Monthly Archives: June 2006

Counselors without borders

Angela Kennedy June 21, 2006

Answering the need for continued mental health services in the devastated Gulf Coast region, 14 George Mason University graduate students and two counselor educators recently spent a week counseling and consoling Hurricane Katrina victims in Mississippi. The trip was initiated through the university pilot project Counselors Without Borders to provide counseling services by supervised graduate students.

“I was continually hearing about the mental health needs on the Gulf Coast,” said Fred Bemak, a counselor educator at George Mason, located in Fairfax, Va. “I’ve been watching the system that was set up to bring in people, and they required licensure and two-week minimum stays. I was getting increasingly mixed messages that the needs were not being met because they were far greater than the mental health resources being deployed.” Bemak, along with his colleague and wife, Rita Chi-Ying Chung, decided to escort and supervise a group of their own students on a mission to assist those still traumatized by the hurricane.

Bemak asked his students if they would be willing to help those affected by the hurricane. “I told them, ‘I have a license, and I’ll supervise you,’” he said. “It’s no different than supervising a practicum or internship.” He added that he believes counseling graduate students have the resources and ability to help communities affected by Hurricane Katrina in a professional capacity greater than simply handing out food or bottles of water. “We can offer our services to help this underserved population,” he said.

No funding was provided for the trip. Initially, 35 students volunteered, knowing they would have to pay their own expenses. Bemak contacted Walter Frazier, president of the Mississippi Branch of the American Mental Health Counselors Association, a division of the American Counseling Association, to collaborate on the trip’s organization. They decided to limit the trip to seven days, reasoning that a two-week time commitment was too difficult, especially given that the trip was to take place in the middle of the semester and most participants were part-time students with jobs and family obligations.

“Our idea was to do a national pilot to see if this would work and perhaps open the door for other teams from other universities,” Bemak said. “We all wanted to see if this was something that was viable.” Bemak also coordinated with the Mississippi Department of Mental Heath and the local Substance Abuse and Mental Health Services Administration team.

After the dates were finally nailed down, 14 of the 35 students who had originally expressed interest committed to go. Bemak and Chung held an orientation on disaster work to inform the students about what they might encounter. Afterward, they gave the students the option of changing their mind about the trip, given that the work would be both mentally and physically taxing. All 14 students stuck by their commitment. The two supervising faculty members and the students went to the campus computer room and purchased their airline tickets online that day.

“What was very interesting was that the other students in our program, because of our social justice mission, were very willing to support this,” Bemak said, adding that a number contributed money and volunteered to pet or house-sit while their fellow students were away. Several pitched in by driving their peers to the airport in Baltimore or loaning digital cameras and video camcorders to those going on the mission. Bemak and Chung spoke to their fellow faculty members, asking if they would be flexible with deadlines and tests for the students who were volunteering. Again, the response was positive. “We had a whole graduate program community of caring,” he said. “Everyone jumped in to support it. Even a very well-known faculty member in the psychology department offered to buy us T-shirts to show who we were.” The T-shirts helped identify the students among the hundreds of aid and relief workers in the centers and shelters.

Before leaving, team members met again for intense training in disaster relief counseling, using materials from ACA, SAMHSA and the American Red Cross in addition to the experiences of their two supervisors.

The deployment

The Mississippi Department of Health, which hadn’t originally been disposed to accepting nonlicensed volunteers, was on board and supporting the George Mason University team. The director and workers of Project Recovery, a government-funded state mental health program, met team members at the airport upon their arrival in Mississippi and drove them to the coast.

“That, to us, symbolized that there was a great need that they are not able to serve with the resources they have,” Bemak said. “They welcomed this team, even though the students were not licensed. It was a very special moment they created because we were not the traditional, licensed, two-week team.”

Frazier had arranged for the team to stay in tents outside a local church. However, a freak cold snap sent temperatures plunging into the 30s. The SAMHSA team contacted Bemak while en route to say it was working to find an alternate location for the students to stay. When team members arrived, they were told they could stay in the same location as the SAMHSA team — in a secure treatment facility for male adolescents.

“There was barbed wire and several locks and codes we had to go through to get to our area,” Bemak said. “We had a building to ourselves because the facility was not full.” Still, the quarters were far from comfortable. Bemak slept in an isolation room with little more than a mattress on the floor. The students bunked up in pairs, making the best of the situation and trying to prepare for the events to come.

Katrina fatigue

For the next week, the students were split up and scattered along the Mississippi coast at seven shelters and disaster response centers. Frazier arranged for rental cars so students could drive back and forth to the locations. Cell phones were also donated so students could stay in contact with Bemak and Chung.

Most of the people the team members approached welcomed the invitation to talk. At first, Bemak said, the students were a bit hesitant about just going up and talking to those affected by the hurricane. But by the end of the trip, they had seen 591 clients. Chung and Bemak roamed from facility to facility, navigating piles of debris and nameless streets to make sure their students were all right.

“(Team members) worked across ethnicities and races, facilitated dialog among those in different ethnic backgrounds and had mini group sessions — informally — as people and families waited in lines for aid,” Bemak said. “We could have tripled our numbers and still not seen all those who needed help. The stories are profound. The frustration is endless. The mental health issues there are escalating. They call it Katrina fatigue.”

Every night after dinner, the group met for two to three hours to debrief and share their experiences. They discussed victims’ stories that had touched them as well as their own emotions and struggles. The counselor supervisors talked about specific interventions and helpful skills the students could use.

“Every night they cried,” Bemak said. “They were moved and pained by the stories, but they grew significantly as counselors.” Many of the students stated that the experience was different from any of their previous training, he said. According to Bemak, every student said they would have agreed to stay through the Thanksgiving holiday to help if they had known the true level of need that still existed months after the hurricane. “They all said that it was a life-changing experience,” he said.

On to Capitol Hill

Since returning, the team has contacted government officials and is scheduled to meet with members of Congress to further focus attention on the need to provide ongoing mental health services to the hurricane victims. The aim is to create a national program with funding for other schools to send teams of counseling students to the Gulf Coast.

“There is so much devastation and everything is destroyed,” Bemak said. “We weren’t aware of how bad it is and how hopeless and hurt a number of the people are. After the experience, we want to bring that awareness back. The situation warrants a completely different response than what we have been doing. The needs are far greater than the kinds of interventions we are making. We need to make a major shift in how we approach it. One of those shifts can be led by teams from universities going down there with graduate students and supervisors.”

Counselors in progress

Following are the stories of two of the counseling graduate students who volunteered to go to Mississippi:

Kelly Badger

“I was nervous to make the decision to go down to Mississippi due to us not knowing exactly what our role would be, (but) it was something that I just had to do. You come across opportunities in your life that you make a personal connection with and it just feels right. It was one of those situations. The people down there are in need, and I have the ability to go down and try and make a difference in some way.”

Badger was apprehensive about her ability to provide effective trauma and disaster relief counseling, even with her professors on hand to supervise. “I knew that this would not be the same type of counseling that I have been doing as a practicum student in school counseling, but my apprehensions were in not knowing what this type of counseling looked like. We read articles and met with Dr. Bemak to discuss situations we might come across and how to best handle them, but nothing can make you feel fully prepared. You learn to trust your gut and believe that you have the skills as well as the heart to help these people.”

After speaking to individuals affected by Katrina and hearing their stories, her concerns faded and her professional skills and confidence grew. The most challenging part for her was dealing with the emotions involved in this type of work.

“I don’t think you can ever be fully prepared to experience the impact that this devastation has on you, especially when you are working so closely with the individuals that it has impacted. It was crucial that we process what we had experienced together at night back at base camp because we were so busy during the day, I never had a chance to really feel what was impacting me and what effect it would have on me.”

Badger was deeply touched that the individuals she talked to felt comfortable enough to share such private and painful stories with her. “Some individuals would hug you and tell you that you had made a difference to them. With some individuals, you could tell a difference in their demeanor toward the end of our time together. Some I will never know if I made an impact at all, but I am confident that there were people I touched, people that feel reaffirmed and feel heard because of me, and that is the most rewarding gift I have ever received.”

One aspect that Badger said doesn’t get much media coverage is the fact that all the hurricane victims had some sort of personal struggle or issue — no matter how normal or ordinary — before Katrina hit; the storm just exacerbated their pre-existing problems. In addition, she said, life issues that residents dealt with prior to Katrina, such as health care, domestic violence, poverty and discrimination, are still there. People continue to deal with these issues, but they are now combined with a lack of shelter, food, clothing, jobs and overall security.

“They have life events that continue to happen and continue to affect them in addition to the devastation that they are faced with (from the hurricane). One individual that really opened my eyes to this was a man who had found out that he was terminal and that his doctors were no longer going to actively fight the cancer in his body.” He had learned this several days before talking with Badger but hadn’t told his family because he didn’t want to burden them.

“He said he didn’t want to put anything else on their plate. He thanked me for listening and told me how good it felt to get it out and to tell someone. I can’t tell you what a gift it was for him to trust me enough to tell me such a personal story and to feel safe enough in our interaction to do so.”

The experience has changed Badger professionally as well as personally. “I am definitely a different counselor, but even more so a different human being. These people have been such an inspiration for me. They are so strong and so resilient.”

She felt connected to those with whom she spoke and feels a responsibility to do whatever she can to continue providing support. “This is going to take a significant amount of time to heal. These people are in pain, they are frustrated, they are angry, and at the same time they are proud and are full of internal resources that push them through. People I spoke with were so thankful for our presence in their community. There is a true need for continued support from the mental health community.”

Badger encourages other graduate students to establish Counselors Without Borders programs and to volunteer in the Gulf Coast region. “You will not regret a moment of it. It is hard, it is emotional, it is draining. But it is all worth it. We were told that this would be the toughest work we might ever do, and I can say without a doubt it has been, but it has also been the most rewarding experience to date. I would not trade that week of my life for anything.”

Marla Zometsky

With all the discussion surrounding what Gulf Coast residents need and how many of those needs are going unmet, Marla Zometsky thought it was important for her, as a future counselor, to serve in a helping capacity. “Particularly as someone who can listen to their concerns, show that people do care about what is happening to them and try to raise awareness that there is still a great need for assistance in this region, including mental health assistance.” She also wanted to go for the educational opportunity. “Professionally, my reason for pursuing a graduate degree in counseling was an interest in trauma counseling, and this project was a great opportunity to personally help those impacted by the hurricane and to obtain direct crisis counseling experience. I could not have had a better chance to learn while doing.”

She tried to prepare herself for the destruction, but witnessing it in person was surreal, especially when she saw small personal items such as photos or books amid piles of rubble that once were homes. “Knowing that many of those I spoke with were still — three months out from the hurricane — living in their cars, in shelters and in tents, (and) feeling that this was unacceptable and due to a true lack of political will on a grand scale, was personally challenging in that I could not make the system work better for them in that moment. Person after person expressed their frustration, fear and weariness trying to obtain shelter or trying to remain in their current shelter until their trailer or more permanent housing came through.”

She also struggled with the fact that once the GMU team left, no one would be there to continue providing needed mental health services. “On my final day, it was a challenge to leave the DRC (disaster response center) knowing that another mental health worker would not be returning the next day, that they were needed and that further plans for their deployment were still under consideration. As I was leaving on the final day, one of the FEMA (Federal Emergency Management Agency) employees asked if I was returning soon and whether someone else would come the following day. I had to acknowledge that I didn’t know when another mental health worker would come, but we were working on it. That was difficult. While I tried to give them hope, I couldn’t promise anything.”

Zometsky said many of the same people and families returned to the centers daily for assistance and to ensure their information was kept up to date. Their anxiety, sadness and frustration levels were nearing their limits, and the student counselors tried their best to draw on their counseling skills and limited experience to defuse the situations any way they could.

“While I wasn’t able to help them with their immediate goals, such as obtaining shelter, I was able to give them an empathetic ear and help them think through their next steps for that day. I tried to reinforce the personal strengths I heard them express, give them the opportunity to convey their emotions and just simply be there for them in those moments.” She said several FEMA workers, many of whom were from the affected areas and also dealing with loss, relied on the mental health workers and asked them to speak directly with distraught persons.

In one such case, a FEMA worker asked Zometsky to speak with an incredibly anxious and distraught mother and her 14-year-old daughter. “She was in line to learn the status of her travel trailer; her family was currently living in a shelter. I walked up and asked if I could sit next to her. Before I could even finish my sentence asking how she was, she started telling me how worried she was that the shelter they were in would close and that she and her family would literally be living on the street. This wasn’t an unfounded fear, as the previous two shelters they were placed in had closed. This family had lost everything — their home, their belongings and their security. They had no permanent place to live, and she had another child, a son, with Tourette’s syndrome. She was deeply concerned with how a lack of structure and security was affecting her children.”

The women was so upset, she could hardly breathe at times, Zometsky said. “I gently placed my hand on hers and asked her if we could take a deep breath together. She had so many things to take care of and so much to worry about that everything was overwhelming her. So we walked through each step she would take while at the DRC today. I reflected her feelings and summarized the incredible amount of work that she had already accomplished in such a short time.” To the young counselor’s surprise, the woman replied, “You are right! I have gotten a lot done!”

Zometsky said, “Although she was still distressed, by the time it was her turn to meet with the caseworker, she seemed to be thinking more clearly and could present her information in a coherent manner.” As the mother spoke to the FEMA caseworker, Zometsky sat and talked with the daughter. The mother had referred to the daughter as “resilient,” and Zometsky asked the teen what she thought of this.

“The young woman felt it was not true and began to cry. She was still mourning the loss of her father, who died a year ago. She shared with me how she had lost the only things she had that remained of him. Her friends were now scattered across the country. She didn’t know how to contact them. She felt alone and as if no one, including her mother, understood her. We talked about what that was like for her and how she was dealing with all this loss. She told me that she wrote music. I responded that she must be very talented and asked if she wrote about her feelings. She said that she did, but that people did not know they were her feelings. Again, I told her how impressed I was and that she seemed like such a unique and talented young lady.”

Zometsky said that throughout her time with the daughter, she simply reflected the feelings she heard the girl express. That was all the girl needed to continue her story and feel that someone understood what she was going through.

“At one point this young lady asked if I was a counselor. I told her I was a ‘wanna-be’ counselor and that I was in training.” The girl laughed at her joke and told Zometsky she had talked with counselors before but did not like them. However, she liked talking with Zometsky.

“I felt honored that we made a connection, and I shared that with her and thanked her.” Zometsky also gave the daughter a list of hotlines she could call in the future if she wanted to talk to someone. “I was touched by the entire experience with that family. I spoke with this young lady for approximately 45 minutes. During the last 15 minutes, I had noticed that the mother had completed her meeting with the caseworker. However, she sat several rows behind us in order to let her daughter continue talking.” Both the mother and daughter hugged Zometsky and thanked her for listening. Though she made them feel better, Zometsky is under no illusion that the stress and anxiety the mother first expressed are permanently gone. However, for the brief time she spent with the mother, Zometsky was able to help her accomplish her tasks at the DRC in a more productive and calm manner.

“Furthermore, this young lady was able to express her sadness and not pretend that everything was OK. She had been feeling like no one cared about her and that she was alone. For a brief time she met with a stranger who allowed her to share how she felt, empathized with her and thought she was important. As a future counselor, I have a new understanding about what it means to be fully present and work in the moment. I have a new appreciation for the basic counseling skills — reflecting, paraphrasing and attending — and the enormous impact they have on the clients and our relationship.”

Like Badger, Zometsky wants counselors and counseling students to be aware that a great need remains for counseling volunteers in the Gulf Coast. “I would also like disaster relief organizations and mental health associations such as the American Counseling Association to know that graduate counseling students are an untapped resource that should be utilized,” Zometsky said. “The people in the Gulf Coast need our help, and we as counseling trainees should not be excluded when implementing a large-scale mental health crisis-counseling plan. Doing so contributes to a system that has left thousands of the affected without mental health respite. Graduate counseling students can help fill the need. I believe the counseling profession has an obligation to do everything possible to help fill this deficit, and recruiting graduate counseling students is one option. Furthermore, it provides students with the hands-on experience that will make them better counselors and future leaders in the social justice counseling movement.”

Zometsky continued, “We need to fight Katrina fatigue. Do not be fooled into thinking that things are all better. While this may be true for some, and I am grateful for the progress already made, there are thousands and thousands that are still without basic human services and who are fearful for their future. We’ll see the mental health impact of Katrina for years to come.”

For more information on establishing a Counselors Without Borders program with counseling student volunteers, contact Fred Bemak at fbemak@gmu.edu.

To donate to the American Red Cross, go to www.redcross.org. In addition, the American Counseling Association Foundation continues to collect donations for the Counselors Care Fund. For complete details, visit the ACA website at www.counseling.org, or call 800.347.6647 ext. 350 to make a contribution.

A new focus on cultural sensitivity

David Kaplan June 2, 2006

Editor’s note: American Counseling Association members received the 2005 ACA Code of Ethics bundled with the December 2005 issue of Counseling Today. Completed over a three-year period, this revision of the ethical code is the first in a decade and includes major updates in areas such as confidentiality, dual relationships, the use of technology in counseling, selecting interventions, record keeping, end-of-life issues, and cultural sensitivity. 

All ACA members are required to abide by the ACA Code of Ethics, and 21 state licensing boards use it as the basis for adjudicating complaints of ethical violations. As a service to members, Counseling Today is publishing a monthly column focusing on new aspects of the ACA Code of Ethics (the ethics code is also available online at www.counseling.org/ethics).  

ACA Chief Professional Officer David Kaplan conducted the following interview with Courtland Lee and Tammy Bringaze, two members of the ACA Ethical Code Revision Task Force.

David Kaplan: It is clear that the revised ACA Code of Ethics has a new focus on cultural sensitivity.

Courtland Lee: That was a primary charge of the Ethical Code Revision Task Force — to look at the revision with an eye on making the code more culturally sensitive. To accomplish this, we kept two questions in mind: 1) How do we need to rethink things in terms of changing population demographics and issues of multiculturalism and, 2) What is missing from the code that will make it more culturally sensitive?

Tammy Bringaze: We realized that multiculturalism and diversity impacts every area of our life and our practice. It affects our sensitivity toward the people we serve. As such, instead of just having one section focusing on cultural sensitivity, we infused multiculturalism and diversity throughout the entire code of ethics.    

CL: As an example, until now it has been considered unethical to receive gifts from clients. However, in some cultures giving a gift is really considered to be the highest form of praise, and to refuse a gift is considered culturally insensitive. So we revised the section on receiving gifts (Standard A.10.e.) to reflect this. It now reads, “Counselors understand the challenges of accepting gifts from clients and recognize that in some cultures, small gifts are a token of respect and showing gratitude. When determining whether or not to accept a gift from clients, counselors take into account the therapeutic relationship, the monetary value of the gift, a client’s motivation for giving the gift and the counselor’s motivation for wanting or declining the gift.”

DK: So based on the last sentence of A.10.e., one of the implications of gift receiving is that even within a cultural context, counselors should not accept a gift that has a substantial monetary value.

CL: Right! While it is important to understand and appreciate the cultural context of a client, the counselor has to use some common sense.

DK: Let’s focus on confidentiality. Standard B.1.a. talks about how important it is for counselors to maintain cultural sensitivity regarding confidentiality, privacy and the disclosure of information.

CL: Much of this is based on the difference between individualistic and collectivist cultures.

TB: For example, I work with Afghan refugees, and the idea of confidentiality has a very different meaning in their culture. It is much more communal. There is really the sense among the Afghans of trying to look out for one another and pull together. The other day I had an Afghan woman come in and sit down in the middle of another woman’s session, and neither blinked an eye. So I thought, “Well, OK. If it works for them, it works for me.” If a counselor were not sensitive to the collectivist norm of the Afghan culture, he or she might feel pretty angry or agitated at the client and ask the “intruder” to leave immediately. If that were done, I’m afraid the counselor would lose the relationship with both clients.

DK: So an implication is that there are some cultures where confidentiality is less important than it is for the dominant American culture.

TB: Yes, I definitely think so.

CL: Another example of the importance of cultural sensitivity regarding confidentiality and the disclosure of information revolves around disciplining a child. When an African American kid tells you, “I got in trouble and I’m afraid to go home because my mom is going to give me a whipping!” it sounds really harsh, as if the kid is going to get the heck beat out of him with a whip. But in the African American community, the term “whipping” generally refers to a form of mild discipline. So understanding how words and meanings are different in different cultures is important.

DK: So staying with this discipline example from a cultural prospective, there would be times when a child reports a “whipping” that would not necessarily trigger mandated reporting laws.

CL: That’s right.

DK: Let’s turn to assessment. Standard E.8., “Multicultural Issues/Diversity in Assessment,” talks about the importance of recognizing the effects of age, color, culture, disability, ethnic group, gender, race, language preference, religion, spirituality, sexual orientation and socioeconomic status on test and inventory administration, interpretation and use.

CL: An important aspect of Standard E.8. is that a counselor must make sure that any inventory or test they utilize has been normed on the population that the counselor is using the instrument with. Back in the 1970s, a group of people, I think from the San Francisco Bay area, instituted a lawsuit against the school system because of the large number of African American schoolchildren who were in special education classes. The outcome was a moratorium on testing until instruments could be normed on the African American population.

DK: The Code of Ethics also now speaks to multiculturalism and diversity in supervision.

TB: We have recognized the ethical complexity of having to speak to the cultures of at least three people in supervision: the supervisor, the supervisee and the client. As we add people, we need to be sensitive to the many cultural layers.

CL: I hope that this will start a new dialogue and research on multicultural and diversity issues in supervision. This is something we talk about, but we really don’t know a lot about it. In particular, when there is a cross-cultural supervisory relationship, it is critical for both the supervisor and supervisee to understand and be sensitive to each other’s cultural view and how that view impacts the counseling process.

DK: Is there a specific example that comes to mind?

CL: I was supervising a graduate student, a white woman who was doing career counseling with a Latino client. My student was getting really frustrated because every time a viable option was explored the client would say, “That sounds like a good career change, but I have to ask my father.” My student had a feminist worldview and felt strongly that the client should not have to check with her father because she was an adult and had free choice. I had to talk to my supervisee about her client’s culture and that the role of the father in protecting his unmarried daughter is an important part of the Latino culture. I therefore encouraged my supervisee to develop a consultative relationship with the father.

DK: Does the revised ethical code infuse multiculturalism and diversity into counselor education and training? 

TB: For the first time, there is a statement in the ethical code that counselor educators must infuse multicultural and diversity material into all courses and workshops (Standard F.11.c.).

DK: CACREP (the Council for Accreditation of Counseling and Related Educational Programs) does not require every course to have multicultural/

diversity material in it. So is it reasonable to say that this goes beyond national training standards?

TB: We are going beyond current expectations and requirements and raising the bar for the profession. I am very proud of that.

DK: What would you say to a counselor educator who states that an ethical mandate to infuse multiculturalism and diversity into course work is a violation of academic freedom?

CL: I would state that a professor’s ethical responsibilities to the counseling profession supersede their role as an academic. I don’t know if that would hold up in court, but that’s how I see it.

DK: As a final topic, the revised ACA Code of Ethics attends to multiculturalism and diversity in research (Standard G.1.g.). What should counselors know about this?

TB: Researchers need to speak to some basic questions: Can the research benefit a diverse group of people? Can the research be applied to a diverse population? Are there any aspects of the research protocol that will be perceived as culturally insensitive by participants?

DK: Has all of the effort to infuse multiculturalism and diversity throughout the revised ACA Code of Ethics moved the profession forward?

CL: Well, I think that remains to be seen. This code has just hit the street. We’ll have to see what unfolds in the next few years. I am very optimistic!

Next month: Permission to refrain from making a diagnosis

Letters to the editor: ct@counseling.org

New mandates for selecting interventions

David Kaplan

American Counseling Association members received the 2005 ACA Code of Ethics bundled with the December 2005 issue of Counseling Today. Completed over a three-year period, this revision of the ethical code is the first in a decade and includes major updates in areas such as confidentiality, dual relationships, the use of technology in counseling, selecting interventions, record keeping, end-of-life issues and cultural sensitivity. 

All ACA members are required to abide by the ACA Code of Ethics, and 21 state licensing boards use it as the basis for adjudicating complaints of ethical violations. As a service to members, Counseling Today is publishing a monthly column focusing on new aspects of the 2005 ACA Code of Ethics (the ethics code is also available online at www.counseling.org/ethics).

ACA Chief Professional Officer David Kaplan conducted the following interview with Barbara Herlihy and Judy Miranti, two members of the ACA Ethical Code Revision Task Force.

Standard C.6.e.
Scientific Bases for Treatment Modalities

Counselors use techniques/procedures/modalities that are grounded in theory and/or have an empirical or scientific foundation. Counselors who do not must define the techniques/procedures as “unproven” or “developing” and explain the potential risks and ethical considerations of using such techniques/procedures and take steps to protect clients from possible harm. (See Standards A.4.a., E.5.c., E.5.d.)

David Kaplan: A new standard in the ACA Code of Ethics (C.6.e., see above) states that counselors now need to use interventions and approaches that are grounded in theory and/or have an empirical or scientific foundation. If there is no theoretical or empirical support for a particular technique or procedure, the counselor must inform the client that the technique or procedure is “unproven” or “developing” and discuss potential risks and other ethical considerations. Why did the Ethical Code Revision Task Force add this new standard?

Barbara Herlihy: There was concern that some counselors implement techniques that grow out of their own bias, are faddish or clearly unproven in a scientific way. The task force felt that counselors need to have a rationale for treatments and procedures that are grounded in an established theory or have a supporting research base. 

Judy Miranti: Much of the discussion about the need to have theoretical or empirical grounding focused on sexual orientation issues in counseling — specifically around reparative/conversion therapy.

DK: Let’s come back to the reparative/conversion therapy issue in just a moment.

First, I do think we need to acknowledge that the new “Scientific Bases for Treatment Modalities” standard advances the profession.

JM: It moves the profession forward by telling counselors that while eclecticism or the application of several techniques could be therapeutic, the treatment modalities selected need to be research-based.

BH: The new standard on scientific bases for treatment modalities reminds us that the counseling profession has developed quite a body of literature both in theory and research which guides us toward effective practice. As such, our work needs to remain grounded in this carefully developed research base.

DK: You mentioned that one of the discussion points around this section was conversion/

reparative therapy — an approach that purports to “convert” homosexuals to heterosexuality.

JM: Both the Ethical Code Revision Task Force and the ACA Executive Committee felt that it was important to look at the biases and prejudices involved in conversion/reparative therapy and the possible harm that this approach can cause.

DK: Since the 2005 ACA Code of Ethics has been published, the Ethics Committee has formally ruled that conversion/reparative therapy does fall under C.6.e. and that any counselor using this approach must tell clients that conversion/reparative therapy is developing or unproven.

BH: Although conversion/reparative therapy may have been the first specific technique, procedure or modality that has been identified as needing to be labeled as “developing” or “unproven,” it is important to note that Standard C.6.e., “Scientific Bases for Treatment Modalities,” wasn’t aimed exclusively at that approach. This new standard was designed to focus broadly on any technique, procedure or modality that might be controversial and whose effectiveness or appropriateness is unfounded or not grounded in research.

DK: Why didn’t the Ethical Code Revision Task Force decide to specifically state in the ethical code that conversion/reparative therapy is banned?

JM: This did come up, and some task force members felt that we should be specific and list approaches that are unethical.

BH: But in the end, we decided that this would set a precedent — the ACA Code of Ethics has never listed specific interventions or approaches that are unethical — and that it was not in the best interest of the counseling profession to start now.

JM: We would not have been able to be all-inclusive and be assured that we had listed every intervention that should be banned. Therefore, a laundry list of forbidden interventions would lead counselors to assume that any intervention not on the list was fully approved by ACA.

DK: And you would worry about harmful techniques, procedures and modalities that were left off the list or were developed after the list was published.

JM: Exactly!

DK: How does a professional counselor know whether a technique, procedure or modality needs to be labeled as unproven or developing? In other words, how does a counselor determine whether Standard C.6.e., “Scientific Bases for Treatment Modalities,” applies to the intervention or approach they are using with a client?

BH: When in doubt about the scientific base of a technique, procedure or modality, use the standard “consult, consult, consult.” Call a former professor. Call an expert. Talk to some colleagues. But by all means, consult.

JM: Utilize resources on the ACA website and other websites. Keep current with the research by going to workshops and reading professional books and journals, and stay in contact with other practitioners who can serve as consultants.

DK: This is a good time to remind readers that ACA’s manager for Ethics and Professional Standards, Larry Freeman (800.347.6647 ext. 314 or lfreeman@counseling.org), provides free ethics consultation to ACA members and that our best-selling book, the ACA Ethical Standards Casebook by Barbara Herlihy and Gerald Corey, was just revised to include the 2005 ACA ethical standards. (Note: For more on the ACA Ethical Standards Casebook, turn to “Behind the Book” on page 30.) The casebook can be ordered at 800.347.6647 ext. 222 or www.counseling.org/publications. Free ethics resources are also available to ACA members at www.counseling.org/ethics.

So far we have been talking about Standard C.6.e., “Scientific Bases for Treatment Modalities,” in terms of the techniques, procedures and modalities that counselors use with their clients. Does it also apply when the counselor is asked for a referral?

BH: If a client requested an approach that was not grounded in theory or an empirical/

scientific foundation, it would be my responsibility to thoroughly discuss the unproven or developing nature of the approach, the limitations of that approach and alternative approaches. If the client proceeded to choose that intervention after this thorough discussion, it would be my responsibility to facilitate that process and provide a referral.

DK: The ACA Ethics Committee has just completed an extensive paper on the subject of referrals for conversion/

reparative therapy and other interventions that do not have a scientific base that very much supports your statement. An abridged version was published on pages 14-15 of the July 2006 edition of Counseling Today, and the complete document is available at www.counseling.org/ethics.

Switching gears, what do you think ACA needs to do to assist professional counselors with the new standard “Scientific Bases for Treatment Modalities”?

JM: We should consider developing a website section for practitioners fashioned around this standard that provides information on proven treatment modalities. We also need to help professional counselors define the potential risks and ethical considerations of specific approaches. Students and counselor educators have access to the most recent literature, but practitioners in the field may not.

DK: Please convey thanks to the entire Ethical Code Revision Task Force for yet another new standard that advances the profession. Any final thoughts?

BH: Professional counselors need to understand that Standard C.6.e. was not meant to be rigid and imply that only techniques, procedures or modalities that have been supported by experimental studies with random selection can be utilized. If that were the case, we would only use cognitive behavior therapy because it is the easiest to study under experimental (or at least quasi-experimental) conditions. We have to think more broadly and inclusively than that and include qualitative and other approaches. The point is that we don’t want counselors using biased approaches that are not thought through and have no evidence of validity.

Next month: New requirement to have a transfer plan

Letters to the editor: ct@counseling.org

Marriage Maintenance

Jonathan Rollins

Romance is ruining marriage in America.

OK, that’s an overstatement if not an outright inaccuracy. But according to Mark Young, co-director of the Florida Marriage and Family Research Institute at the University of Central Florida, romance — or rather what he labels the “myth of romance” — really does contribute to the high divorce rate in the United States. Approximately one out of every two marriages in the United States ends in divorce, and the divorce rate is closer to 60 percent in Young’s home state of Florida.

One of the contributing factors, says Young, a professor and coordinator of the counselor education program at UCF, is the fallacy that romance should be a constant in marriage, and if it’s not, then it’s time to bail out. The reality is quite different, he says. “Romance is like the Fourth of July,” Young says with a laugh. “It comes around once a year and is quite exciting, but friendship (between a couple) is the real answer to a good marriage.”

Chasing after the mirage of constant romance often leads people to seek out affairs, Young says, but a lack of romance is rarely the root problem in a relationship. “The problem is a problem of maintenance,” he says. “It’s more of a deterioration that leads up to people being disillusioned. What really makes or breaks the marriage is the day in and day out communication.” According to statistics Young cited from the Family Research Council, 78 percent of all couples who seek counseling indicate that communication is a problem in their relationship.

Andrew Daire, Young’s co-director at the Florida Marriage and Family Research Institute and clinical director of the counselor education program at UCF, says society’s increasing complexity is putting more strain on marriages. “But I personally believe (the divorce rate) has to do with what I call the ‘fast food mentality’ of our culture,” he says. “It’s that mentality that if you don’t like what you have, then you just move on and get a new one instead of dealing with the challenges.”

Stronger marriages, stronger families

UCF operates a community counseling clinic that sees approximately 1,500 clients per year, according to Young. In many instances, parents drop off their children for psychotherapy, he says, when the real problem is the family unit itself. In fact, helping children — particularly those from at-risk families — was the impetus for Young and Daire to create the Florida Marriage and Family Research Institute in 2003.

The institute’s mission is to facilitate the development of research and clinical initiatives to better support couples, marriages and families. It applied for and received a three-year demonstration grant in 2003 through Promoting Safe and Stable Families, a program of the U.S. Department of Health and Human Services Administration for Children and Families. The grant, which expires Sept. 30, was used to establish the institute’s Stronger Marriages and Stronger Families Program. The program provides brief couples counseling, weekend marriage and couples education workshops, premarital counseling and follow-up groups, as well as whole agency training and an annual conference for direct service providers. The program, with Joanne Vogel serving as project director, is also in the process of identifying best practices through research initiatives.

“We have seen hundreds of couples in our clinic and in marriage enrichment programs using counseling students in their practica and internships,” Young says. “I believe our project and (similar) initiatives would be of interest to other counselors. One reason is that couples work has become a specialty area for counselors, and they can now receive specialized training. Another is the growing research in that area and funding that counselors might wish to apply for.” Young notes that another federal program, the Healthy Marriage Initiative, provides more than $100 million per year for marriage promotion, and he hopes that more counselors and counseling programs will pursue these and other similar grants.

Why has the federal government taken such an interest in what it terms “healthy marriages”? “The research says people who are married do better in all sorts of ways,” Young explains. “They have fewer illnesses, they live longer, their children do better in school. That evidence has hit people on both sides of the political spectrum.”

At the same time, Daire points out that the Healthy Marriage Initiative and similar programs are not trying to force people to get married but rather providing support for those who do. “The research is clear and solid,” he says. “When marriages fail and kids are raised in high-conflict environments or in divorced households, they are much more likely to suffer whichever ill you want to throw a dart at, such as poor school performance or involvement in the juvenile justice system.”

Marriage education vs. marriage counseling

The Stronger Marriages and Stronger Families Program was the only counselor-led effort of the seven demonstration projects funded through the Promoting Safe and Stable Families Program in 2003. While each of the six other projects focused exclusively on marriage education as opposed to marriage counseling, the Stronger Marriages and Stronger Families Program provided both services, in part to compare the efficacy of the two approaches.

As Daire admits, some critics question the overall value and effectiveness of marriage counseling and therapy. But he looks at the debate from another angle. “Marriage counseling is really the emergency room,” he says. “The success rate is going to be less at this point than if the couple did preventative treatment. We’re pretty much the trauma unit.”

Young backs that theory up, explaining that a problem typically crops up in a married couple’s relationship six years before they seek counseling to correct it. “People learn to adjust to bad situations,” he says. “They learn to avoid it because they think it’s going to go away. … You have to have a very positive attitude to be a couples counselor because couples come in very discouraged and distressed. The counselor’s job is to lend hope.”

Even so, based on preliminary observations in the Stronger Marriages and Stronger Families Program, it appears that couples counseling will prove to be just as effective (if not more so) than marriage education, Young says. The better news, he says, is that both approaches typically led to significant improvements in the relationships of couples who participated in either counseling or enrichment/education activities through the Stronger Marriages and Stronger Families Program.

The program is currently comparing results from two of the direct services it provided: Stronger Marriage and Stronger Couples 16-hour enrichment workshops, which were based on David Olsen’s Prepare/Enrich model, and six one-hour sessions of brief couples counseling based on Young and Lynn Long’s Integrative Approach to Couples Counseling. “The next step,” Young says, “is to determine which treatment is best for which couple at which time.”

As Young explains, marriage education tends to be a programmed approach that takes couples through a step-by-step process in a group format. A “preventative” approach, it usually touches on multiple relationship topics (communication, finances, sex, conflict resolution, relationship expectations, etc.) regardless of whether participating couples view the topics as problem areas in their marriages.

Marriage counseling, on the other hand, involves just the counselor and the couple (although group counseling can also be used, especially as a follow-up or reinforcement tool). The focus in couples counseling is finding a resolution to a central issue, Young says, rather than providing a broad overview of marriage and relationship topics. “Most of these marriage education programs are being provided by volunteers and paraprofessionals,” he says, “while an expertise in family dynamics and couples dynamics is really necessary for marriage counseling.”

But neither Young nor Daire tries to downplay the benefits of marriage education. Some counselors feel threatened by the field of marriage education, Daire says, but they should realize that its focus is exactly that — education, not counseling. Besides, he advises, marriage education is a great complement to traditional couples counseling because of its preventative approach. “Relationship education is a viable modality in working with clients,” Daire says. “I would encourage counselors to really embrace it and try to get trained on the different curricula that are available.” Counselors in private practice may find relationship education materials especially helpful with some of their clients, he adds.

Trying to reframe the challenges of marriage

In working with the Stronger Marriages and Stronger Families Program and trying to secure additional grants for the Florida Marriage and Family Research Center, Daire has been struck by the genuine need to market the benefits of both marriage counseling and marriage education to the general public. The reluctance of couples to engage in “maintenance activities” for their relationship has surprised him.

Daire and Young both mention a demonstration project in another state in which couples were invited to attend an all-expenses-paid marriage enrichment retreat at a bed and breakfast for a weekend. While more than 4,000 people were invited, only 42 signed up to participate. “People are complaining that they need tools to help them in their marriages,” Daire says, “but it seems like if you build it and offer it for free and even offer incentives, they don’t come. … More time and money is spent on maintaining our cars than our marriages. People make sure their cars get their oil changed four times a year, but many of them won’t consider going to a marriage conference.”

Daire acknowledges that it’s sometimes exasperating how quickly couples will contemplate divorce without giving any consideration to marriage education or counseling. Somehow, he says, that mindset has to be changed.

Daire was recently reading a newspaper article in which an elderly gentleman was interviewed. The man said it was surprising to him just how preoccupied members of the younger generations are with trying to “find” their soul mates. In actuality, he said, soul mates are created by going through the trials and tribulations of marriage and relationships.

“That really reframes the challenges of marriage not as a bad thing,” Daire says, “but as something that can strengthen our relationship.”

For more information on the Florida Marriage & Family Research Center and its Stronger Marriages and Stronger Families Program, visit www.ucfcounselored.org/families.

 

SIDEBAR:

Relationship danger zones

Spouses of all stripes can be excused if they harbor some seeds of concern as they approach their seventh year of marriage. After all, the phenomenon known as the seven-year itch is lurking around the corner, just waiting to lay waste to even the most solid of unions. But if they can only weather the storm, they can take some comfort in knowing that it should be smooth sailing after that. Right?

According to Mark Young, coordinator of counselor education at the University of Central Florida and co-director of the university’s Florida Marriage and Family Research Center, couples don’t need to feel any undue dread about the “unlucky” seventh-year anniversary. If the seven-year itch was ever anything more than a myth, he says, it likely doesn’t apply now, mainly because many couples are waiting until they’re older (and oftentimes more established, settled or mature) to get married.

That’s the good news. The bad news? Couples should expect to confront several “danger zones” during the course of their marriage, usually related to developmental pressures. According to Young, these stress points often coincide with:

  • The birth of the first child. “There’s a complete reorientation,” Young says. “You now have a triangle in your relationship.” This is an especially important time for couples to seek counseling, he says. “No one is really prepared for the 24-hour nature of a child,” Young says. “It’s not like a Labrador retriever.”
  • Children becoming teenagers. Couples end up spending the great majority of their time talking about or dealing with issues related to their teenagers, Young says, while often completely ignoring critical maintenance activities in their marriage in the process.
  • A woman turning 30 or a man turning 40. These are “dangerous times,” Young says, because of what’s going on inside the head of the individual who is reaching a self-perceived milestone age.
  • The empty nest years. So much effort has gone into raising the children that when they’re gone, a husband and wife can feel like two strangers living in the same house. At the same time, spouses who have remained together “for the sake of the kids” often feel that it’s finally “safe” to get divorced once their children are in college. “In fact,” Young says, “it’s pretty devastating.”
  • Retirement. Young recounts what one woman told him about how difficult it was to suddenly have her husband home all day, every day. “I’ve been cooking his eggs for 30 years,” she said, “and now he wants to tell me how to do it.”

— Jonathan Rollins

 

Deployed Husbands, Waiting Wives

Angela Kennedy

There is an old saying that if the military wanted you to have a wife, they would have issued you one.

Fortunately today, the U.S. Armed Forces are beginning to recognize the direct correlation between a soldier’s home life and job performance. They are learning that the emotional well-being of the family — especially the spouse — affects the service member both on and off duty. Knowing that, every branch of the U.S. military now provides some type of family support services. Those services may not be enough, however, when a loved one is called to war. That’s when the strength of the military family unit is brutally tested.

American Counseling Association member Eileen Rakowitz has developed an existential group therapy model specifically for military wives — the women who say goodbye to their uniformed husbands and are left to wonder and worry if they will ever be together again. Rakowitz, a senior at Saint Louis University, hopes that counselors who work with the military population will try her model and find success in alleviating some of the anxiety and fears of these “waiting wives.”

Her interest in counseling military wives grew out of a project for a group therapy class. Rakowitz began researching the subject in early 2005 but, to her surprise, found mostly outdated materials and a large gap in the literature. What little she did find was reflective of the times in which it was written, focusing only on “waiting wives.” There was no mention of the possibility of “waiting husbands.”

“As a student, you rarely find big gaps in research, but this was a big gap,” Rakowitz says. “When I looked at the current literature, there was very little on this — nothing very specific, nothing that had a theory tied in or structure. It was mostly about support groups. Since there is little research on the effects of the war in Iraq on spouses and families at home, we can look to the impact previous wars have had on military spouses in order to build a bridge from the past to our current situation. I wanted to raise awareness that this is something we should really look at, especially in our current situation. We are at war. There are a lot of people over (seas), and there are people here who are going through this anxiety.” In an effort to draw the attention of more counselors to this topic, Rakowitz presented a poster session on her proposed therapy model at the ACA Convention in Montréal earlier this year.

Rakowitz notes a stereotype persists that these wives need to be strong for their husbands who are at war. In other words, she’s supposed to be the rock for him. But in reality, Rakowitz says, these wives are facing tremendous anxiety, and with that anxiety comes fear, sadness and loneliness. “These things need to be talked about while the husband is deployed so the wives can be strong for them,” she says.

Existential therapy focuses on the development of a client’s self-awareness by delving into issues of aloneness, meaninglessness and mortality, all of which military wives struggle with when their husbands deploy to a combat zone. Rakowitz’s proposed model examines the anxiety these women are experiencing through existential themes in an attempt to help them find support, hope and meaning in their lives. When their husbands deploy, military wives are left with bigger boots to fill because they are expected to take on new roles and responsibilities. At the same time, they often have tremendous influence on their husbands’ performance overseas. Rakowitz notes that coping with the absence of a loved one can stir up a multitude of questions, emotional and somatic responses, and problems at home.

“The themes of existential therapy are questioning responsibility, life and death — those themes that can be very abstract but in this population seem so concrete because those are exactly the things that they are dealing with,” she says. “Having a group that is more cognitive or solution-focused won’t work because there is no solution. This approach may help them to embrace those themes that they are going through.”

Common issues and stages

  • When their husbands deploy, wives face several common issues. They may:
  • Experience anxiety, sadness, fear, loneliness and resentment
  • Struggle with new roles and responsibilities
  • Find a lack of therapeutic resources available to them
  • Fail to properly support themselves, their families or their spouses fighting abroad

Rakowitz notes that many military wives have difficulty remaining optimistic and maintaining family integrity. Their self-esteem falters and they feel powerless. These wives often go through three stages:

  • Protesting (crying, searching for meaning and answers, resisting)
  • Feeling despair (loss of hope, apathy, withdrawal)
  • Detaching (superficial sociability)

“Although those are stages, it’s more circular,” Rakowitz says. “It’s more like a pattern within a cycle.”

To be resilient and supportive of her spouse overseas, a wife must first receive the necessary emotional, spiritual, physical and social support. “The stages are typical responses to anxiety,” Rakowitz says. “That’s why I think a group setting makes more sense than individual therapy because they will find universality and normalcy with other women going through the same emotions.” The common bond that develops between the group participants offers a sense of altruism, emotional catharsis and hope, she says. Rakowitz acknowledges that many of the ideas in her model are derived from group therapy legends Irvin Yalom and former ACA President Samuel Gladding.

Existential therapy is said to be an optimistic approach in that it embraces human potential, while remaining a realistic approach through recognition of human limitation. While the therapy examines people’s awareness of themselves and their human existence, it also recognizes that people do not exist in isolation from one another. It considers the need to be connected as natural but says people must ultimately come to realize that they cannot depend on others for validation and happiness. Rakowitz believes this presents an applicable theory for helping this population of women to learn about themselves through shared life experiences while also finding strength in socialization.

Group structure and logistics

According to the guidelines provided by Rakowitz, groups should be open-ended, meet weekly and contain no more than eight participants to allow for individual attention and interaction. Wives would be allowed to both voluntarily join and leave the group, with no restrictions related to rank or military grade. Preferably, the group would meet in a safe, private location, possibly including on the base or installation. Rakowitz says group membership should be limited to those who currently have deployed spouses.

She recommends recruiting group members by publicizing the group and talking with colleagues of established military organizations. Counselors can request that written announcements be posted in health service offices, childcare or nursery facilities, libraries and/or recreation centers on base. The announcement should have a positive tone, she says, and describe the group as a form of support for wives who are facing anxiety due to the deployment of their spouses. Information can also be made available through organizations that provide referrals to support groups for military personnel, including the United Services Organization, Army Community Services, Navy and Marine Corps Family Services and Air Force Family Support Services. Since this is an existential group, Rakowitz says some of the themes should be mentioned to help potential group members understand the theoretical framework the therapist will be using. Counselors should have additional resources available if a member needs supplementary support.

The goals of the group are to provide a comfortable setting for emotional release and to instill hope, love and other therapeutic factors that may provide military wives with the necessary support to become healthier, happier individuals. Rakowitz reasons that if the wives are able to find meaning in their experiences, they can be a healthier support for their husbands stationed overseas and for their families at home.

“Living authentically is a long-term goal that is overarching all the specific goals,” she says. “It will help them have more meaning in their day-to-day life even after their spouse returns.” Living an authentic life is about learning how to find meaning in every event — hardships as well as good times, she explains. “It’s embracing those events, good and bad, and living life to the fullest,” she says.

“Something important to consider in this particular group is to talk about what will happen when the husband returns or if the husband is killed at war,” Rakowitz says. “If a husband returns from deployment, the wife can experience distress due to re-establishing roles in the household, changing ways of communication and dealing with possible physical abuse if the husband is struggling with post-traumatic stress disorder. Since there are also difficulties associated with the husband’s return, the therapist should have resources available for these wives or couples.”

Waiting husbands?

Because of the limited information available, Rakowitz chose to frame her model around women, but she is optimistic that “waiting husbands” can also benefit from an existential group therapy model. “Most of the information that I did find was on military wives, but it’s obvious that we need to look at the husbands, too,” she says. “I’m sure there is a difference between the sexes, so it’s something that we as a profession need to examine.”

There is much encouragement for women to get help and a variety of services offered on base so that they can meet other “waiting wives,” Rakowitz says. But she adds that civilian husbands married to women in the military don’t usually seek help. They are usually struggling in silence at home.

“I’m hoping that this model will encourage others to look into this,” Rakowitz says. “We need to figure out what works for both genders because there aren’t a lot of professional articles out there to help counselors with this situation. We are currently in the midst of a war that has no definite end or outcome, so it is crucial that we begin to provide the proper therapy for spouses who are struggling to emotionally and financially support themselves, their loved ones overseas and their families.”