Ethics in Relation to Mountains Beyond Mountains

Mountains Beyond Mountains Author Tracy Kidder writes, "The world is full of miserable places…" His tongue-in-cheek quote then continues, "One way of living comfortably is not to think about them or, when you do, to send money." Kidder then proceeds to write Mountains Beyond Mountains (2003) and the Robert Frost "road not taken" by Dr.

Paul Farmer that is completely opposite to "sending money." Another Mother Theresa, Farmer focuses nearly all his waking time on the poverty and disease of Haiti's people, at the cost of forsaking the richness of family life with his wife and children. Although Farmer is a physician, his story holds considerable meaning for those in the counseling field. Similar to Farmer, many caring individuals become counselors to help the "miserable people" who fill the world.

They want to do much more than "send money." Also, like Farmer, they are confronted with the impact of this decision on their lives. Many counselors enjoy a rewarding career and find a healthy balance in their life, while others, unfortunately, become emotionally overwhelmed. The ACA Code of Ethics (2005) very clearly states that counselors must refrain from providing professional services when their impairment may harm a client.

Regardless of their desire to be like Farmer and solve "mountains beyond mountains," counselors must ever be vigilant and take action when they need help with their emotional problems. Farmer first went to Haiti after studying anthropology at Duke University and was extremely upset by the dismal healthcare provided and the even worse health conditions. Caring physicians from abroad often came to Haiti, lent assistance, and then returned home. The suffering continued.

A health study by Farmer concluded that infant and youth mortality in the country was horrific, as was maternal hunger, prostitution, disease and death. Unlike the other doctors, Farmer believed he could make a difference and would not leave the Haitians behind: "Living in Haiti, I realized that a minor error in one setting of power and privilege could have an enormous impact on the poor in another" (Kidder, 2003, p. 78). Resolving to make his mark, Farmer pursued a combined M.D./Ph.D.

degree, or what he called a "marriage," in medicine and anthropology at Harvard. Even then, Farmer rarely was found on campus, typically living in Haiti and only returning for his exams. His anthropological and medical involvement began to go much further into the realm of religion: "How could a just God permit great misery?" he asked at the time.

The Haitian peasants responded with the proverb: "Bondye konn bay, men li pa konn separe," or "God gives but doesn't share." That is, according to Farmer, "God gives us humans everything we need to flourish, but he's not the one who's supposed to divvy up the loot. That charge was laid upon us" (Kidder, 2003, p. 79). Haiti soon became Farmer's calling, his passion, or, some have said, his obsession.

In Mountains beyond Mountains, Kidder (2003) follows Farmer as he works in the Haitian hospitals from sunrise to sunset, as he walks great distances to pursue patients, as he travels from one country to the next, as he writes one grant after another to raise funds for medical care, and as he directly sends those funds and his Harvard salary to his parent organization in Boston that oversees his global efforts called Partners in Health. The miraculous aspect of Farmer is that he is truly acting out his dream.

Even those who disagree with his often unorthodox ways of medical treatment admit that with Farmer there is no pretense. He continually goes to superman lengths to fulfill his goals. Why does he do it? He answers, "The problem is, if I don't work this hard, someone will die who doesn't have to" (p. 191). There is so much death in Haiti, he stresses, that sometimes even he is sickened by it.

Unlike many other people, Farmer has a deep internal strength that somehow keeps him positive and sane amidst this horrific and insane environment. This is Farmer's fix: He continually needs reassurance that he is doing everything that one person can do. "How am I doin" he asks regularly (Kidder, 2003, p. 189). Taking on more than the can cure, he naturally asks for encouragement. The fact that he does not become despondent is amazing and extremely enviable.

He once wrote, "I've never known despair and I don't think I ever will," and said, "No one believes that I am cheerful because of what I say and write, but I say and write those things because they are true" (ibid). Kidder admits that Farmer sometimes becomes sad, but it does not take much to cheer him up. However, even Farmer has his infallibilities, for no one can be all things to all people.

He has received a fair amount of criticism from friends about not spending more time with his family. They say to one another, "Can you imagine what it would be like to be married to him?" He counsels people to take vacations, when he does not ever take them himself.

Further, he berates himself for loving his own child more than those in Haiti, because of the religious philosophy of "Love they neighbor as thyself." Kidder writes that many people would like to build a life like Farmer's, where they could wake up in the morning knowing what they ought to do and feeling they were doing it. Yet Kidder cannot think of many who would assume the difficulties and give up the comforts and time with family as Farmer does.

There are many counselors who do wake up each morning and know what they ought to do and feel like they are doing it. These therapists explain that their careers provide a host of personal benefits, such as making them a better or wiser person, increasing their self-awareness and appreciation for human relationships, accelerating psychological development and a capacity to enjoy life, and forming spiritual service and enhancements in a value system (Kumar et al., 2007). However, it is a well-known fact that counseling is not an easy field.

Caring for others at the same time as caring for oneself is frequently a major dilemma faced by counselors. In most cases, therapists have to work extremely hard and may see little or no progress with clients for lengthy periods of time, if ever. For many practitioners, the stress of the job becomes too great, which often leads to emotional issues, burnout and even traumatic stress. Kumar et al. (2007) found that two-thirds of psychiatrists have moderate to high levels of emotional exhaustion and also a low level of personal accomplishment.

Researchers such as Baird and Jenkins (2003) list the many reactions that counselors have to their emotional upheaval: burnout, or a combination of emotional exhaustion, loss of caring about client feelings, and compassion fatigue; countertransference, or loss of treatment objectivity; emotional depletion, or being emotionally numb; secondary trauma, or stressed by their clients' stress; and vicarious trauma, or a disruption in trust, safety and control. Similarly, Radeke and Mahoney (2000) surveyed therapists and found that 80% suffer emotional depletion; 28%, emotional exhaustion; 24%, anxiety; and 19%, depression.

It comes as no surprise that so many counselors suffer from emotional problems. As Farmer faces the continual health issues of the Haitians, counselors continually face the problems of clients and their families. Clinicians who help traumatized clients are at considerable risk for adverse reactions because of their "exposure to emotionally shocking images of horror and suffering that are characteristic of serious trauma" (McCann & Pearlman, 1990, as cited in Wise).

For example, family counselors know that children of all ages are physically, sexually and emotionally abused and neglected by their parents or caregivers on a daily basis. The U.S. Department of Health and Human Services (2004) finds that about 875,000 children are severely harmed by family members every year. Tippett (2007) explains that sometimes in this world the best that counselors can do is plant the seed, attend patiently and reverently to a reality they cannot change quickly or even in their lifetime, and be present to suffering they cannot banish" (p. 58).

Skovolt (2001) adds that counseling cannot be any other way, because the counselors' work is a dance between two or more people who are constantly changing directions. Skovolt says, how wonderful it would be if a practitioner's work was like spray painting another person and being able to control the artistic outcome. This way it would be possible to accomplish something that would make the counselors feel better. However, admits Skovolt, people are fortunately not that malleable.

In hundreds of clinical hours during his 300-plus years of practice, Skovolt has suggested many ways that clients could help themselves in times of deep trouble. Numerous times they rejected his suggestions, brushing them away like bothersome horseflies. That comes with the territory of being a counselor. Skovolt says that no one -- the client or the counselor -- wants freedom of choice taken away. Self-determination is critical for all humans.

Counselors have to receive and absorb their client's traumatic stories at the same time as being hopeful, supportive, and empathic, which often places considerable stress on their emotional health and psychological well-being. This is especially the case if the counselors do not have someone else with whom to share their thoughts and feelings and/or are having a difficult time in their own personal lives.

Many mental healthcare workers gain much satisfaction from helping the survivors of traumatic events and feel privileged to help their clients gain strength and fortitude in the healing process (Kassam-Adams, 1995). On the other hand, many other counselors have a very difficult time overcoming traumatic events when they consist of serious injury or a threat to their client's physical well-being. Examples of traumatic events that clients face include physical or sexual assault, domestic violence, school- or work-related violence, natural disasters, and neighborhood or community violence.

The stress that counselors gain from helping traumatized individuals is positively associated with compassion fatigue, because they have the tendency to turn to their own internal store of personal characteristics to help others. According to Tedeschi and Calhoun (1998), the same personal traits that allow counselors to help clients alter negative responses to posttraumatic growth place professionals at risk of developing compassion fatigue. When practitioners focus on others without practicing their own self-care, negative behaviors can arise, such as lethargy, isolation, internalized anger and depression and substance abuse.

Counselors have to be ever aware of this delicate balance between health and fatigue. The traumas in the clients' lives often impact the counselors' emotional stability. The opposite is also true: The trauma in the counselors' lives can negatively impact their clients. Everall and Paulson (2004) explain how counselor burnout, which is similar to secondary traumatic stress (STS), has the ability to have a negative effect on the therapist's ability to deliver high-quality care.

Although burnout and STS have different clinical definitions, they do have descriptive commonalities, similar symptoms, and shared themes, and the client may see the outcome of both of these illnesses in a similar fashion as presented in the counseling session. Both burnout and STS are often cumulative and may lead to the counselor suffering from depression, insomnia, or loss of intimacy with friends and family (Arvay & Uhlemann, 1996, as cited by Everall and Paulson).

These effects of burnout and STS may result in a counseling session with lower levels of empathy, respect, and positive feelings for the client. In addition, depersonalization has the tendency to lead to negative counselor behavior, which may include making derogatory responses to the client, demining the client as a person, and not responding correctly to client needs. Counselors who ignore or do not properly respond to their feelings of STS or burnout have a greater chance of experiencing disruptive empathic abilities.

They also have a greater likelihood of having problems maintaining a therapeutic attitude and holding to boundary violations (Everall and Paulson, 2004), which leads to crossing therapeutic barriers and, more commonly, providing incomplete treatments. Everall and Paulson (2004) explain that counselors who are suffering from STS or burnout may not be able to act responsibly in counseling sessions, as well as with their regular job duties.

They may not be able to communicate with or have a desire to interact in social and family circles, can be reluctant to check for messages or return calls, and may often be pleased when appointments are cancelled. These counselors may actually begin to agree with those clients who feel hopeless, frustrated, or pessimistic, as well as start doubting the effectiveness of their counseling work. Therapists who are burned out or troubled with STS often daydream or have escape fantasies and are very reluctant to start their day.

Being cynical, losing spontaneity and a sense of enthusiasm, procrastinating, not sleeping, being physically and mentally exhausted, lacking social and family involvement and giving thought to quitting work all go hand in hand with depression, as well as being burned out and having STS. When counselors reaches this point of burnout, it is important for them to ask, "Am I doing my work as well as I might? Should I search for ways of becoming more effective?" (Pawlovich, 2000, p. 46).

This is the main thrust of the part of the ACA Code of Ethics (2005) that deals impairment and incapacitation: These areas read: 2.g. Impairment Counselors are alert to the signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when such impairment is likely to harm a client or others.

They seek assistance for problems that reach the level of professional impairment, and, if necessary, they limit, suspend, or terminate their professional responsibilities until such time it is determined that they may safely resume their work. Counselors assist colleagues or supervisors in recognizing their own professional impairment and provide consultation and assistance when warranted with colleagues or supervisors showing signs of impairment and intervene as appropriate to prevent imminent harm to clients. C.2.h.

Counselor Incapacitation or Termination of Practice When counselors leave a practice, they follow a prepared plan for transfer of clients and files. Counselors prepare and disseminate to an identified colleague or "records custodian" a plan for the transfer of clients and files in the case of their incapacitation, death, or termination of practice. According to Everall and Paulson (2004), the counselor and/or supervisor needs to take preventative measures to counteract the negative impact of burnout or STS.

As noted by the ACA Code of Ethics (2005), this is a matter of personal health and welfare, and it is an ethical duty to maintain the provision of service to clients to the highest quality possible. Counselors can take three levels of action. The first is self-regulation, the second is contacting a supervisor, and the third is having colleagues intervene. The client's needs are first and foremost in whatever approach is taken.

Even before any problems with STS or burnout occur, it is essential for counselors to better understand how these health concerns can arise and what steps will be taken if and when they occur. Norcross (2000) turns to the Socratic philosophy and states that the concepts of "know thyself " and "heal thyself " should be closely adhered to by all practitioners; psychological principles, methodology, and academic studies should be considered by the counselors to know the best way to proceed.

Mahoney (1997) agrees with Norcross, saying that it is an ethical necessity to protect both clients and therapists. Self-monitoring is an ethical task that all therapists need to perform on a regular basis. Similarly, Pearlman and Saakvitne (1995) believe that the impact of being traumatized can be responded to and reduced if the counselor becomes aware of the situation and addresses it.

Counselors have the responsibility of identifying and accepting signs of burnout and trauma in themselves as a normal response, so if problems occur they can more readily define strategies and find the necessary support to counteract negative effects. Norcross (2000) relates a study where both program directors and professional psychologists listed "self-awareness / self-monitoring" as the most important contributor to maximum functioning among mental health therapists. Because it is so difficult to determine and measure counseling competence, regular self-monitoring may be the most efficient way of ensuring that effective.