is PHIPA compliant.
So are there any rules in PHIPA I need to be mindful of?
PHIPA provides a framework for how health professionals are permitted to engage with the personal and confidential information of our clients. The rules that apply to a brick and mortar clinic are essentially identical to a virtual one. If you were following the rules at your normal office, you likely remain complaint with PHIPA online.
There is a key wording in PHIPA that health practitioners need to be aware of: Reasonable.
This is a term that comes up routinely throughout PHIPA and the Information and Privacy Commissioner of Ontario's (IPC) rulings, fact sheets, and advice on the application of PHIPA.
Within PHIPA itself:
“A health information custodian shall take steps that are reasonable in the circumstances to ensure that [PHI] in the custodian’s custody or control is protected against theft, loss and unauthorized use or disclosure…”
Within IPC's Fact Sheets on Protection:
A Health Information Custodian "must take steps that are reasonable in the circumstances to [protect] personal health information in their custody or control”
Within IPC's Fact Sheets on Encryption:
“‘strong encryption’ does not refer to a particular technical or design specification, or even to a specific encryption feature that could be inserted into a … specification.”
“Encryption must be commensurate with, and responsive to, known threats and risks”
The IPC goes on to note that "reasonable" is situationally dependant. A large governmental funded organization may be expected to have a highly encrypted system that is locked down through high end security software, where a small private practice is, at the very least, expected to use passwords and flip the switch for basic encryption already built into their computers. It is readily apparent that the IPC is not expecting small clinics to be security experts, but that reasonable protections should be put in place.
The reality is that every video software solution is encrypted, though the nature of that encryption may vary to some degree. No one seems to be questioning the ethical use of the telephone in care. Video software is providing only a visual addition to what can be acquired by phone. In essence, a clinician would have to seemingly put in a concerted effort to break the rules here.
What do regulatory colleges have to say?
Again not much in terms of technology use. The College of Psychologists of Ontario (CPO) introduced a variety of telehealth guidelines in 2017. These focused primarily on the requirement to maintain the same standard of care over telehealth solutions that you would in person. Otherwise, most of the focus here was insuring you are practicing within your scope, in jurisdictions that you are permitted, and in a manner that is covered by liability insurance. The College of Registered Psychotherapists of Ontario (CRPO) has a fairly similar set of rules.
The only real area of note with both colleges is the expectation that clinicians are competent in care over this medium and that back-up solutions are in place for any technology failure (e.g. switch to the phone if you cannot get your video to connect and a client is in crisis). As is typical with most of these rules, competency is not defined. If we want to keep it simple though, I would suggest that clinicians be able to recognize how technology may preclude certain types of treatment/service and that they either modify their approach to avoid any compromises or do not offer such services over that medium. That being said, during times such as these, it may be important to remember that "best practice" and "competent practice" are not always equivalent. This medium may not be one's preferred manner of providing clinical support, but that does not mean that it precludes us from providing competent and necessary care during a time of high need.
What is all this news I keep hearing about Zoom Cloud Meetings being the boogeyman?
There is a lot of sensationalistic news going around right now regarding Zoom Cloud Meetings, which happens to be my personal telehealth solution of choice. Zoom appears to be the focus of these reports due to the surge in usage it has received during the COVID pandemic, which has resulted in a lot more attention to the platform, but has also made it a juicy target for technology reporters during a particularly notable slow time for that industry.
The problem is that the majority of these reports are utter nonsense, extremely overblown, silly semantic arguments, or, at times, clearly being fostered by other video platform providers who see this as an opportunity for a financial windfall. I thought I would tackle some of the most common silly worries I have been seeing. I would also like to remind people that the Zoom platform is actually what many other platforms people have earmarked as "safe" is built upon, which means these solutions are really no different than Zoom's offerings. I would also like to note that Zoom is now the platform of choice for Ontario's criminal courts during the COVID shutdown. You can be fairly confident that this group did its due diligence.
Is Zoom is selling my information to Facebook? No. Many software companies allow you to login using your Facebook or Google credentials. In a sense, this is actually a security feature, as the confirmation of your identity is handled by this third party and you do not have to worry about having another login and password out there that could be hacked and released. In order to allow this login format, Zoom has to communicate with Facebooks servers to allow them to confirm you are who you say you are. This process does not pass on additional information and your attendees do not actually need a Zoom account in the first place (they simply click and attend as guests).
Another cause of the "Facebook" is stealing your information fear is that Zoom used a Facebook "analytics plugin". Analytic plugins are used to acquire technical information about a user (e.g. what computer platform you are using; what web browser you are using). They are needed to provide smooth and personalized services and are imbedded everywhere, including this website. Facebook and Google are amongst the biggest analytics companies in the world, so I would have been surprised if Zoom did not have this relationship with Facebook. The important detail for readers to know is that this information is not of the personal and confidential type, and certainly does not pose a health information risk.
I heard the free and pro version of Zoom is not PHIPA compliant? PHIPA compliance is not a thing. At best, it is a misunderstanding of how PHIPA works. At worst, it is a manipulative marketing technique.
I was told Zoom is not end to end encrypted. Admittedly, Zoom did use the term end to end encrypted in a non-traditional manner, though they were semantically correct. In theory, end to end encryption is generally accepted to mean that all communication goes through a secure and direct communication between two end points. Think of it as a tunnel between two places that no one can see into or get into other than the two people who initiated the travel between those two places. This sounds like a good idea, but this sort of security is unnecessary, not practical, and would actually be compromising to care and safety. A end-to-end tunnel such as this would prevent group meetings (e.g. that third person would not be able to get into the tunnel), break virus scanners (e.g. computers in the cloud would not be able scan files to see if someone is trying to send you a virus), and cause a number of logistic issues.
In essence, Zoom acts as a relay of fully encrypted sessions. The signal is encrypted by your computer, goes to the relay station, is received by the end user, and only they can decrypt it. So, in a manner, it is fair to say that this transmission is encrypted end to end. If we required end to end AND direct communication without relay, we would not be able to use the phone to talk to patients, send documents by courier, use a fax machine, implement digital outcome and progress monitoring measures, or any electronic records software. In essence, Zoom's security is the equivalent of taking information, locking it in a safe, sending that safe by armed courier to the intended recipient, and then have them lock their response in that safe and send it back through the same means. That is more secure than most ways we currently communicate.
Is Zoom spying on my clients? This was a real sensational one. Zoom used to have a software feature for large group meetings and webinars that alerted the presenter if the audience was no longer attending to the screen. They have turned this off due to privacy complaints, but this is far from "spying". In case you were wondering, I can tell when you are not paying attention to me in person as well.
But Zoom was hacked, and people can control my computer! While this may not make anyone feel better, most software platforms have been hacked in one way or another and new bugs are found every day. This is actually one of the reasons I prefer more popular platforms, because these bugs are spotted more quickly, and the company has the resources to squash those bugs. I have used smaller platforms that I have generally loved, but ultimately ended up abandoning them because it took months to fix small issues and I began to seriously worry that they would not even know if they had been hacked.
So, does Zoom have any serious bugs? Absolutely, but fortunately you probably do not have to worry about them. The current issues they have been working to resolve include the ability to obtain higher access to your computer than you would wish IF a hacker was physically sitting at your computer and you logged them in (why would you do that?) or if you are sent a malicious link by a hacker you happen to be having a meeting with. The latter is a problem nearly every chat application has dealt with, including your text message app. I would simply suggest not chatting with hackers or letting them come into your house during social isolation. Problem solved!
The reality is that all software platforms experience these types of bugs. It is good that they are highlighted, because that is how they get fixed. The key is whether one would reasonably think these bugs pose a risk to patient privacy or safety, and they clearly do not.
I heard that Zoom Trolls are attacking our sessions! I wanted to leave this one for last, as it is a perfect example of sensational news and people not actually reading the article. So Zoom allows you to host large scale group meetings. People log into these meetings by following a shared link. You can make it that each attendee needs to be approved for entry, but when your meeting is hosting a 1000 people you usually turn that off. So a couple of groups have hosted these meetings AND publicly posted their invites for the meeting. Some jerks showed up and started saying offensive things. Some of those jerks were racists and the FBI, rightfully so, is investigating those individuals for hate crimes. Somehow this turned into articles about the FBI investigating Zoom, which is untrue and just silly to believe given the scenario. This would be the equivalent of a streaker running into a public park and the police coming in and arresting the sandbox. These Zoom troll stories are so laughable that they are not worth talking about any further.
So should I just install a platform like Zoom and not worry about it? Definitely not. You need to do some due diligence, but you need to do "reasonable" due diligence. You do not need to know about the differences between AES128 and AES256 encryption, but rather need to know that your communication is encrypted. You need to trust legitimate IT professionals or informed peers who have knowledge of technology AND health regulatory law. Ask them not if a platform has "no risk", but rather if it poses a "reasonable" risk to your patients.
You also need to act in a "reasonable" manner in how you use these platforms. I particularly like the different levels of security I can put in place on Zoom that are ironically rarely available on some of the more higher end telehealth solutions. Here is a list of settings and procedures you should put on right away:
In the end, it is important for us to recognize that any concerns that have been flagged about telehealth solutions like Zoom are not unique to that platform. Just as important, we need to recognize that these problems do not appear to pose any meaningful risk to care or patient privacy. We need to stay informed about the solutions we use, but spreading unsubstantiated fears and misleading information does compromise care and THAT is the real risk here.
Readers who would like to learn more about the provision of care over telehealth are welcome to contact FLEX to join in on our telehealth webinar series. I would also encourage professionals to visit the Telebehavioral Health Institute website and sign up for their excellent newsletter. It provides free webinars periodically and offers reasonably priced intensive training on implementing ethical and efficacious telehealth solutions. I studied with this institute early in my telehealth journey and found it to be an excellent resource.
Hundreds of millions of people all around the world are currently in either legally-enforced lockdown or self-managed seclusion. For the first time ever, every neighbourhood, city, state/province, country, and continent are dealing with a common stressor. We could point to the world wars as a comparison, but, for many, that reality was only experienced through radio broadcasts and news reels. Now, a common stressor is at each of our doorsteps, and, at this moment, we are all at home to greet that visitor.
Over the next few weeks, I hope to continue to share with readers a glimpse into my home and how we are managing seclusion. It has certainly not always been rosy, but I think we are doing a pretty good job. Those who follow me on social media have seen some of our more exciting adventures. We do not tend to take photos when we get in an argument or voices are raised, but those moments certainly do exist. My goal has to been to use those moments to recognize how we got there and to be on the lookout for the next time that particular hook arises and, instead of biting it, we try a different action and see if the outcome has changed.
Bringing Adventures Home
It was only a month into winter when my 5-year old began asking when we would be able to go to the beach again. He loves water and sand, and has only slight patience for cold and snow. I was certainly feeling the same way, so we agreed that a Caribbean vacation was needed. We were supposed to go next week. It seems pretty clear that it is going to be a while before we are seaside again.
So I came up with the idea of bringing the beach home. It was a brisk day outside, so we set up our beach at the patio windows and enjoyed the sun. Our beachside picnic was complete with sunwear, beach towels, seaside tunes, and a picnic lunch. We had to leave our sand digging to a game of Minecraft later in the day, but we have plans to venture out to the sandbox as soon as we get a warmer day.
The great thing about having a five-year-old is that they can do marvelous things with their imagination. We sometimes forget that this potential for fun is still in each of us; we just need to set an intention to foster that creativity. As a self-described man-child, this was not a particularly hard leap for me, but I am confident that each of us can use our minds to foster a little fun wherever, and with whomever, you are experiencing seclusion.
Leaning Towards Seclusion
Likely because I am chronically busy (or potentially naive), I occasionally fantasize about a few months of seclusion in a space station or at an Antarctica research outpost. While seclusion may be new to many of us, there is certainly many people who experience this on a fairly regular basis and actually seek out these environments on purpose.
So, our beach adventure day was followed by a deep dive into the lives of the astronauts on the International Space Station. We began with child friendly videos on YouTube and then proceeded to depart the security of our station for rope tethered spacewalks in the back yard. While the neighbors may perceive that our home has fallen into the mouth of madness, these small adventures help normalize the seclusion experience and have also added a little joy and learning into our days. As a bonus, we returned inside for some space rations and Chris Hadfield’s Space Oddity.
Building New Routines
Inspired by this week’s Wellness Wednesday post by fellow therapist blogger Jessica Danilewitz, I decided today we would add a new routine to our seclusion days. Jessica discussed how our daily lives are generally full of predictable routines that essentially anchor each day and allow us some stability when unexpected daily stressors emerge. In seclusion, most routines are disrupted, which can make it easy for every day to turn into sloth-inspired lazy Sunday.
So keeping with my draw to educational and unusual approaches to managing stress and disrupt seclusion, I decided we would teach my son about the English tradition of High Tea. We had our first tea (chocolate milk for him) this morning, enjoyed some cookies, and talked about our day so far and what we hoped to accomplish in the hours ahead. Cucumber sandwiches are on the menu for tomorrow.
Thinking Outside the Box While Inside the Box
By introducing a combination of predictable routines and unpredictable endeavours into our day, we are creating an opportunity to grow and flourish during our time together. It requires a little creativity and ingenuity, but I have to admit that I have thoroughly enjoyed much of our time together over the last two weeks. I do not know what the weeks ahead will bring, but I do know that we will aim to be mindful of how our home needs to adapt and shift to these challenges. Join me again next week for a deeper discussion on how we have managed some of the more substantial stressors and conflicts that have arisen in the home.
Understanding that my perception can be disconnected from those around me, and that even my own perception could change from one moment to the next, was something that was engrained in me many years ago. The ability to challenge one's perceptions can be helpful in my roles as a psychotherapist or diagnostic assessor, but I really cannot point to any particular university professor or professional mentor planting this particular seed, though many of these individuals certainly did help that seed grow. Instead, we can thank Mr. W (I do remember his full name) and his student enrichment program at my former high school in Thunder Bay.
Mr. W's enrichment program was one of my most formative experiences of my adolescence, and is something I reflect on often. It was a program that I frankly requested to join because my two best friends were invited in and I no longer had anyone to hang out with at lunch. While my motivations for joining were unorthodox, I am certainly thankful that Mr. W welcomed me into the program, given that it clearly has had a profound effect on me both personally and professionally.
Mr. W challenged us with a variety of activities that forced us to think outside the box and look at problems through a new lens. He also spent a great deal of time on philosophical discussions, where concepts such as "Perception is Reality" was not an unheard of topic. He was a soft-spoken and non-reactive man who challenged us in ways that I had never experienced before. I also recall that he did all this without much emotion, beyond a small smile and a nod of the head.
Decades later, I was fortunate to have an opportunity to expand my secular mindfulness training with a variety of local and international Buddhist teachers of note. I felt immediately comfortable in this setting and the sense of familiarity with both the teachers and their teachings was obvious. I still remember the moment when my brain spit out a thought that still makes me laugh to this day: "Holy crap, I was in a secret Buddhist high school program!"
I have read much about how mindfulness got introduced to the west back in the 70's and 80's. Many of these reflections focused on attempts to transparently bring mindfulness into health care and education that were met with a resounding thud. As a result, many of these teachings were secularized and introduced in a more covert fashion. Nearly a half century later, this continues to be a necessary approach in many sectors. To be honest, a lot of our secular understanding (and acceptance) of mindfulness and meditation practices probably is owed to the challenges these early practitioners faced.
Now, let me be clear, I'm not saying that Mr. W was certainly a Buddhist, or that he was deliberately sneaking Buddhist principals into our classroom. Still, it has been hard to ignore the realization that so many of the lessons we had there are core Buddhist or Hindu teachings. Similarly, Mr. W, himself, was a good head shaving and a brown robe away from being a white clone of Thich Nhat Hanh.
Where Mr. W engrained the idea that perception, which is mailable, is the primary determinant of our reality, my Buddhist, and secular mindfulness teachers, brought to me the complementary concept of "Beginners Mind". Instead of challenging your perceptions and seeking alternative interpretations of one's reality, Beginners Mind is anchored in taking the opportunity to look at something as if you have truly never seen it before.
In my trainings, we explored Beginners Mind by quite literally looking at things through an alternative viewpoint. Ever wonder why some people take better photographs than you? It is not necessarily because they have been professionally trained. Instead, they may be simply seeing things in a way you are not. The trick here is to not try to see it through their eyes (which would be "Perception is Reality"), but instead to let go of how you normally line up the photo and instead just explore the subject. A Beginners Mind looks at things from different angles and distances. It studies the subject as parts and as a whole. Because the thing being studied is new to the Beginners Mind, preconceived notions of what something is or how it should be seen are thrown out the window.
While my mindfulness teachers planted the seed of Beginners Mind, it was certainly the birth of my son, Master X (I also remember his full name), that allowed that seed to grow and flourish. Every day over the last five years has been an opportunity to see the world through a different and naive perspective. Even when my son has formed a good understanding of a portion of his reality, we are only a few moments away from an observation or question that shows that there is still much to learn and explore in this world. Watching my son, I can see the wonder of exploration in his eyes and he has taught me lessons about our world that either I have long forgotten or never learned in the first place. Occasionally, I will even try to share a moment of his perspective, which can simply be facilitated by just getting down to his level and seeing how it looks from that angle (as a tall person I can sometimes even get this by seeing things at my colleagues level).
Personally, these teachings, I fear, can sometimes make me seem a bit flighty. For instance, it would not be unusual for me to get in a disagreement with my wife and seem quite rigid in my belief on the matter and completely shift to her side the next day. This is rarely me capitulating, but rather me taking the time to consider the situation from viewpoints other than my own. Unsurprisingly, my initial perceptions are not always entirely accurate, and the thoughts and behaviours those perceptions drove not always helpful.
Professionally, it can seem more like a gift. It allows me to highlight alternative interpretations for situations my clients are in (perception) or to simply ask questions, many of which may seem a bit odd on the surface, that may promote a fuller understanding of the situation they find themselves in (beginners mind).
Facilitating this on your own is not hard. All you really need to do is accept the possibility that your perception of your reality is either incorrect or, at the very least, not identical to the perception of others. Once you can accept that, seeing things in different ways is really not that hard. This may be a mental exercise, where you try to consider how others may be feeling, or a physical one that has you simply getting down lower to the ground and seeing how someone else sees the situation.
Photo used under Creative Commons license. Source here.
Photo: Perception Author: Quinn Dombrowski. See the side panel for additional copyright information.
Exploring one's family is not an unfamiliar tool used in therapy. Many family systems and interpersonal approaches use a mapping of familial relations as a better way to understand the dynamic within a family system or to understand how those close to you impact you in a positive or negative manner. A common tool used within these approaches is a genogram, which looks like a family tree, but focuses beyond genetics and explores the interpersonal nature of the relationships within our immediate and extended family.
This does not mean that a more traditional exploration of one's family tree cannot be a meaningful tool in treatment. Tom Rue (1998) shared some insights on how a variety of individual and family therapists have used genealogical exercises to understand repeated family histories, to solidify one's self identity, or as an exercise in self-authoring.
Since Rue's 1998 piece, we have only seen the interest in genealogy and family histories explode: Premium web databases are now available from Ancestry and MyHeritage as not only web services, but apps you can navigate on your phone; A half dozen DNA services are available that provide insights into your family connections and even how much Neanderthal DNA you still have; and we have several reality tv shows that can help you figure out how closely related you are to Beyoncé.
In keeping with the therapeutic approaches shared by Rue, these services appear to be promising happiness through an increased understanding and connection to one's past.
Professor of Molecular Biology, Nathan Lents, rebuts the recent genealogy trend, focusing heavily on the flaws and accuracy gaps in genealogical research. Indeed, sloppy research makes these types of errors easy, and providing a more accurate narrative is certainly time intensive and requires notable attention and due diligence (Note: This in itself can actually be a fairly effective mindfulness exercise).
Lents also postulates that focusing on your connectivity with distant relatives of more than a few generations ago is essentially meaningless. He goes on to highlight the arguing that we are all connected and should thus get along by pointing to the shared heritage of individual's like Barack Obama and Dick Cheney is a fallacy and will lead to no meaningful change in the world.
While none of Lents arguments here are inherently incorrect, I believe he is missing the point. Ironically, he actually conveyed the exact point he appeared to miss:
"Now is when I have to come clean and admit that I have enjoyed keeping up with the efforts of my relatives to trace our family tree. I have pictures on my bedroom wall of ancestors that I’ve never met, but whose story I tell."
Perhaps Lents microbiological roots cause him to focus too much on genetic connection in genealogy to the detriment of the far more important narratives that can come along with genealogical research. Historians within many of the worlds indigenous populations recognize how oral story telling traditions were the anchor of a connected society. Within these societies, narratives communicate cultural beliefs, values, practices, and shared history. Many will also point to the increasing loss of these traditional practices as a significant contributor to the challenges many indigenous cultures experience today.
While familial narratives may not be observed as an anchor of many traditional Caucasian societies, I would argue that this was still a clear practice across in a diverse range of cultures only a generation or two ago. For instance, it is fair to say that the majority our parents and grandparents have a deeper understanding and connection to their immediate and more distant ancestors. A generation ago, this information was maintained by the family, as opposed to algorithms and network connections on Facebook that we seem to rely on these days.
I would also argue that the what we have lost by moving away from storytelling is not the lessons of our past and a deeper understanding of our historical roots, but rather a loss of connection with our immediate family. Being in my 40's, there is not a whole lot in my day-to-day life that brings forth a deep connection with my mother, my aunts and uncles, or cousins. There are of course a few overlaps. My mother certainly wants to hear what my son is up to at school and we shared a common profession that sometimes contributes to meaningful conversation, but do chats about work, recent my car troubles, or raising hydro bills really result in meaningful conversation and connection between myself and my mother?
One way we can connect is through our history. I began a deep dive into my families genealogical origins a few years ago. My father was in a fight with cancer that he would ultimately lose, and I felt inspired to take the time we had left to learn a little bit more about our shared history. Of particular interest to the two of us was a mystery regarding the origins of the family name and its seeming absence from our country of origin. Exploring that history allowed for many engaging and meaningful conversations, but also spawned a new way for me to feel connected with other family members in a similar manner.
I had a bit of insomnia this morning and decided to explore an ancestry line of my mother's that I had previously dug too deeply into. After only a few minutes of work, I came across Major General Brown of Fordell who was a significant player in the battle of Inverkeithing (Scotland 1651). It did not end well for Brown of Fordell, but the story of the battle was something I shared over breakfast with my mother only a few hours later. In the absence of this research, we would have undoubtedly discussed the weather, our plans for the week, or meaningless politics. Instead, we had a lively and engaging conversation about our shared history and, through that, built further connection with each other in the here and now.
It is that live and active connection that is meaningful. Our connections to the past are certainly interesting, but these have no real meaning to our current identities and certainly will not change how we act in our day-to-day lives. The increased connection we fostered this morning, however, will foster growth.
When we are children, the connection between ourselves and our parents, good or bad, are everything. As we age, we become increasingly disengaged and disconnected. Our busy lives and the many distractions we face foster movement apart and require legitimate effort to stay connected. We generally put in the time to connect by checking in, sending a Facebook update or text, but we do not really have a meaningful connection the way we have in the past. Exploring shared history, whether it is something we experienced together or only through genetic connection allows us an opportunity to foster those more meaningful connections we had earlier in our lives. It is these connections that are important, not the fact that we are related to Brown of Fordell. Our historical connections are simply an opportunity to connect in the here in now through shared storytelling and meaningful in the moment engagement. In the end, those were the connections we were really seeking all along.
Want to explore your own genealogical history?
Getting started in genealogical research can be challenging and overwhelming. Instead of signing up for expensive ancestry archive services or DNA testing, why not begin by just speaking to your family about their relatives. Use free accounts on Ancestry or Geni to begin a simple family tree based on those you already know. Use this as an opportunity to start conversations about the shared history and memories you already have within your immediate family. After that, take a look at your public library, which likely has a free national database from Ancestry available to you. From that point forward there are many great online and local communities to expand your search and understand what resources are available to you.
Photo used under Creative Commons license. Source here.
Photo: Family day out Author: judy dean . See the side panel for additional copyright information.
Mindfulness: Attention and Intention
Clients have increasingly found me through mindfulness circles over the last few years. I first began engaging with a combined secular and non-secular mindfulness community in 2012. Prior to this, I had some exposure to mindfulness through conferences and readings, but the first time I attempted any formal meditation practice was a year earlier in a Tai Chi class that I had impulsively signed my wife and I up for through a Groupon-like coupon site.
Prior to this, I had enjoyed watching a local group of retirees practice Tai Chi each morning on the way to work. I am not sure what exactly drew me to Tai Chi. Undoubtedly, how focused and at peace these practitioners appeared was part of the allure. This was certainly not something I generally experienced in my go-go-go lifestyle. Admittedly, my thoughts were not entirely about peace and serenity. I also got a kick out of the idea of looking like a slow-motion ninja.
Prior to Tai Chi, my exposure to mindfulness meditation was restricted to what I had been exposed to in the media. For years, the media had been highlighting a mindfulness wave that was framed as the solution to improved health and wellness, productivity, and learning. Based on my admittedly superficial review of the material, the media appeared to be claiming that a focused preiod of daily breathing was the answer to most of life's problems. I was fairly certain that I had been breathing for quite a few years by this point in my life, and I certainly did not have the perfectly balanced life they were promoting. So, to be frank, I was skeptical.
At that point in my career, I had seen many therapy "waves" come and go. These approaches often began as a narrow, but fruitful opportunity for growth or recovery. Over time, however, it was not unusual for these approaches to be framed as an avenue of improving all aspects of one's life. This is generally when these approaches fumble and become a therapy fad, often losing the benefits that their narrower application had initially provided. The last five minutes of my first Tai Chi class, however, would change my mind about one's potential for expansive and holistic change.
While it was only five minutes of focused breathing, I noticed something right away: My mind was BUSY. I mean really really really busy. Initially it would only take a breath or two before I disengaged from focusing on my breathing and my mind wandered to something that was not important and certainly in no relevant to the moment that I was currently in. At the minutes passed, I began to notice this loss of focus more quickly and was provided the opportunity to again focus on my breathing. Undoubtedly, this cycle happened again and again.
I was a bit embarrassed at first by how challenging it was to stay focused for only five minutes. The important part, I would come to learn, was that I was "noticing" it. Where, in the past, my mind could have taken me on a journey that took some time to come back from.
As the weeks progressed, my ability to notice when I was distracted began to extend outside of that Tai Chi class or my weekly meditation homework. I started to notice when I was being drawn away from my intended points of focus while driving, while conversing with my wife, while at work, while eating, while in the shower, and, during basically every single activity I was attempting to do.
It was quite apparent that mindfulness was not improving my ability to sustain my focus. What it was doing, however, was increasing my awareness of the present moment. That awareness was quite powerful, in that it provided me the opportunity to recognize when I was no longer focused on my intended activity.
With my clients I refer to these concepts as "attention" and "intention".
It is a common misconception that attention is reflective of one's ability to sustain their focus over an extended period of time. You can ponder the future (or the past), but you cannot be attentive to the future (or the past) because you are not there right now. Right now, try to pay attention to exactly what is going to happen five minutes from now outside of the Novo Medical Centre in Port Vila, Vanuantu. Remember, not what you imagine is happening, but what is actually happening exactly five minutes from now. Struggling? Of course, because even if you were standing there, you do not know what is going to happen in five minutes. So, let us try to stop mastering the manipulation of time and space and pay attention to the here and now in this present moment.
Attention reflects one's ability to be aware of what is happening to them in the here in now. It is that attention, that allows one to foster intention.
Intention refers to what one is attempting to engage in right now. At this very moment, for instance, I am intending to write an article. Over the last two paragraphs, I have noticed (attention!) my mind pulling towards the fact that the music I was listening to has stopped, that I have to get ready to leave for a meeting in 19 minutes, and that I am feeling quite exhausted by a lingering chest cold that I have been dealing with for a few days. That is a lot of distraction over what, without typing out these distractions themselves, would have been only 4 sentences of text.
While these are legitimate distractions that I was unable to avoid, my "attention" to them allowed med to disengage from these transient mental experiences. In other words, I did not need to act on them. Instead, I have simply let go of each of these thoughts and returned to my intended action, writing this article.
In the absence of being attuned to my moment to moment experience, I may have found myself hooked to these thoughts and spent some time adjusting the playlist on my phone, getting ready earlier than I need to, or ruminating in the suffering of my cold. Instead, I noticed these fleeting thoughts, let them pass, and continued on with my intended action.
As a result, I am now mere sentences away from completing this entry. Simply typing that has caused a fleeting thought: "Now you can get to those other things!". My intention, however, was to write and publish this post, not just write it, leave it, and forget about it until later. So, I let that thought pass and continue to write.
Bringing this back to my mindful breathing practice:
When meditating, my intention is to focus on my breathing. A mental distraction emerges, my attention notices that distraction and that I have been pulled away from my intention. I, then, have an opportunity to intentionally return to that point of focus.
This practice mirrors what I have experienced here:
I sat at my computer with the intention of writing this article. My attention noticed dozens of fleeting distractions that risked pulling me away from my intended action. That awareness, then, provided me the opportunity to disengage from these distractions and continue with my intended action.
Prior to introducing a mindfulness practice, I have no doubt that this scenario would have played out quite differently:
I sat at my computer with the intention of writing an article. My music stopped playing and I picked up my phone to build a new playlist. While there, a friend texted me a hilarious video of cats being scared of cucumbers (this is a thing, but take this opportunity to make an intention to look this up at another time) and I began a deep dive into the irrational fears of cats. I briefly think about writing an article about fear, but instead head to bed to lie down for a bit because I have a cold and am feeling a bit tired. Besides, lying in bed is a far more comfortable way to watch cat videos. My eyes briefly notice the time and I freak out, realizing I am going to be late for an appointment downtown. I run around and get ready in a sense of rushed panic. I then drive more quickly than I had intended to the city and am probably not as focused on driving as I need to be. We will leave the alternative history there, as I would rather not consider the potential consequences of that last one.
Now, though, I do notice the time again and realize I am cutting it close for being able to comfortably make it to my meeting. While the article is done and edited, I intended to finish and publish the article this morning. That intention, however, now conflicts with another intention, so I now choose to adjust my intention and return to this final step later. Due to my increased self-awareness, I am aware of the risk of forgetting that intended action, so I set a reminder to pop up on my return home. For now, it's time to move on to my next intention and to bring that same attention to the next moment in my day.
Photo used under Creative Commons license. Source here.
Photo: time to meditate Author: Betty Nudler. See the side panel for additional copyright information.
Welcome to Self-Disclosure
Depending on who you talk to, self-disclosure by a therapist is either a giant misstep that risks destroying the therapeutic relationship or a tremendously helpful tool in building trust and demonstrating how the lessons that emerge in treatment can lead to personal growth in success.
Given the strong opinions my peers hold on this matter, it certainly does not seem like creating a blog called Self-Disclosure is one of my brightest idea. I do, however, enjoy being a contrarian once in a while. Which, I suppose, is my first self-disclosure?
Back to the debate. I would challenge both sides to consider that both of these opinions are correct. Like most things, it is all about context.
Personally, I have always found self-disclosure to be helpful to my clients. I am certainly willing to admit that I am a flawed person and I make mistakes. While I also can be blind to the complexities of my own experiences, I like to think that I have a bit of additional insight into what I do, why I do it, and how it impacts myself and others as a result of my career choice and my own journey towards self-awareness and increasingly intentional action. I am also more than willing to challenge my blind spots by seeking the thoughts of others when I feel stuck along the way.
So how does self-disclosure help my clients? Well, it is pretty simple to be honest. I sincerely believe that my clients benefit from the opportunity to hear that they are not alone in facing life’s challenges, that we can all shift our thoughts and behaviours to some degree, and that the tools we demonstrate in session actually do work. The therapeutic alliance surveys I complete with every client do seem to support this conclusion.
So where is the risk? If your intention as a therapist is to be observed as an absolute authority, self-disclosure may not be for you. If you can comfortably accept that your client may see you as a holistic human being, then you may wish to consider treading into the self-disclosure waters a little bit and see how it fits you and your clients.
The key with self-disclosure is to fully understand that its intention is to help your client move forward towards their goals. If you are not disclosing to satisfy that intention or, potentially worse, you do not even know why you are disclosing in the first place, you are probably making a major therapeutic misstep.
I had the opportunity to be a “mock patient” a few times when I was in graduate school. It was an exciting opportunity to see the unique approaches of my peers and to observe some future therapeutic greats in the making. It was also the opportunity to see some serious self-disclosure missteps. The most alarming began with a response to my concerns that began with “You think you have problems?” and ended with a lengthy discussion of how their childhood was worse than my fake backstory. Oh boy. Now that is a self-disclosure that seems only intended to serve the therapists own pathological interests.
So, what kind of self-disclosures will we have here? Well, in my opinion, I had a great childhood, so we will not be seeing a repeat of my mock-patient experience!
Instead, my goal here is to just share some of the helpful lessons and insights I have picked up along my journey that may be helpful to a diverse range of readers. I intend to talk about wellness and continued growth in a manner that could support my former patients, but will leave the more intense therapeutic discussions to the treatment room.
I will also dabble in some more holistic discussions on community mental health and issues that emerge in my advocacy work. Finally, I will at times pull back the curtain a bit on the mind and challenges mental health and wellness providers face every day. My intention there is to help stimulate discussions with my peers and to help all of us grow together as practitioners.
That is indeed a fairly diverse range of subjects and, certainly, these will not all apply to you. However, if you stick around, I can promise something helpful will not be too many posts away. So, let us see what I will disclose next.
Whenever available, Self-Disclosure will include a supplemental reading list for those who would like to dig a little more in to a topic of discussion.
A qualitative analysis of client perceptions of the effects of helpful therapist self-disclosure in long-term therapy (pay wall)
Therapist self‐disclosure: Research‐based suggestions for practitioners (pay wall)
The role of therapist self-disclosure in psychotherapy: A qualitative review (pay wall)
Counselor self-disclosure: Encouragement or impediment to client growth? (free read)
Photo used under Creative Commons license. Source here.
Photo: WELCOME Author: Prayitno. See the side panel for additional copyright information.
Michael Decaire is an Ontario-based psychologist and psychotherapist. He writes on topics of wellness, mental health advocacy, and professional practice.
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