Monthly Archives: July 2009

Crossing the great divide

Jonathan Rollins July 15, 2009

Editor’s note: This is the first in a two-part series examining how counselors can work more effectively with clients who hold strong religious beliefs. The second article will appear in the August issue.

Jill D. Duba has long been interested in where issues of religion and faith fit into the counseling process, sparked in part by her own developing faith and the questions she wrestled with along the way. “A person’s faith development is such a journey,” says Duba, an assistant professor in the Department of Counseling and Student Affairs at Western Kentucky University. “I often found myself thinking, ‘It would be nice if there was a mental health professional whom I could bounce my personal reflections off of,’ but there really wasn’t.”

That point was further driven home to Duba when she sought counseling while going through a divorce. It was important to Duba to filter what was happening in her life through her faith perspective, so she tried to broach the subject. “I brought up my faith as bait for the therapist in session, but she never took it. It was very frustrating for me, so I stopped going to see her,” says Duba, a member of the American Counseling Association, the International Association of Marriage and Family Counselors, the Association for Counselor Education and Supervision and other professional counseling organizations. “You know, I’m an informed client, so when she avoided talking about religious issues, I was able to say to myself, ‘She’s the one with the problem, not me.’ But most clients aren’t going to be able to reframe that.”

“Based on those experiences, I’ve taken it on myself to say to my students and my profession, ‘Hey, you’ve got to pay attention to a client’s religion and faith in counseling,” says Duba, who has researched and written about the subject extensively.

Duba isn’t alone in her perception that many counselors and related helping professionals remain hesitant to engage their clients’ religious identities and sensibilities. The reasons are varied but may include a lack of proper training, a fear that counselors are imposing their values on the client by even mentioning anything of a religious nature, a struggle overcoming their own bad experiences with organized religion or a distaste for the client’s religious beliefs and values.

When Robert Brammer attempted to obtain a dual doctorate in counseling and religion, he was told that the fields were incompatible. “My initial reaction was that it was very sad that we don’t see how intertwined these two fields really are. After all, the cultural identity of religion is fundamental for a large number of people,” says Brammer, an associate professor of psychology and director of both the mental health and school counseling graduate programs at Central Washington University.

J. Scott Young was likewise taken aback as he embarked on a counseling career. Growing up in a highly religious family, he thought of himself as “spiritually curious” and had been intrigued by Eastern religious thought since he was a kid. “So when I came to graduate school 20 years ago, I was interested in how religion/
 spirituality and psychology relate as people look for meaning in what is happening to them. I was struck by the fact that it really wasn’t talked about at all, and I thought it was a bit odd that we wouldn’t consider these connections as counselors,” says Young, professor and chair of the Department of Counseling and Educational Development at the University of North Carolina at Greensboro.

“Both religion and psychology are trying to answer some of the same questions,” Young adds, “but from very different perspectives.”

A historical tension

Those different perspectives have contributed to what Young terms a “historical tension” between religion and the mental health professions. “I’m not personally uncomfortable working with religious clients, but I often hear that concern from counselors — that it brings them great anxiety,” says Young, coauthor with Craig Cashwell of Integrating Spirituality and Religion Into Counseling , which is published by ACA. “If a conservatively religious person comes in for counseling, the worldview is a little different from that of the typically more liberal counselor. If (the client) holds really rigid perspectives, it sort of goes against the mental health perspective that most counselors are working from. Counseling’s emphasis on self-determination goes back to the self and how decisions can make the individual happy, while in religion, the emphasis is on sacrificial ideas. There is a focus on God and others. In some instances, that’s actually getting in the way of the client being happy. In other instances, it brings them their greatest joy.”

Studies have shown that mental health practitioners tend to be less religious than the average American, Young says. However, he thinks counselors, as a group, are more open to religious belief — both their own and that of clients — than their colleagues in related mental health fields because “we don’t teach one model. It’s a buffet of beliefs in counseling.”

Perhaps for that reason, the concept of spirituality has made greater inroads into counseling than has religion. As Brammer explains, “Spirituality is a broader construct that includes all of our religious beliefs and focuses on an individualized component. Religion is an organized sense of beliefs that is shared, that is corporate, and there is a behavioral component to it.”

Adds Lisa Jackson-Cherry, the outgoing president of the Association for Spiritual, Ethical and Religious Values in Counseling, a division of ACA, “When you look at religion, it involves customs, traditions and a set belief system shared by a group of individuals. A person doesn’t necessarily need to belong to a religious group to be spiritual.”

Young, Brammer and others in the counseling profession readily acknowledge that clients who have strong religious beliefs generally cast a wary eye toward counseling, sometimes out of suspicion that practitioners will try to divest them of their faith, sometimes because they assume the counselor will judge them negatively for their religious views or even regard them as pathological for expressing faith in a higher power at all.

“Historically, a lot of counseling approaches have taken a neutral or even negative view of religion — think of (Sigmund) Freud and (Albert) Ellis,” says Richard Watts, professor and director of the Center for Research and Doctoral Studies in Counselor Education at Sam Houston State University and editor of the ASERVIC journal Counseling and Values. “Of course, Ellis later went on to say that the Bible was the greatest self-help book ever published, even though he didn’t believe in it personally.”

Even when religious clients don’t sense any hostility toward their beliefs, they may question whether a secular counselor can truly grasp what drives their life. “Religion is about the transcendent, while in counseling, the approach is more humanistic,” explains ACA member Kenneth Anich, an associate professor of psychology at Divine Word College and a member of the Society of the Divine Word, an international congregation of Catholic missionary priests. “When the client is devout — whether the client is Muslim, Roman Catholic, Protestant or some other religion — for them, life is about a personal relationship with a higher power they identify with and not just about being a ‘good guy.’ The question for these clients is will the counselor respect that as a guiding force in their life?”

LaVerne Hanes Stevens, an ACA member who is both a counselor and an ordained Protestant minister, concurs. “There are so many worldviews, and when a person is truly guided by their faith, they want congruency. When they come for counseling, it’s often at a time when they are struggling to find congruency between their faith and their problem. The two may seem divergent or even conflicting, yet the individual wants to protect and preserve the faith they have developed,” she says. “During times of struggle, people realize just how vulnerable they are, so they are reluctant to sit and receive advice from someone who may be in opposition to what they believe.”

These individuals often have a fear of being judged, not just by the counselor but by their religious body for needing “outside” help, she says. “There can be an added sense of shame: ‘As a person of faith, my life should transcend these habits or struggles.’ So they may decide to stay in a place of struggle without getting help at all,” says Stevens, who wrote the book The Fruit of Your Pain precisely because she saw certain elements of religious extremism making people of faith believe that they weren’t “allowed” to struggle.

Individuals for whom religion is an important part of their identity can struggle with the same problems — including pornography, depression, substance abuse and temptation in their marriage — as those who profess no faith in a higher power, says Stevens, who has done clinical practice work in both secular and faith-based settings. “But when they’re struggling is when religious clients are least likely to feel they should be talking about God to a counselor,” she says. “Some may even worry that they will spoil the image of their faith in front of a nonbeliever. You know, ‘A-ha! I knew you Christians or you Muslims or you Jewish people weren’t really …”

It’s interesting, says Anich, that the wall separating therapy and religion or matters of faith wasn’t always so imposing. He points out that the original definition of therapy was “doing the work of the gods or serving the gods.”

“Therapy really had to do with soul work until we tried to move it into the field of pure science,” he says. “Then, if something didn’t make perfect logical sense, we decided that it didn’t exist and labeled it stupid. Therapy championed a belief that humans are machines that just need to be oiled correctly.”

But he believes that wall is slowly being lowered again. According to Anich, when he joined ACA in 1975, there was virtually no mention of a person’s spirituality or religious beliefs having any type of role in the therapeutic process. “It was almost treated as if it was unethical,” he says. “But now I see all these sessions on spirituality and treating the person holistically at ACA conferences. We’re realizing again that people are not machines.”

Anich says this gradual acknowledgement that clients’ religious beliefs and religious identity are important to the counseling process is a very positive development. “There is this history of the twain shall not meet,” he says, “but I think there is a real hunger for it among clients.”

Stumbling blocks

In the opinion of those interviewed by Counseling Today , counselors who avoid bringing up issues of faith and religion are actually doing their clients a disservice. “In looking at treating the whole person, I believe that if an individual comes in with a strong religious foundation, that aspect of their lives should at least be investigated,” says Jackson-Cherry, chair of the Department of Counseling and director of the community and pastoral counseling program at Marymount University. “I think religion is a very heavy cultural component. Their religion is part of their identity, and we should have the desire to learn about their religious beliefs. Counselors inviting clients to express who they are in all areas is important.”

“I think there are still a lot of counselors and counseling students who are resistant because they believe they are somehow imposing their own values on the client in even asking basic questions about religion in the intake,” adds Jackson-Cherry, who maintains a private practice in Maryland. “We assess for everything from suicide to sexual orientation, but if we ask about religion, we assume we’re instilling our own values.”

In fact, adds Watts, it could be a covert imposition of the counselor’s values on the client if issues of faith and religion are ignored. “To not address the client’s faith is to leave a big hole in the counselor’s understanding of the client,” he says. “Typically, the religious or spiritual beliefs of spiritually active clients provide a values system for how they see themselves and others in the world. To truly understand a person, you have to understand the values and constructs that guide his or her life.”

“To me, a counselor would be acting unprofessionally to say, ‘I just don’t discuss these issues.’ They’re on the spectrum of multicultural and diversity issues,” says Michael Kocet, incoming president of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling and past chair of the ACA Ethics Revision Task Force. “I don’t think counselors have to specialize in spirituality issues, but they should be open to working on them if that’s important to their clients.”

Many counselors don’t feel competent touching on issues of religion and spirituality, Kocet says. In those instances, they need to pursue competence — read counseling literature, take workshops, seek supervision and collaborate with others, including religious leaders of diverse faiths, he says.

But counselors who disagree with certain religious viewpoints may assume that it’s fine to simply refer these clients on to another professional. “In some cases, it’s absolutely ethical for a counselor to refer, but it can be unethical if it’s simply a matter of perpetuating our own prejudices and bigotry as counselors,” says Kocet, chair of the Department of Counselor Education at Bridgewater State College. “It’s at least bordering on unethical conduct if we refer when we actually have the necessary competency to work with them. Referrals should not be automatic, and the ethical step doesn’t end at the referral. We have to identify what’s blocking us from working effectively with that client. ”

Counselors also have to be careful not to make assumptions about clients based on their stated religious background, Kocet warns. For instance, he says, even if the counselor and client come from the same faith background, the counselor shouldn’t assume that they have the same beliefs. Or if a client identifies as being religiously conservative, the counselor shouldn’t automatically conclude that the client is anti-homosexual.

Watts has also heard counselors and counselors-in-training admit to reservations about working with clients who hold divergent religious views and beliefs. “I view religion and spirituality under the rubric of cultural diversity,” he says. “By definition, I don’t need to believe the same thing that the client does. That’s analogous to having to change skin color to work with someone of a different ethnicity. If a counselor doesn’t attend to religious issues in counseling, I think they’re being culturally insensitive and unethical.”

Neither does Anich believe that the counselor and client must share the same — or even similar — religious beliefs to have a productive, respectful relationship. As a guest professor at the University of New Orleans, he taught a class on integrating counseling and spirituality. To his students’ surprise, his first guest speaker was a Wicca high priestess. “One of the main points I want to get across to students is that the only thing that will fail them in their work is intolerance,” he says.

When Anich was a chaplain in a hospital, he was asked to speak with a nurse overheard administering satanic rites to a patient. In working with the nurse, who identified herself as a high priestess in the satanic church, Anich used a simple but effective approach that he recommends for any counselor struggling with a client’s religious values, views or beliefs. “I simply engaged her and asked her what her beliefs meant to her,” Anich says. “And even as a satanic believer, she was comfortable coming and talking to me — a Catholic priest. She told me, ‘You’re the first religious person who didn’t run from me as soon as I told you what I am.’”

The counselor educators with whom Counseling Today spoke said that graduate programs need to do a better job of preparing counseling students to deal with religious issues (also see “The student perspective” on p. 31), but many also emphasized the importance of practitioners taking steps to become more conversant with religious clients. “It needs to start outside of the counseling office,” Duba says. “Counselors are their own toolbox. Build relationships with people who are religiously different than you outside of the workplace. We have to practice being uncomfortable and put ourselves out there. Stumbling through conversations of a religious nature (outside of the office) will be a big help.”

Brammer, an ACA member, advocates counselors attending different religious events and asking questions about anything they don’t understand. “Developing religious multicultural competency requires exposure,” he says. “If we fail to understand the religion from a personal perspective, our questions may sound like an anthropological investigation. It would be like a counselor who hates sports and exercise helping an Olympic athlete with performance anxiety. Clients need to believe their counselors can understand their culture and preferred coping mechanisms.”

“If you want to work with this population, you have to develop competency for it,” says Stevens, who works for Chestnut Health Systems training clinicians to do substance abuse assessments and treatment planning using the Global Appraisal of Individual Needs. She encourages counselors to talk with clergy and other spiritual leaders. Taking that step will help counselors learn more about their clients’ belief systems while simultaneously allowing them to market themselves and develop relationships with spiritual leaders for possible consultation later, she says. “The only way to develop that bond of trust is to spend time talking with various religious leaders,” says Stevens.

Next month: Effective counseling approaches for working with religious clients.

ASERVIC Competencies

In May, the Association for Spiritual, Ethical and Religious Values in Counseling approved its revised Competencies for Addressing Spiritual and Religious Issues in Counseling.

Culture and worldview

1. The professional counselor can describe the similarities and differences between spirituality and religion, including the basic beliefs of various spiritual systems, major world religions, agnosticism and atheism.

2. The professional counselor recognizes that the client’s beliefs (or absence of beliefs) about spirituality and/or religion are central to his or her worldview and can influence psychosocial functioning.

Counselor self-awareness

3. The professional counselor actively explores his or her own attitudes, beliefs and values about spirituality and/or religion.

4. The professional counselor continuously evaluates the influence of his or her own spiritual and/or religious beliefs and values on the client and the counseling process.

5. The professional counselor can identify the limits of his or her understanding of the client’s spiritual and/or religious perspective and is acquainted with religious and spiritual resources, including leaders, who can be avenues for consultation and to whom the counselor can refer.

Human and spiritual development

6. The professional counselor can describe and apply various models 
 of spiritual and/or religious development and their relationship to human development.


7. The professional counselor responds to client communications about spirituality and/or religion with acceptance and sensitivity.

8. The professional counselor uses spiritual and/or religious concepts that are consistent with the client’s spiritual and/or religious perspectives and that are acceptable to the client.

9. The professional counselor can recognize spiritual and/or religious themes in client communication and is able to address these with the client when they are therapeutically relevant.


10. During the intake and assessment processes, the professional counselor strives to understand a client’s spiritual and/or religious perspective by gathering information from the client and/or other sources.

Diagnosis and treatment

11. When making a diagnosis, the professional counselor recognizes that the client’s spiritual and/or religious perspectives can (a) enhance well-being, (b) contribute to client problems and/or (c) exacerbate symptoms.

12. The professional counselor sets goals with the client that are consistent with the client’s spiritual and/or religious perspectives.

13. The professional counselor is able to (a) modify therapeutic techniques to include a client’s spiritual and/or religious perspectives and (b) utilize spiritual and/or religious practices as techniques when appropriate and acceptable to a client’s viewpoint.

14. The professional counselor can therapeutically apply theory and current research supporting the inclusion of a client’s spiritual and/or religious perspectives and practices.

Jonathan Rollins is the editor-in-chief of Counseling Today. Contact him at

Living life to the full

Lynne Shallcross July 14, 2009

At the age of 75, Jenny was dealing with more than
  her fair share of grief. She had recently lost both her son and her husband of 50 years to cancer. She was also terminally ill with cancer herself.

“Jenny was dealing with complicated grief — the loss of her husband and son, plus her own diagnosis,” says Christine Moll, associate professor in the Department of Counseling and Human Services at Canisius College in Buffalo, N.Y. “She felt genuine sorrow for her remaining family members and the tremendous loss they were feeling.”

At a time when Jenny had perhaps her greatest need for counseling, there was yet one more hurdle to face — she was unable to travel to a clinician’s office. So instead, Moll went to her.

Earlier in her career, Moll, a past president of the Association for Adult Development and Aging, a division of the American Counseling Association, worked with Catholic Charities of Buffalo in a group known as the Geriatric Outreach Treatment Team. The team focused solely on conducting at-home visits with people over the age of 60 who could not travel.

“Over the course of about three months, Jenny and I worked on her accepting her diagnosis as part of her life journey and her anticipation of meeting her husband, son and other family members on the ‘other side,’” Moll says. “Jenny shared her life story, her own early childhood and how her family of origin managed during the Great Depression. We discussed the strengths and gifts that she and her family possessed to live through those hardships. How might those strengths serve her now?”

As Jenny’s health weakened, her daughter and daughter-in-law were often there when Moll made her visits. “We spoke of Jenny as a mother and grandmother, her love for her family and how that love would be carried on in her absence,” Moll says. “What legacies would continue with family meals, celebrations and in life, especially as her grandchildren grew into adults themselves?”

“My last visit with Jenny was about 12 hours before her death,” Moll continues. “She was peaceful and ready to move on to what she believed to be eternal life with her God and her family who had predeceased her. Interestingly enough, as they witnessed Jenny’s peace, her daughter and daughter-in-law were able to let go of their anger and ‘let her go’ in peace.”

Similar to Jenny’s experience with loss and her own mortality, challenges can mount for people as they age, says Larry Golden, an associate professor in the University of Texas at San Antonio Department of Counseling. The challenge for counselors, he says, is helping these clients to cope.

Golden, an ACA member who ran a private practice for 25 years, divides older adults into two categories: “old-old” and “young-old.” He categorizes the first group as those in their 80s and 90s who are becoming physically frail and possibly struggling with dementia. Clients in this group may be struggling with a decision over whether to move to an assisted living center or enter hospice care, he says. Many different entities may have an interest in the person’s decision, from the health care industry to family members, Golden says, adding that the counselor has the opportunity to serve as an advocate for the client. “Our primary concern as counselors is advocacy,” he says. “(But) the individual, depending on their mental competence, should have the last word.”

Golden defines the young-old as people in their 60s and 70s who are in good health. Although their counseling needs don’t differ much from any other age group, he says their commitment and openness to the counseling process is generally greater. The same person who had alcohol problems in his 20s might seek counseling in his later years more ready to embrace change and see life differently, Golden explains. Likewise, someone with a history of failed relationships might meet a partner in her later years and become invested in ensuring the relationship’s success. “This group takes counseling very, very seriously,” Golden says, and in his opinion, that’s what makes them such rewarding clients. “We usually meet people in counseling when they’re in trouble. I would just as soon meet them when they’re serious about the work.”

Bumps in the road of life

While people often say that they dream of retiring, the realities can prove nightmarish for many individuals. “People leaving their profession is like a death,” Golden says. “My identity doesn’t exist anymore at the point I retire.” That struggle is an opening for counselors, however. “Group counseling can be very effective because it helps normalize the kinds of anxiety people feel,” he says. Finances are another stressor related to retirement, so Golden suggests counselors who want to specialize in retirement issues consider collaborating with a financial expert or learning more about finances themselves.

Chronic health problems can pose another uphill battle for people as they age, says Summer M. Reiner, an assistant professor at the College at Brockport in New York and incoming president of AADA. They experience discomfort on a constant basis and mourn the ability to do things as quickly as they used to, she says. It’s important for counselors to focus on what it means to that client to be going through those struggles. “The bottom line is acknowledging that the person is experiencing that condition,” Reiner says.

It’s also imperative for counselors to know about clients’ illnesses and what medications they are taking, Moll adds Being knowledgeable of the side effects of an illness or medication can help the counselor better understand the client’s situation. As an example, Moll cites a client who has suffered a stroke, leaving that person more labile or teary. If counselors aren’t paying attention to that, Moll says, they might misinterpret the frequency of the tears and conclude that it’s something more serious, such as depression.

Loss and grief go hand in hand and can weigh heavily on people as they go through life. People lose spouses and partners, family members and friends. With a country at war and violence on the streets, Moll adds, that loss can come in the form of younger family members as well. “Loss is a ‘change’ that we cannot change, and we are often left feeling ‘orphanated,’ eviscerated and just plain sad,” she says. “Loss for an older adult can be more challenging because our losses sometimes accumulate, so that with each loss we feel as if a surgical wound, well-healed, has reopened. Loss may remind us of our own mortality.”

“Grief is a normal emotional reaction,” she continues. “A counselor can assist the grieving client to come to terms with the separation from their loved one and how life has changed with the absence of loved ones and to live life in its new form.”

For many people, religious faith can be of crucial assistance when dealing with grief, and Reiner points to studies showing that spirituality increases as people age. Attempting to incorporate that spirituality into counseling is important, says Reiner, who suggests counselors review the Association for Spiritual, Ethical and Religious Values in Counseling’s competencies and then talk to clients about what they believe and if spirituality could be a means of support to them. “The client is the best person to educate the counselor about their beliefs,” she says.

All three counselors agree that finances can be a significant barrier in getting counseling for older adults on a fixed income. The client might not have insurance or be able to afford the copay. “We better get effective at getting Medicare coverage for LPCs (licensed professional counselors),” Golden says. “We will continue to be shut out of opportunities to work with older adults until we get Medicare coverage.” In the meantime, Moll notes, social service agencies often provide counseling on a sliding scale where the fee is dependent on the client’s income or ability to pay. Worship communities and community centers might also provide counseling services to members.

Like Moll’s client Jenny experienced, simply getting to a practitioner’s office may offer another challenge for older adult clients. Moll and her colleagues solved the problem by visiting their clients at home. For those counselors for whom making house calls isn’t feasible, Reiner suggests helping clients navigate options such as local van service or public transportation.

This is your life

As the years pass by, emotional baggage can build up. That’s when “life review” can help, Golden says. Life review is a counseling intervention that Golden says he uses mostly with old-old people, as long as they’re not struggling with dementia. “There’s a tendency in old people to want to reminisce, to talk about the good old days,” he says. “There’s a serious side to that that counselors can capitalize on.”

In the process of the counselor asking questions about the client’s life comes talk about the good, the bad and the unresolved. “One of the reasons older people reminisce is because they are trying to get some resolution to issues in their lives,” Golden says. “The questions could be everything from tell me about your first friend to tell me about your first romantic relationship to what are some of your memories of your children? You don’t get very far before people get into some issues.”

“(Life review) provides one last chance to make sense of your life,” he continues. “It can even lead to decisions to reconcile or to reframe an issue in a way that lends itself to acceptance rather than bitterness. These are some of the tasks of the old-old.”

In addition to life review, counselors say there are other do’s and don’ts when working with older adult clients. Among their best tips:

  • DO coordinate with physicians. Clients are oftentimes seeing multiple physicians, Reiner says, and it’s helpful for a counselor to know what treatments clients are receiving and what medications they may be taking.
  • DON’T be shocked. “Many of us think (sexual) intimacy stops at a particular age,” Moll says. “It doesn’t.”
  • DO address the client’s needs and barriers, then attend to the emotional strain that could come with those needs or experiences. For instance, Reiner says, if a client uses a wheelchair and the ramp is inconvenient or nonexistent, address how to make it easier for the client to access the counselor’s services. Then address the client’s feelings about how frustrating it might be to experience barriers due to physical limitations.
  • DO be attentive. Speak clearly and audibly, Moll says. Pay close attention to the client’s ability to hear, see and move. “Make sure they’re comfortable,” she says.
  • DON’T make assumptions. Don’t assume that clients aren’t concerned with their sexuality, their leisure time or their family needs just because they’re older, Reiner advises. Likewise, don’t assume that a client is distraught, grieving or even sad if a spouse or partner has died, she says. “Don’t jump to conclusions about what things can mean to a person. Remember that although they’re aging and they have a lot to deal with, they’re still full people.”
  • DO enjoy older clients. “Working with older adults is as much of a journey as working with any other age group,” Moll says. “I genuinely enjoy the person and the uniqueness of the person.”

Connecting with clients

Counselors who are passionate about working with older adults and would like to build their client base can start by networking with local doctors. Try internists, heart specialists or other doctors likely to have a larger elderly patient base, Moll suggests. Build relationships with them and then ask them to refer clients whom they think might benefit from counseling. Reiner agrees that doctors can be a great resource, pointing out that older adults might make more doctor’s appointments if they’re lonely and in need of interaction. Physicians might pick up on that and be able to refer the client.

Reiner also recommends that counselors visit the local library or senior center to meet older adults and put out pamphlets. Pamphlets are effective at helping to spread the word, she says, because even if someone who picks it up doesn’t need counseling, that person might think of a friend or family member to refer. Hospice is another good resource, Reiner adds. Even if the person receiving hospice care doesn’t want counseling, a spouse or elderly sibling might benefit from it.

When you connect with older adult clients and begin working with them, Moll says, it’s important to remember that the length of one’s life story is what makes it even more powerful. “These clients’ stories are rich and powerful and historical and full of wisdom,” she says. “There’s much to be learned.”

What has Moll learned from Jenny and her other clients? Above all, resiliency. “What each (client) has taught me is that there’s something to be said for resiliency, there’s something to be said for seeing the glass half full.”

Moll’s own father, who passed away about six years ago, exemplified resiliency, she says. In his younger years, he loved to golf, and he didn’t let the aging process stop him. Instead, he adapted the game to fit his stage in life. Out on the green, someone would help him tee the ball up, then after a short swing, he’d move the ball to within chipping distance and finish out the hole. “He played practically up to the end,” Moll says. “He simply went with what he could do.”

That idea of the glass being half full isn’t lost on Moll, and it’s a philosophy she tries to share with her clients. “It’s how we transcend our limitations,” she says, “to find quality in what we have in front of us.”

Lynne Shallcross is a staff writer for Counseling Today. Contact her at

Letters to the editor:

Measuring counselor success

Chris Morkides

Lonnie Rowell knows all about the benefits of evidence-based counseling practice, a subject that has consumed much of his life for the past 10 years. Not everyone, however, is quite so enthusiastic.

“I was told by a counselor educator yesterday that she didn’t want anybody to look too closely at what she does,” says Rowell, an associate professor and codirector of the counseling program at the University of San Diego and a member of the American Counseling Association. “’We know what we’re doing is effective, and we don’t want administrators looking at our results,’ she told me. It’s an extreme example, but it is an example of counselors being pushed out of their comfort zones.”

ACA member Patricia Kyle recognizes the merits of evidence-based practice — using therapy that is tested, scrutinized and then applied in clinical settings. However, she questions local agencies that rely almost exclusively on certain types of evidence-based practice primarily because their bills are paid by federal and state agencies that accept those modalities and require the use of evidence-based practice.

“I had a student in my family counseling class who chose a theoretical model and made choices based on that model. The student did an excellent job,” says Kyle, an assistant professor of psychology at Southern Oregon University. “She went out, interviewed for a job and was told, ’We can’t hire you because this isn’t an evidence-based practice.”

The model chosen by the student?

“I’m not sure,” Kyle says. “But it wasn’t cognitive behavioral. That much I know.”

Trying to answer an enduring question

Evidence-based practice is not a new concept, with the Federal Action Agenda providing the impetus for it a decade ago. But evidence-based practice has picked up steam in recent years as counselors and other mental health workers seek to improve their efficacy, insurance companies look for quantifiable results and the people who control governmental funding attempt to determine where monies can best be apportioned.

Then there is that age-old question still looming in the public’s mind: Does therapy really work? Evidence-based practice and the testing of the efficacy of counseling modalities is a response to that question. Testing whether a particular practice meets client needs may also help to change the public’s perception of psychotherapy as a “soft” science.

“There is no perfect test out there,” says ACA member Paul West, an assistant professor of counseling education at Alvernia University. “But I can do my best with what we have. That is a whole lot better than doing no outcomes research at all.”

John Murphy, a professor of psychology and counseling at the University of Central Arkansas, agrees. “Sometimes, I’ll hear people say, ’I just know intuitively how my client is doing.’ That scares me,” says Murphy, a member of ACA. “Without denying the part that art and experience play in this profession, I think it would be arrogant for someone to rely solely on their judgment — and not some sort of testing — to determine whether counseling is effective.”

What should counselors do in the age of evidence-based practice? That has been the subject of much talk and a number of presentations at ACA conferences in recent years.

Kyle, along with Lani Fujitsubo and Paul Murray, both professors of psychology at Southern Oregon, presented on “Counselors Dealing With the Impact of Evidence-Based Practice” at the 2009 ACA Conference in Charlotte, N.C. She cited the American Psychological Association’s definition of evidence-based practice in her presentation: “Practice is evidence-based which utilizes scientific research findings and/or methods of assessing therapy process and outcome in some way to inform clinical practice.” Kyle also noted some of the attributes of evidence-based practice, including transparency, standardization, research, replication and attaining meaningful outcomes.

However, Kyle still isn’t a true believer in evidence-based practice, at least not in the way it’s being utilized today. “We all support the underlying concept that counselors should be accountable to their clients and use strategies that have an evidence base,” she says, “but we (her copresenters and other critics) have concerns about how evidence-based practice is being implemented on the federal and state levels.”

Specifically, Kyle is concerned that agencies receiving federal and state funding will end up relying solely on approved programs, which, she points out, haven’t necessarily cornered the market on effectiveness. In many cases, she says, other interventions (“non-approved programs”) simply haven’t been reviewed according to the standards required by the Substance Abuse and Mental Health Services Administration (SAMHSA) at the federal level or other agencies at the state level.

According to Kyle, humanistic, gestalt, existential, Jungian and Adlerian approaches largely have not been reviewed. At this writing, SAMHSA’s National Registry of Evidence-based Programs and Practices ( included 137 interventions. Plug in the word “gestalt” in SAMHSA’S search engine, and nothing comes up. Insert “existential” and, again, nothing appears. Insert “cognitive behavioral,” however, and 19 interventions appear.

“Existentialists don’t even like the label ’existentialists,’ much less going out and finding data,” Kyle says.

Compiling that data, doing research and submitting the findings to federal and state agencies is exactly what Kyle advocates though. “The list of approved practices is narrow,” she says. “But it doesn’t have to be so narrow.”

Kyle mentions other problems she thinks are endemic with tests that lead to the approval of certain practices, including a lack of research on the impact of the therapeutic alliance and what she sees as the process of science squeezing art out of therapy.

In spite of those reservations, however, she comes down on the side of evidence-based practice overall. “Any ethical counselor wants to make sure they are using strategies that have positive outcomes,” Kyle says.

Quality control

The way West looks at it, all counseling is evidence based. What’s in question is the quality of the evidence.

“You have your client satisfaction surveys,” West says, “but we don’t know if they are just evidence of the strength of the client-counselor relationship. A client may say you’re the best thing since soft butter, but it might not be evidence of the effectiveness of counseling.”

OK, so why not ask the therapist if counseling has been effective?

“It’s a question of bias,” says West, who presented on “The Role of Evidence-Based Therapy Programs in the Determination of Treatment Effectiveness” at the 2009 ACA Conference. “Say I’ve developed this treatment plan, and the client has completed this and this and this. Who’s to say the treatment plan helped bring about change? And if it doesn’t work, do I look at myself, or do I say the client screwed up?”

Then why not go by a book that outlines the best practice for particular situations?

“Yes, there is evidence that certain treatment approaches work for certain problems,” West says. “An example of that is in substance abuse. Everybody does a type of 12-step program that is supposed to be effective. But we know that only 16 to 17 percent respond to substance abuse treatment. Is that really best practice?”

For West, empirical evidence with pre- and post-tests that are tied to clinical results should be the foundation of counseling. “If I’m doing therapy correctly, the test I use should have good reliability and validity and should include a broad range of issues. If I let this guide my assessment, I should be able to tell whether there is change at the finish.”

West concedes, however, that the use of testing and evidence-based practice has encountered resistance. “And not just in counseling, but with human services across the board,” he says. “First of all, there is no mandate for it. One, the insurance companies don’t all require people to prove that their efforts work. Even in the ACA Code of Ethics , there is nothing that says you have to do outcomes research.”

Additional reasons for resistance are that many counselors simply do not like research or are not offered adequate training in school, West says. “If you only have one research course in school, is that really enough?” he asks.

Fear of failure also comes into play, West says. Some counselors are worried that outcomes research will show that what they’ve been doing all along isn’t working. For these counselors, engaging in evidence-based practice may be akin to “slitting (their own) throat and possibly losing their job,” he says.

How should counselors measure success then? According to West, it isn’t about measuring the outcome of Program A versus Program B. Likewise, it isn’t about theoretical models. “Because we really haven’t found that one theory is better than another,” he says.

It is, however, about the quality of the research, West says. “Does Program A do valid research and follow guidelines based on the population it treats? The idea of a client getting well has to be defined. It might not be about making a behavioral change, say, for someone suffering from chronic mental illness. It might just be about whether the client is taking his medication.”

Action research

West suggests that mental health agencies could and should make better use of colleges and universities to formulate evidence-based practices.

Rowell, who presented on “Action Research in Counseling: Closing the Gap Between Research and Practice” at the 2008 ACA Conference in Honolulu, agrees. He is a proponent of “collaborative action research” and sends his students out into real-world clinical settings to work hand-in-hand with practitioners.

Why action research? In part because of public skepticism of the effectiveness of counseling, Rowell says, and in part because of the lack of adequate graduate school training programs. “And within the field itself, practitioners often don’t use research correctly,” Rowell says. “It’s a well-established fact within school counseling, but it also happens within clinical mental health settings. (Mental health professionals) read journals, but they don’t read them carefully.”

Rowell’s students help school counselors formulate questions, do the research, test whether interventions are working and, if not, determine what may work instead. Rowell believes action research also could help underfunded, overburdened community mental health settings.

The goal is twofold, he says: to help students learn the value of research and to help practitioners come up with successful, empirically tested counseling methods. “Psychology, as a profession, needs to hold itself accountable,” Rowell says.

Client feedback

For Murphy, all the evidence needed in formulating evidence-based practice is sitting in the chair across from the counselor during therapy sessions. “Who better to ask about the effectiveness of treatment than the client himself? The consumer should be the primary measure, if not the sole measure,” contends Murphy, who presented on “Client Feedback Tools: A Fast Track to Better Outcomes in Counseling” at the 2009 ACA Conference.

Murphy advocates starting off each session with a short question-and-answer period. During this time, clients relate how they are doing individually, interpersonally, socially and overall and then tell the counselor what they want to work on. This introduction, he says, should last about five minutes.

The counselor concludes each session by asking the client to fill out a form explaining how the session went. This takes about one minute, he says. “I tell them to be honest. If I’m not connecting with them, I sincerely want to know about it,” Murphy says.

Murphy points to studies showing the client’s perception of the client-therapist relationship as the most reliable predictor of the success of therapy. So Murphy wants to know about those perceptions early and often. “It allows you to create a conversation around areas the client is concerned with,” he says. “It’s an ongoing thing. If things are going well, great. If things aren’t going well, you talk about what you can do differently.”

Aside from the efficacy of therapy, Murphy sees another reason for having the client take the lead. “If you’re blaming the client when things aren’t going well, it’s not only counterproductive,” he says, “it’s downright bad manners.”

ACA member Chris Morkides is a psychoterapist in private practice in Swarthmore, Pa. Contact him at

Letters to the editor:

In honor of those who lead

Richard Yep July 1, 2009

Richard Yep

What identifies a person as a leader? Is it the most popular person? The person who is able to rally the greatest number of volunteers? Perhaps it is the person who inspires others to follow the most ethical and professional path? I’m not sure, but I do know that July is the month when many American Counseling Association members take on new roles in order to support the association’s various activities. Many of our branch, division, region and other affiliated organizations change their leadership as well.

Regardless of where you serve, I welcome new leaders into the ACA family. Your work as volunteer leaders will be instrumental in achieving the goals that have been set. You are, without a doubt, the lifeblood of our organization, and your contributions to the profession can be significant as we move forward.

This month, we welcome Lynn Linde as the new president of ACA. I have known Lynn for many years, and her role as a volunteer leader is exemplary. The staff and I look forward to working more closely with Lynn as she sets about carrying on the mission of ACA. She will be an excellent advocate for the counseling profession. Her work as an educator, a practitioner and a high-level state administrator has provided Lynn with a unique perspective on the needs of our members and the counseling profession. For more on Lynn, read “Meet the president” on page 42.

In addition, a number of members will be joining ACA committees, task forces, the Governing Council and related organizational affiliates as leaders. I wish all of you the very best and continue to be in awe of the time you are willing to invest to be such an integral part of carrying out our mission.

Later this month, many counseling professionals from around the country will gather in the Washington, D.C., area for the ACA Institute for Leadership Training. All four ACA regions will be represented, and many division leaders will also attend the event. I want you to know that your leaders will also go to Capitol Hill to let our elected representatives know that counselors do have a voice (and a vote!).

For those of you interested in serving in leadership positions, yet unsure whether you have the experience or skills necessary, I say simply, let us know who you are. There are plenty of spaces at the table, and you need not have “prior experience” as long as you possess the drive, determination and time to help make a difference.

ACA and the counseling profession are in a unique position to truly make a difference in the lives of clients, students and communities. As we roll out new projects and services, I both encourage and welcome your participation.

As always, I hope you will contact me with any comments, questions or suggestions that you might have. Please contact me via e-mail at or by phone at 800.347.6647 ext. 231.

Thanks and be well.