Monthly Archives: October 2006

Experience before job: A chicken-and-egg dilemma

Stacy Notaras Murphy October 7, 2006

Summer Reiner’s first job after graduating with a master’s degree in school counseling was as a bank teller. Initially she viewed her $7-per-hour position as a reasonable way to bide her time while VirtualSchool1looking for a counseling job in her school district in western New York. Soon, however, she realized that her dream job might not be just around the corner.

“What you find there is that school districts do not hire people who have not worked as school counselors and been paid for that work,” Reiner explains. “You usually won’t even get an interview. Most of us simply were unable to get interviews for local jobs.”

Recent graduates of school and mental health counseling programs can face tough odds when trying to land that crucial first position after completing their master’s degrees. Some of the field’s newest members find that the chicken-and-egg analogy fits their dilemma all too well: You can’t get a counseling job without experience, and you can’t get experience without a job.

David Kaplan, chief professional officer for the American Counseling Association and past chair of the Department of Counselor Education and Rehabilitation Programs at Emporia State University in Emporia, Kan., describes this situation as a burgeoning crisis. “This is something that really needs to be addressed by the profession,” he says. “I just saw too many students who couldn’t get an entry-level job and were told, ‘Come back when you’re licensed.’ But they couldn’t find a job that would have them engaging in activities that would lead to licensure. In some cases it meant that they would take a job for a few years at a halfway house, put that in and pay for their supervision. But to take a job there when what you really want to do is work in a mental health agency (is frustrating). … Our graduates should not have to negotiate for pay cuts because they’re not licensed. They’ve gone through too much and are too well-qualified to have to do that.”

Complex compromises

When Josh Riley began looking for work, he quickly realized that securing the “perfect job” might be difficult without his license. His wish list included living in his chosen city, serving his preferred client population and bringing in a high-level salary. By securing a job as an addictions specialist with the Whitman-Walker Clinic in Washington, D.C., Riley reached two of his three post-graduate goals.

“As it turns out, the pay really isn’t enough to service my loans, so I am deferring some of them and concentrating on my higher-interest debt first,” says Riley, an ACA member who graduated with his master’s degree last May. “But it was important enough for me to have a job that I really cared about, with an organization I really believed in, working with a population that I really wanted to work with. That drove my search more than the financial consideration. However, it’s now very stressful to have as much debt as I do, making what I make. But I also see this as kind of a steppingstone. In that way, I am getting great supervised experience that’s going to go toward my licensure. So there’s a trade-off there.”

Riley accepted the opportunity of being hired by his former internship site, a bonus that many veteran counselors say students ought to consider, even when selecting an internship while in school. “Because it was at my internship site, I felt like I had a foot in the door,” Riley says. “They actually asked me if I was interested in applying for the job.”

He adds that the yearlong internship experience built up his confidence about the work he is doing, making the transition to full-time work much more comfortable. “In terms of competence, I really feel like I’m doing the job well,” he says. “I feel like I have an advantage working for an agency because it’s a bigger place to draw clients from, and I’m getting supervision. I see those as real benefits in spite of the salary. I’m willing to make that trade-off for the experience and the hours that I am accruing.”

Compromise is often a necessity for new counseling grads. “I hated every minute of my job search,” laughs Anna Dyess, an ACA member who graduated with a master’s degree in counseling last spring. Yet she notes that her career development coursework helped ease the job search process. “My coursework really prepared me to do some of those things I wouldn’t have done too rapidly on my own,” she says. “For example, my résumé was in good shape, my cover letters were in a great format, I had many ideas of what I was looking for in a position. Ultimately, it came down to trying to decide what job was the best fit for me. The toughest part was balancing the pros and cons to make that final decision.”

“Being unlicensed changes what’s available to you,” she concedes. “You begin your search thinking about the clients you’d like to work with, but you end by realizing that you really are just looking for a job that will help you get licensure.” Still, Dyess knew that choosing the right entry-level position with a larger health care organization might help her move toward her long-term goal of working in palliative care.

After securing several informational interviews, Dyess applied for 10 solid leads and had three formal interviews. Eventually, the CareerBuilder.com site introduced her to the organization that would become her employer. She has been working as an evaluations specialist and therapist for the Lakeview Center in Pensacola, Fla., since September.

Dyess used the Internet almost exclusively in her job search. She recalls the complex undertaking of using various phrases in hopes of locating appropriate positions. “Every site uses a different keyword for counseling – mental health counselor, mental counselor, therapist, psychology field,” she says. “Narrowing that down to something that’s just for my degree would have been enormously helpful.” (Note: A new service from the ACA Career Center should now help eliminate such needle-in-a-haystack searches. A partnership between ACA and CareerBuilder.com has resulted in the ACA Job Center webpage, where ACA members can search prefiltered specialty positions for both master’s- and doctoral-level positions within the counseling profession. Members can access the resource by going to www.counseling.org and clicking on “Career Center.” From there, look for the ACA Job Center logo on the left-hand side of the page.)

Dyess reminds herself that working toward licensure is worth the compromise of bringing home a lower salary. “I knew that what was available to nonlicensed, master’s-level graduates is not the job you dream of,” she says. “Instead, the decision becomes what job do I get that will help me get to the job I dream of?” Dyess notes that her current position offers a one-stop-shop approach to working toward her licensure hours. “They are willing to provide supervision and are willing to support me in that process,” she explains. “Their benefits package was great, and the organization is a large, well-known name in the area. I know that it is recognizable and lots of people have started there.”

Backdoor options

Creativity often is the key to getting a foot in the door. Reiner quickly decided that she’d rather follow her dream of working with children in schools than living the life of a bank teller. After widening her geographical requirements, she soon found a good position in Maryland that would give her the experience required by employers in her home state of New York. “Fortunately, my husband was willing to quit his job (and) move to Maryland. We lived with my aunt and uncle for a year and a half, all so I could get my foot in the door,” she says.

When Reiner returned to western New York, she sent out several résumés, waited and soon had several interviews. “I tried to look at (moving) like it was opening doors to new experiences,” she says. “When we went down to Maryland, it was something we enjoyed, but I felt guilty about having my husband move. If we didn’t have housing, or if we’d had children, that probably wouldn’t have worked for us. I would probably still be a bank teller.” Reiner, an ACA member, is now a Ph.D. candidate at the University of Connecticut.

Living in an area with a saturated school counselor market meant Reiner had to think differently about obtaining the right kind of experience. She says several of her friends from western New York either moved or found jobs with mental health agencies, despite their education in school counseling. A large group of Reiner’s fellow alumni were recruited and relocated to Las Vegas, where the applicant pool for school counselors was dwindling. Taking steps to research alternative locations may help new counseling graduates secure better positions.

While the market for school counselors may be tight in western New York, the opposite is happening in Alabama. There, mental health graduates are filling some school counseling jobs when they can’t find appropriate positions elsewhere. Stephanie Puleo, an ACA member who is the counseling program coordinator and CACREP liaison at the University of Montevallo in Montevallo, Ala., notes that many of the school’s graduates are having trouble finding adequate entry-level jobs.

“Some are kind of going around the state certification process for school counselors,” Puleo says, “coming in the back door to that avenue even though they’re not specifically trained as school counselors. Obviously they don’t need the (licensed professional counselor) credentialing to get those jobs, (but it) is a scary kind of thing that they’re not trained as school counselors.”

Even school counseling jobs are few and far between in her state, Puleo concedes. But “when the applicant pool of qualified school counselors is exhausted, they will turn to people who have degrees in community counseling or even marriage and family for that matter,” she notes. “Some of our students know that is going to happen, so they take the school counseling courses as electives, but they … haven’t had practicum and internship experiences in schools.”

Meanwhile, other Montevallo students are accepting lower-level jobs to get by while looking for better positions. “Many of our students end up taking bachelor’s-level jobs at nonprofit agencies until they can get enough work experience and enough supervision to pursue licensure,” Puleo says. “When we do our follow-up surveys, they come back statistically looking like everybody is getting jobs, but they’re certainly not getting jobs that they’re the most qualified for.

“I think what’s happening in the field is that the so-called ‘entry-level’ jobs are really not entry level at all. When advertising for a job at the master’s level, employers are actually looking for people who are fully licensed. You can’t get fully licensed right out of school, and so those are not really entry-level jobs.”

Victims of our own success?

Considering the long road the counseling profession has traveled to insist on licensure from its membership, the current conundrum begs the question: Are we victims of our own success?

Prior to 1976, counseling graduates didn’t face as many hurdles in finding a job, as supervision hours and licensure were not yet requisite. But after years of hard work, 48 states, the District of Columbia and Puerto Rico all have licensure mandates. While that has helped raise the profile of the counseling profession, the flipside is that mental health centers now seek the insurance reimbursement benefits of licensure. Given the choice of hiring an unlicensed graduate or someone who can bill insurance from their first day, the potential discrimination makes sense.

“I strongly believe that the licensure laws are in place to protect the public, so I wouldn’t want to see the licensure laws changed,” Puleo says. “What I would want to see is the employers becoming more educated and more flexible. My position always goes back to advocacy. I’m not comfortable calling ourselves ‘victims.’ We’ve advocated all these years for our place in the market. I think we need to focus our advocacy efforts on educating people about the purpose of licensure and what that means, how it works in different states and so forth. Whether you’re the student or the counselor educator or not, I think we all have an advocacy role to play.”

Puleo puts much of the responsibility for educating potential employers on the graduate school programs themselves. “It really is grassroots,” she says. “A lot of it begins with the places the schools select to be part of their internship and practicum sites. You start there by educating those people, because they’re going to have to be partners with the institutions as far as supervising students. As the pre-master’s students are in the field, they can begin advocating with the other agencies they network with. I really think the institutions can be instrumental as we create partnerships with onsite supervisors.”

Puleo notes that the University of Montevallo is working to reach out to organizations that could hire its students, advocating for them to be accepted into the same applicant pool as those who have other mental health degrees. “We try to educate those employers about the licensure process,” she says. “Alabama first got licensure in 1979, and the requirements have changed over the years. It used to be an easier process with a lot of flexibility. Now it’s become very rigid, with a two-year process requiring 3,000 hours of licensed supervision, during which you are an ‘associate licensed counselor.’ Many employers are looking for fully licensed individuals, but they’re only willing to pay very low entry-level salaries, not realizing that 3,000-hour difference.”

“We’re advocating and teaching the students to advocate for themselves in terms of educating employers,” she continues. “In Alabama, you can’t become an associate licensed counselor without having a job first. That’s the vicious cycle: They can’t get a job until they’re licensed, and they can’t get licensed until they have a job. As a result, they’re taking jobs for which they probably would have been qualified at the bachelor’s level just to get a foot in the door.”

Some veteran counselor educators also are calling on their already-established colleagues to remember back to the days when they were new graduates and to get involved in advocating for counseling’s next generations. Pat Schwallie-Giddis, a former acting executive director of ACA who is the director of graduate programs in counseling/human organizational studies at George Washington University in Washington, D.C., notes that the benefits of mentoring and supervision go both ways. As a past president of the D.C. Mental Health Counselors Association, she has seen many of her colleagues offer reduced-rate supervision fees to new graduates.

“It has become a problem where recent graduates are having difficulty finding somebody at their work site — it may not be included in their employment agreements — and it’s costly to pay for somebody to supervise them,” Schwallie-Giddis says. “We ought to encourage other potential supervisors to join organizations and get their names out in this manner.” She notes that the networking experience may benefit both supervisors and supervisees.

Patience and preparation

Despite the challenges, counselor educators encourage new graduates to be patient and imaginative when considering their options. Many new graduates report the “ego-blow” of discovering that the available entry-level jobs may not even require a master’s degree. But others suggest that even bachelor’s-level positions can offer good information and experience, as well as prelicensure hours. Many of these jobs include a variety of supervision opportunities at no extra charge as an employment benefit. They also offer the chance to learn more about an organization before applying for a higher position. The organization gets to know the new employee, while the new employee gathers a lot of information that may help secure a better job.

Some counselor educators recommend that current students consider additional course work (particularly course work that is required for licensure) to make themselves more attractive to future employers. Allen Wilcoxon, an ACA member who is a counselor educator at the University of Alabama, notes that his program has witnessed agencies hiring students based on their licensure eligibility upon graduation.

“In our state, graduation from a CACREP-accredited program ensures the licensure applicant meets the academic requirements for licensure,” he says. “Further, many of our graduating students take the (National Counselor Examination) during their final semester of study. Additionally, we strongly encourage our pending graduates to complete as much of the licensure application as possible to expedite their submission and review. To a prospective employer, a graduate from a CACREP program with a high rate of success on the NCE — sometimes with a passing score in hand — and a submitted application for licensure presents a good situation for employment, though that employment is often with the stipulation of licensure within a very brief period of time.”

Meanwhile, it’s never too soon to get involved with the larger counseling community. Schwallie-Giddis advises her students to seek out professional and mentoring relationships as soon as possible. “When they join the local mental health association or ACA, they immediately have more access to resources than they would otherwise,” she explains. “I suggest that they do some networking (and) find someone who would be willing to mentor them.”

Reiner agrees that mentoring is an invaluable resource. “School counselor mentors also provide an opportunity for new grads to expand their network, which hopefully would result in greater job opportunities,” she says. “As employed school counselors get to know (new graduates) and their commitment to the profession, they could share this information with hiring principals (or) possibly even introduce the student to the principal.”

Dyess adds that being up-front about employment aspirations, even with those outside the counseling field, may help graduate students and new professionals build a more effective network for finding the right job. “The best resources you have are the people around you,” she advises. “The really great leads I got were from people who knew people. I found out about this job and interviewed with this woman because she’s a friend of my stepmother’s mother. Talk about six degrees of separation! People are very helpful if you’re willing to ask.”

“If you can somehow connect yourself to someone else, you can advance,” Dyess says. “I have never met the man who recommended me for my job, although I’ve had several phone conversations. Again, these are the contacts you get if you’re willing to tell people that you are looking for a job.”

 

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Stacy Notaras Murphy is a pastoral psychotherapist at PC&CC in Washington, D.C., and a contributing writer for Counseling Today. Contact her at stacymurphy@pastoralcounselingdc.com.

Letters to the editor: ct@counseling.org

A healthy mind-set

Jonathan Rollins

Judy Maris was halfway through her counseling internship and foundering. In her early 50s, she had decided to make a drastic career change and entered Montana State University’s mental health counseling program. Now, with the finish line in sight, self-doubt was threatening to overtake her.

“I was finding myself knocked off my feet again and again during my internship,” she says. “I was getting caught up in the client narratives and going immediately to problem solving. I was trying really hard to do it ‘right’ each day and instead ended up feeling clumsy and awkward. Struggling had become my M.O.”

At the same time, Maris was beginning a counseling elective course taught by her practicum supervisor, John Christopher. There was double incentive for Maris’ enrollment in the class. First, “I had a lot of respect for John,” Maris says. “He is an incredibly ‘present’ person. Even if you don’t know that concept, you understand quickly that here is someone who is truly ‘with’ you. I wanted to have that, too.” Her second reason? “The class didn’t seem too hard,” she admits. “I basically thought it was a yoga class.”

Christopher’s class, Mind-Body Medicine and the Art of Self-Care, does involve yoga. It also involves meditation, relaxation techniques and qigong, a Chinese discipline of gentle, graceful movements related to tai chi. Christopher, a counseling professor and member of the American Counseling Association, designed the course six years ago primarily to improve students’ self-care through mindfulness-based stress reduction techniques. To his surprise (and to the surprise of many counseling students, who assume they are simply signing up for an “easy” course), the class has had an even more significant impact. “I’ve been shocked at how powerful the course has been,” Christopher acknowledges. “It was really more about self-care. I wasn’t expecting the overflow into the students’ counseling practices to be so profound.”

Maris, who earned her master’s degree in 2005 and is now working in a private practice under supervision as she pursues licensure, believes the class ultimately altered the course of her counseling career. “My internship supervisor (at Montana State) started noticing a change in my work before I did,” she says. “As I was taking the (Mind-Body Medicine) class, my work took on a new organic quality, showed much more spontaneity and was enlivened. I started getting great results as far as shifts in my clients, and it had nothing to do with problem solving. I was learning how to genuinely feel positive regard for my clients, let go of judgments and be present in the moment. I was learning to contain clients’ anxiety without joining in. We’re told over and over again (as counseling students) that this is what we need to do, but no one had told us how.”

Christopher didn’t exactly tell Maris how either, but his course did something even better — it showed her. “It was the class that had the most impact on both my clinical work and on my personal life,” she says. “It was a transformative experience for me.”

Lessons in self-care

Stress, burnout and even vicarious trauma are facts of life for counselors. Surprisingly, Christopher says, relatively few counseling programs teach students how to deal with those problems. “Self-care is something we mostly give lip service to,” he says. “We all recognize that self-care is central to the field, but we don’t have many techniques for helping students to achieve that.”

Christopher first got interested in yoga, meditation and the martial arts as avenues to tap into human potential as a young man. He later became a yoga instructor and then went back to school for a degree in counseling. “For years,” he says, “I didn’t know how to integrate my commitment to spiritual practices with my counseling practice or my thinking about clients. They were two different worlds.”

But approximately eight years ago, a nurse at Montana State returned from a seminar and approached Christopher about helping her to run some mindfulness-based stress reduction programs at the local hospital. From there, a colleague suggested that Christopher design a similar course for counseling students.

Students in Christopher’s Mind-Body Medicine course meet twice a week and spend the first 75 minutes of each class practicing qigong, yoga and meditation. Different students are drawn to each of the specific disciplines. “The multiple methods show them that there are different avenues into the mind,” Christopher says. The next 45 minutes are spent reviewing readings and empirical research articles on the disciplines and discussing their applications to counseling.

Students are also expected to practice the disciplines outside of class for 45-minute sessions four times per week. In addition, students maintain experiential journals in which they comment on the readings and reflect on the mindfulness-based practices. “Their journals are really kind of works of art,” Christopher says. “Oftentimes, they’re very open about their personal struggles and how this course is impacting them.”

Maris remembers vividly the unexpected challenges posed to her early on in class by the seemingly simple process of meditating. “It was very challenging for me to sit still and quiet my mind,” says Maris, a member of the American Mental Health Counselors Association, a division of ACA. “It was staggering to find out the cacophony of noise going on in my mind all the time. I became aware that it was controlling my life.”

While those revelations can be startling, says Christopher, part of the process of self-care is becoming more aware of when we’re feeling stressed out and frazzled. “Mindfulness-based practices are really about slowing down,” he explains. “There’s something really healing about that. A lot of the strategies in our culture are based on avoidance or denial. Mindfulness is about directly encountering one’s emotional fatigue and stress, going through the experience fully and coming through the other side when you’re ready. It’s about allowing ourselves to have moments of surrender or dying and rebirth.”

That principle holds true even for the most experienced professional counselors, Christopher says. “After a difficult session with a client, you should give yourself five minutes to sit in a chair and let everything you’re feeling flood through you. That process serves as a release. But we often don’t do that. Instead we rush to get another cup of coffee.”

From classroom to counseling room

“I think counselors, as a group, are really pretty hard on themselves,” Maris says. “The biggest piece of self-care for me was letting go of beating myself up all the time. I let go of the judgments and let go of the need to control everything. I’ve learned to just accept whatever is in this moment, whether that’s fatigue or a cramp in my leg or the phone ringing. … Doing ‘nothing’ (in response to a problem) runs counter to our whole culture, but for me, learning to do that happened while meditating on the cushion. For me, the heart and soul of the course was sitting by myself on a cushion in silence.”

What has become more apparent with each year that Christopher teaches his class is that the mindfulness practices meant to help students manage their stress are also having a dynamic impact on their actual counseling skills. According to Christopher’s published research, students report that the course:

  • Increases their comfort with a client’s silence or expression of strong emotions
  • Increases their clarity of thought and capacity for reflection
  • Increases their capacity for empathy and compassion
  • Enhances their listening abilities
  • Improves their ability to focus on clients and the therapeutic process

Being “present” is a struggle for most people, Christopher says, but mastering that concept is especially important for counselors, who must be focused on their clients. Mindfulness practices help counselors do exactly that. “Learning listening skills requires a kind of discipline,” Christopher says. “This is similar to the kind of discipline required for and cultivated by mindfulness practices. It’s a learned discipline to live in the moment — to stay in the present — instead of dwelling in the past or future.”

Maris says that engaging in low-impact activities such as yoga, qigong and meditation on a daily basis helped her both physically and emotionally. “It’s a way of beginning each day being aware of your own body instead of the hundred things you need to do,” she says. “I found myself more at ease and sleeping better at night.”

Now that she is out of the classroom and working full time as a counselor, Maris has fallen out of the habit of practicing yoga. But meditation remains a part of her daily routine, and the tools she acquired in Christopher’s class are still integral to her therapeutic approach. “I have my days when I’m not centered and back into the mode of following the client’s narrative,” she says, “but I usually take three to five minutes before each session to focus my mind, attention and breathing.” Inspired by her experience in Christopher’s class, Maris even went on a 10-day meditation retreat, spending 13 hours a day on the meditation cushion.

Getting clients centered

The mindfulness practices that have proved so successful with counselors-in-training can also be of great benefit to clients, Christopher says. In particular, he believes the disciplines can help clients who are struggling with anxiety or depression, who are overly self-critical, who have a tendency to be spectators rather than actively engaged or who haven’t learned to be comfortable with the full range of emotional experiences. Even so, Christopher says, “I don’t teach students about how to introduce these practices to clients because you first have to be really dedicated to practicing them on your own.”

Still, many of Christopher’s students have gone on to integrate elements of mindfulness practices into their counseling sessions with clients. Maris regularly develops mindfulness practices for her counseling clients, sometimes leading them through a meditation exercise as they sit on a cushion, other times simply sitting in silence with them. “It’s not traditional stuff,” Maris says, “but for clients who are able to become mindful in session, it helps transition them from the chaos of their lives to the present moment and to become more in tune with themselves. It’s a way to begin to disconnect from your reactivity.”

Not every client is able to enter mindfulness, Maris says. Still, she does what she can to calm their minds. When she works with clients who exhibit high anxiety levels, for instance, she notices that their breathing is shallow and rapid. Before learning mindfulness-based practices, Maris says, she likely would have fed off the clients’ anxiety. Now, she attempts the opposite approach — getting anxiety-ridden clients to feed off of her calm. She begins by intentionally slowing her own breathing and talking to the clients in a soft, measured tone. After some time, clients often fall in line with Maris’ deep, unhurried breathing, releasing tension and relaxing their minds without ever being verbally instructed to do so. “That seems to bring them as close to mindfulness as they’re able to be at the moment,” Maris says.

Maris is up front about her belief in the usefulness of mindfulness practices and meditation with clients and always asks permission before using them in therapy. Client reaction has been exceedingly positive, she says, but she won’t attempt to use mindfulness techniques with certain clients. “A moment of silence would be too terrifying for them,” she says. “The noise of their lives in their minds is a safety factor for them.” She adds that she is also cautious about using mindfulness practices with certain trauma victims.

Christopher’s research has shown that the Mind-Body Medicine class at Montana State is consistently transformative for counseling students. He is undertaking a follow-up study to determine the course’s long-term impact. “Our preliminary analysis indicates that about half the students remain committed to some type of formal practice,” he says, “and the vast majority find ways to incorporate mindfulness principles into their everyday lives and self-care strategies.”

There has been some discussion about making the course a requirement for counseling students at the university. Maris is a proponent of that thought. “I can’t think of anything that has as far-reaching a positive effect as developing some type of meditation practice,” she says. “We (counselors) deal with a lot of human suffering. To be able to deal with that fully and compassionately, we have to be able to be compassionate with ourselves first.”

Obligations for protecting the confidentiality of the deceased

David Kaplan

This is the 10th and final interview in a series of columns that have focused on new aspects of the revised ACA Code of Ethics. The previous nine updates, as well as the entire text of the ACA Code of Ethics and additional resources, are available on the ACA website at www.counseling.org/ethics. For this final update, ACA Chief Professional Officer David Kaplan interviewed Judy Miranti and Michael Kocet, two members of the ACA Ethics Code Revision Task Force.

B.3.f. Deceased Clients

Counselors protect the confidentiality of deceased clients, consistent with legal requirements and agency or setting policies.

David Kaplan: Why did the Ethics Code Revision Task Force feel a need to add a standard (B.3.f.) addressing the confidentiality of a deceased client?

Judy Miranti: I don’t think we had any initial intent to say, “We’re going to protect the confidentiality of our clients in death.” It evolved as we focused on client welfare. And it turned into a very unique part of the revised ethics code.

Michael Kocet: The task force felt that addressing the welfare of a client means protecting confidentiality in perpetuity, and, therefore, confidentiality should not end when a client passes away. There may be circumstances where an individual does not want information shared, even upon their death, and so a counselor needs to make a reasonable assessment of when and where it’s appropriate to maintain that confidentiality. A person’s death should not mean that any and all information about that person in the counseling relationship is open to public scrutiny or discussion.

DK: Let’s look at a scenario. A 22-year-old client commits suicide. His mother approaches you and says, “I need to know if my son really hated me when he killed himself.”

JM: This is a difficult situation, but the welfare of the deceased client is paramount.

MK: I agree. The welfare of the client is still existent, even after death. The bottom line comes down to the issue that we still have to protect the son’s privacy, even after he dies, and to make our best clinical judgment in terms of what he would want done with the information. If we make a determination that the client would give consent to the requested information being shared with his mother and we have some prior documentation to that effect, then I would go ahead and respond to the mother. But if there is uncertainty, I would keep the client’s statements about his mother confidential.

DK: So are you essentially saying that whatever rules applied while the client was alive would also apply after the client died?

JM: Yes.

MK: Here is a scenario I use when I train counselors. An elderly client dies and the adult children start a legal court fight over the estate. One daughter says, “Dad went to counseling, so he must have been crazy. I’ll check with his counselor and look at the counseling records. It’ll prove that dad didn’t know what he was talking about and that he was not in his right mind when he left the house to my brother.” We would honor the counseling relationship even after the client was deceased and protect the privacy and confidentiality of the father by refusing the daughter’s request to review her father’s case notes.

DK: Let’s look at a scenario that involves positive sentiments. A client dies tragically and before their time. During the counseling, the client said some very loving and heartfelt statements about family members. Would it be appropriate for the counselor to contact the grieving family and say, “I’m really sorry to hear what happened. I just wanted to let you know that your partner” or your father or your mother “had some very loving things to say about you”?

JM: Your professional judgment is going to come into play. You don’t have to divulge all the particulars. If the client said some loving things about family members, I think it would be a comfort to them in their grief to know that.

DK: What is the role of informed consent in protecting the confidentiality of a deceased client?

MK: It is now important to build the concept that confidentiality does not stop upon the death of a person into the informed consent process.

DK: Is it appropriate for a counselor to go to the funeral of a deceased client who has died unexpectedly?

JM: The counselor needs to ask herself or himself the question: What would be the purpose of going to the funeral? 

MK: Based on an honest appraisal of that question, the counselor would have to assess whether going to the funeral would be beneficial or harmful to the memory of the deceased client. In that respect, it is no different than evaluating the beneficial versus harmful aspects of attending a client’s wedding or graduation ceremony.

If your professional judgment clearly indicates it would be beneficial, you can choose to go to the funeral service. It may be prudent to sit in a chair off to the side where you don’t have to necessarily interact with others. You can pay your respects to the client and then leave without having to interact with too many people. If someone asks you how you know the deceased, you can simply state that you worked with them professionally. 

On the other hand, if the client’s family clearly knew about and might have even been involved in the counseling at times, you might be more active in paying your respects if there is reason to believe that the family would be comfortable with and comforted by your presence.

DK: Can the case history of a deceased client be used when teaching classes or as an example during a professional presentation?

JM: The same rules apply as to a living client. You can use case examples for educational purposes as long as identifying information is removed so that the client cannot be identified. 

DK: What should be done with the records of a deceased client?

MK: Once again, the same rule applies as for a client who is living. The ACA Code of Ethics does not state a specific length of time to keep records. However, many state licensing laws require that records be kept for seven years. Therefore, seven years is a reasonable amount of time to keep the file of a deceased client.

DK: Speaking of records, what is the appropriate way to react to a subpoena for information from the file of a deceased client?

MK: If I made a professional judgment that divulging information could in any way harm my deceased client, I would, with the assistance of the lawyer provided by my liability insurance company such as the ACA Insurance Trust, decline to provide information.

JM: At the point the court indicated that I had no choice but to comply with the subpoena, I would give the minimal amount of information possible. I would protect the client’s confidentiality as much as possible, even after death.

DK: To wrap up, what would you say is the key to Standard B.3.f. and protecting the confidentiality of a deceased client?

MK: That the counseling relationship exists even through death. We continue to honor that relationship after a client dies. As such, whatever statements in the ACA Code of Ethics applied when the client, supervisee, student or research participant was alive continue to apply after they are deceased. If a counselor would not disclose information when a client was alive, they should not disclose that information in their death.

Relieving third-party payment headaches

Robert J. Walsh and Norman C. Dasenbrook

Q: I have had difficulty collecting third-party payments from a certain insurance company. My claims either get denied or I have to bill multiple times for the same sessions. I have tried dealing directly with the insurance company with little or no success. Do I have to hire an attorney?

A: Hiring an attorney is the last resort. Dealing with insurance/managed care companies can be frustrating, although, by and large, we have had a positive experience with third-party payers. The major frustration is the time it takes to follow up on a claim that is denied or not paid. Making multiple phone calls, wasting time on "hold," writing letters, sending e-mails, etc., all take the counselor’s time — time that is better spent treating clients or marketing the practice.

Your informed consent document needs to address the collection of fees, not only from the client but from third-party payers as well. We recommend that the financial section of your informed consent document contain a statement such as the following: "As a courtesy, we will bill your insurance company or third-party payer for you, if requested. In the event that the claims are denied, it is the client’s responsibly to pay the balance due."

Your client and the client’s employer — or more specifically, the human resources department (benefits manager) — are the best options for dealing with a stubborn insurance company. That’s because they pay the premiums!

We have found that a call or letter from the client to the insurance company is more effective than contacts from the counselor’s office. If that

doesn’t work, both the client and the counselor (with appropriate signed releases of information) can enlist the help of the benefits manager at the client’s place of employment. The insurance company wants to keep the employer happy, and the employer wants to keep the employee happy. We have resolved numerous insurance problems by having both the client and benefits manager communicate directly with the insurance company.

Typically, an appeal letter is sent from the client, after a signed release, to the managed care or insurance company. A copy is sent to the company’s benefits manager. The clinician also sends an appeal to both the client’s benefits manager and managed care or insurance company outlining the clinician’s credentials and stating the reason the client was referred to him/her.

The clinician should also ask his or her state organization to develop a response to denials. The state organization’s written response to denials should outline the training and extent of practicum involved in the clinician’s licensure. This response should be sent to the client’s employer with a copy to the insurance or managed care company.

For more on informed consent, working with third-party payers and examples of denial appeal letters, log on to the American Counseling Association website at www.counseling.org and go to the "Private Practice Pointers" section. From there, click on "Working with managed care," "Managed care response templates" or "Implementing informed consent."

Q: I am a provider with a certain insurance company that referred a client to me. My usual fee is $80. They paid me only $63 per session. Is there anything I can do legally? I know I cannot legally bill the client for the extra $17 per session. She says she cannot afford it. Any help or insight would be greatly appreciated.

A: Sorry, there is nothing to be done, and managed care does not allow balance billing. Just as airlines sign up with Travelocity, Orbitz or other discount agencies to fill extra seats, we sign up with managed care companies and take a reduction for the opportunity to get their referrals. Most of us accept this as part of "doing business."

If your practice really takes off, you can opt out of some of the "lower paying" managed care companies and focus your practice on the "better paying" ones. A comprehensive list of fee schedules for 56 managed care companies, insurance companies and employee assistance programs has recently been updated and can be downloaded from the "Private Practice Pointers" section of ACA’s website (www.counseling.org). Good luck!

Note: We hope to see many of our readers in March 2007 at the ACA Convention in Detroit. Attend our Private Practice Learning Institute or our minisessions at the Career Center. Or simply stop by the Walsh and Dasenbrook Consulting booth in the exhibit hall and give us your feedback on our column.

Robert J. Walsh and Norman C. Dasenbrook are co-authors of The Complete Guide to Private Practice for Licensed Mental Health Professionals (www.counseling-privatepractice.com). ACA members can e-mail their questions to walshgasp@aol.com and access a series of bulletins on various private practice topics on the ACA website at www.counseling.org.

Letters to the editor: ct@counseling.org

Sorting out certification

Jim Paterson

Having finally finished the rigorous training it takes to become a counselor, the last thing you may want to think about is attaining even more education or the possible benefits of tacking on another set of letters after your last name. But after taking some time to recharge, you might want to explore some interesting specialty areas of counseling through the pursuit of voluntary certifications.

National certifications enhance your expertise, stretch your mind and bolster your resume. And, of course, earning these certifications may put you in a position to work in a specialized counseling field for which you have a particular interest and skill set.

“They indicate that you want to be the best counselor that you can and, depending on the type of certification, can prove that you undertook training in a specific area of expertise beyond that needed for a generic professional license,” says ACA Chief Professional Officer David Kaplan. “The analogy is to board certification in medicine. An ophthalmologist doesn’t need to be board certified to practice; they already have a license to practice as a physician. But voluntarily getting board certified shows that they have met rigorous standards and know a lot about eye diseases.”

Counseling credentials are typically offered through a professional group and accredited, usually by an organization such as the National Organization for Competency Assurance. The NOCA website (www.noca.org) offers excellent information about certification and a list of certifications that the organization, through its accreditation commission, has reviewed (see www.noca.org/ncca/accredorg.htm).

One prominent set of credentials comes from the National Board for Certified Counselors. “NBCC gets all the credit in the world for catalyzing the professionalization of counseling through its certification program,” says Kaplan, adding that the organization’s credentials were groundbreaking.

ACA established NBCC in 1982 to set general standards for counselors with its National Certified Counselor designation. NBCC now also offers three other specialty certifications for clinical mental health counseling, school counseling and addictions counseling. The NCC designation is a prerequisite or co-requisite for NBCC’s other specialty certifications, and each certification requires some experience in that particular field.

NBCC and the Academy of Clinical Mental Health Counselors created the Certified Clinical Mental Health Counselor credential. Today, nearly 1,200 counselors have the certification. Some states make CCMHC holders the authorized providers of mental health services for insurance purposes.

The Master Addictions Counselor credential grew out of a collaboration between an ACA division, the International Association of Addictions and Offender Counselors, and NBCC. “While there are several addictions credentials on the market, NBCC’s designation identifies a master’s-level counseling practitioner with specific knowledge and experience in the addictions field,” says Susan Shafer, executive projects director at NBCC.

The third specialty credential offered by NBCC is the National Certified School Counselor. This credential acknowledges school counselors with master’s degrees and two years of work in schools, as well as passage through a challenging application and examination process.

Through its certifications, NBCC reports that the organization is able to:

  • Generate client referrals through a referral service
  • Ensure portability of nationally recognized credentials
  • Keep NCCs up-to-date on current professional credentialing issues through a newsletter
  • Offer participants a voice in — and a way to support — the proper development of national standards “by counselors, not legislators”

Switching gears to another specialty area, 16 counselors have become certified as Forensic Health Evaluators, according to Norman Hoffman, president of the National Board of Forensic Evaluators. The program, which certifies counselors for court-related mental health evaluations, requires full mental health state licensure and 40 hours of forensic experience, along with a rigorous program of study and testing that typically takes a year.

“These people have to be well trained,” Hoffman says. “You can ruin a case by saying the wrong thing under cross-examination. Most therapists aren’t prepared for this. It is very different work. You need to provide unbiased, objective evaluations.”

Currently, he says, 50 additional counselors are working on the certification. “If you are interested in court work — child custody evaluations, determining insanity, personal injury cases and other mental health issues, this is something to consider and work for in your future,” he says.

ACA division certifications

Other certifications exist independently. The National Career Development Association offers training for the Global Career Development Facilitator credential, which is designed for those who do not have a master’s degree in counseling but are providing career services. The credential is offered by the Center for Credentialing and Education, an affiliate of NBCC.

“A CDF may serve as a career group facilitator, job search trainer, career resource center coordinator, career coach, career development case manager, intake interviewer, occupational and labor market information resource person, human resource career development coordinator, employment/placement specialist or workforce development staff person,” says NCDA Executive Director Deneen Pennington.

NCDA also has a Master Career Counselor designation. MCCs must have two years of membership and three years of experience. They also must maintain the National Certified Counselor credential and state licensed psychologist credential, complete three credits in each of six NCDA competency areas and complete work experience under a certified supervisor or licensed counseling professional and document that half of their current full-time work is directly related to career counseling.

Another specialty credential is available from the International Association of Marriage and Family Counselors, which offers certification as a Certified Family Therapist. In 1994, IAMFC set up the National Credentialing Academy to establish and monitor this national certification system for counselors in the field.

In addition, another ACA division, the American Rehabilitation Counseling Association, offers Rehabilitation Counselor certification. “It is extremely rewarding,” says ARCA President Irmo Marini, a professor and graduate coordinator at the University of Texas-Pan American in Edinburg. “They can work in vocational rehabilitation, for nonprofit agencies, in the government, as vocational experts in forensics and with disabled students and others. National job demand in this area is very high.”

New national counseling certifications are also on the horizon. For instance, one of ACA’s divisions, the Association for Spiritual, Ethical and Religious Values in Counseling, has recently taken preliminary steps to develop a certification. Other groups are studying similar actions.

Kaplan says counselors new to the profession should consider a specialty certification either to enhance their knowledge or to establish, improve or change their area of expertise. But he also advises them to be selective. “There was a time when we were advised to get as many certifications as we could so you had as many letters after your name as possible,” he says. “In this day and age, you can drive yourself crazy trying to keep up. Now it is probably best to focus on one specialty certification that you really want for your practice. Completing it will be very rewarding.”