Monthly Archives: April 2010

Treating trauma

Lynne Shallcross April 15, 2010

In just the first two months of 2010, devastating earthquakes rocked Haiti and Chile, a University of Alabama in Huntsville professor stood accused of gunning down colleagues at a faculty meeting and a reportedly disgruntled pilot flew his private airplane into an Internal Revenue Service building in Austin, Texas. These tragedies ranged in scope and affected people in different states and countries, but one common denominator was the trauma they no doubt left in their wake.

Natural disasters, ongoing wars, terrorist attacks, plane crashes, school violence and abuse are among the most widely recognized causes of trauma, but one expert points out that trauma can also stem from events that don’t necessarily make the national news. “Every day, counselors work with clients who are exposed to or experience the tragedies of daily life — auto accidents, the sudden loss of family members, friends, classmates or coworkers,” says Jane Webber, associate professor at New Jersey City University and coordinator of the university’s counseling and school counseling program. “Where we once considered traumatic events as rare, we now know that most people experience one or more such events in their lifetime.”

Carlos Zalaquett remembers working with a 64-year-old client who was referred to him for treatment for depression. “While discussing her history and intake form, she mentioned that she had felt depressed and anxious for the last four years,” says Zalaquett, coordinator of the clinical mental health counseling program and the graduate certificate in mental health counseling in the University of South Florida Department of Psychological and Social Foundations. “She didn’t have a prior history of these symptoms, but her family believed that aging and lack of a support or social network led to her current situation.”

As the two explored the woman’s strengths and therapeutic goals, the client shared with Zalaquett the goal of driving her car again. “Upon exploring the reasons for mentioning this goal, which was somewhat puzzling to me, she reported surviving a near-death car accident four years prior,” says Zalaquett, a member of the American Counseling Association. “She described living a life encompassing all of her current therapeutic goals, including driving her own car, before this traumatic crash.”

The focus of treatment rapidly shifted to addressing the client’s post-traumatic stress reaction following the accident, Zalaquett says. “We used systematic desensitization, imagery techniques and in vivo exposure to help her reduce her fear of driving and get her in the driver’s seat. Four months later, she was driving and, much to the surprise of her family, was no longer clinically depressed or anxious. She had reestablished a connection to a social network of friends and acquaintances.”

The challenges the client was facing originated from trauma, according to Zalaquett. “This original source was forgotten by her and her family due to the marked anxiety and depressive symptomology and social isolation observed, all of which were assumed to be the cause of her symptoms and not the consequences of her trauma. I saw her two years after the completion of her treatment. This time she was driving a close friend to therapy.”

The root of the problem

While the causes of trauma can vary widely, Zalaquett says, it is important to recognize when an event implies exposure to an extreme traumatic stressor. These events generally involve serious injury or the threat of death to the individual or witnessing an event that involves death, injury or threat of another person. Trauma can also develop when a person learns about the unexpected or violent death of, or serious harm or injury to, a family member or close associate, he adds.

“There are many traumatic events that do not meet the criterion of threatened death but are like ‘living death,'” adds Webber, who, along with J. Barry Mascari, served as editor for Terrorism, Trauma and Tragedies: A Counselor’s Guide to Preparing and Responding, the third edition of which was recently published by the ACA Foundation. Individual complex traumas such as sexual and physical abuse, domestic violence, ongoing harassment or bullying can fall into this category, Webber says.

Some of the signs and symptoms associated with trauma-induced stress include sleep disturbance, emotional instability and impaired concentration, Zalaquett says. When people have become emotionally or psychologically overwhelmed, they often protect themselves through denial, disbelief and dissociation, he adds. Traumatized individuals can have difficulty performing regular duties, might experience flashbacks or nightmares and may respond to events that remind them of the trauma. “Flood victims, for example, may demonstrate very strong emotional responses to rain, storm clouds, the sound of running water or the sight or smell of mud,” he says.

Zalaquett says counselors should also be aware that clients might express their emotional distress physically, complaining of headaches, backaches, stomachaches, sudden sweating or heart palpitations, constipation or diarrhea, or susceptibility to colds and other illnesses.

But the signs of trauma aren’t always visible, Webber says, so counselors should remain patient and supportive. “I have often worked with clients who, although they have been to several therapists, have never disclosed their symptoms or their trauma history,” she says. “Being fully present in the moment with such a client helps to build a safe environment. It may be weeks or months before the client feels safe enough with the counselor to disclose even a small hint.”

Presenting problems, intake forms and case histories can provide clues to a client’s traumatic experiences, says Webber, a past chair of the ACA Foundation who teaches disaster response, trauma and crisis counseling. “Asking solution-focused questions helps. For example, ‘When was the last time you felt good? When do you not feel this way? What are you doing when you feel differently?’ With training and supervised experience, counselors often develop an intuitive feeling about traumatized individuals — a sixth sense about the client’s fears, terror, feelings of being threatened and resulting self-protectiveness. The counselor ‘feels’ as the client feels and is alert to triggers that increase symptoms like hyperarousal, hypervigilance, dissociation, numbing, anxiety and avoidance of reminders of events.”

Counselors strongly emphasize the importance of helping clients understand that the feelings they are experiencing after a traumatic event are completely normal. But according to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, when post-traumatic stress symptoms persist for at least a month, a diagnosis of post-traumatic stress disorder (PTSD) might be considered. “For individuals experiencing PTSD, many emotional and cognitive processes become more intense, while paradoxically, others are deadened,” Zalaquett says. “In a sense, individuals who have their lives suddenly and drastically changed by destructive events essentially experience more than they can integrate, and their feelings of personal control, competence, security and safety are all greatly diminished. They now view the environment — and to some extent, other people — as unsafe. On guard, they are ready for danger at all times. This state of hypervigilance also increases the likelihood of social withdrawal and isolation and decreases the likelihood these individuals will seek assistance for their distress.”

Not everyone exposed to a traumatic event develops PTSD or other serious disorders, however. Webber notes studies have shown that the majority of people in mass disasters experience personal and spiritual growth and create new existential meaning as a result of their experience.

Certain trauma tasks are time sensitive, Webber says, such as securing an individual’s immediate physical and emotional safety, whether in the aftermath of an earthquake or in a situation of child sexual abuse. “Research shows that when survivors of mass disasters receive psychological first aid, this speeds the return to normal functioning,” she says. “Psychological first aid also provides for identification and referral for additional support for those with predisposing conditions or more serious problems.”

In disaster situations, many counselors want to begin providing counseling immediately, but doing so may have unintended negative consequences, Zalaquett advises. It is essential to conduct initial screenings of individuals to check for known symptoms or risk factors for PTSD before providing treatment, he says. “Counseling and other appropriate mental health treatments are indicated for those who are unable to overcome the trauma without assistance,” he says. “Also, early intervention for trauma survivors should emphasize helping them to connect with natural social support networks and resources available, as this has been shown to reduce the likelihood of chronic PTSD and enhance post-disaster functioning.”

Webber agrees that disasters have a different set of rules. “It is easy to confuse disaster mental health and trauma therapy,” she says. “Psychological first aid in disaster mental health is very different in purpose and use than trauma treatment. We must not only be knowledgeable about both but also know what protocol to use and when.”

Reaching out

Recognizing traumatic stress symptoms and cultural factors associated with survivors is key to developing appropriate therapeutic interventions, according to Zalaquett. Techniques vary but can include challenging irrational beliefs, correcting distorted thoughts and biases, role-playing, systematic desensitization, exposure with response prevention, relaxation training and biofeedback. But most important, he says, are the goals of counseling.

“The primary counseling goal is to establish rapport and provide a safe and culturally respectful environment for the survivor,” Zalaquett says. “As the survivor begins to talk about whatever he or she decides, the counselor should be prepared to ask questions to elicit deeper reflection. The counseling goal is to guide the process deeper to increase understanding of the client’s feelings. As long as the client does not become overwhelmed, continue to broaden the emotional and psychological scope of the session by allowing more difficult material to surface. In general, when uncertain about what an individual wants to talk about, the best approach is to ask and trust the client’s process.”

Webber agrees that establishing safety and stability for clients, not only in the therapeutic session but also in their lives, should be first and foremost for counselors. After that, Webber recommends a variety of helpful techniques:

  • Use metaphors that can be seen, heard and felt to help clients become attuned to where distress is felt in their bodies, she says. For example, have the client visualize the trauma as a pressure cooker with the toggle shaking and ready to blow.
  • Use grounding techniques to help clients stabilize. For example, Webber says, ask clients to name five non-distressing objects they can see, five non-distressing objects they can hear and five non-distressing objects they can touch. Integrate this exercise with deep breathing.
  • Try multisensory materials in sand play, play therapy, drama and art therapy. “I find that sand play integrates touch, seeing, hearing, smelling and even tasting,” she says. “Choosing miniature figures and objects that appeal to you and creating a scene in the sand is very powerful.”
  • Consider eye-movement desensitization and reprocessing therapy and brainspotting. “(A counselor) must have training, but I can’t imagine trauma treatment without these brain-based power therapies that reduce flashbacks and intrusive memories quickly,” Webber says.
  • Use drama. “Psychodrama offers a kinesthetic multisensory modality for clients to express their feelings and act out their sensory traumatic memories,” Webber says. “It provides a way to talk about trauma and one’s reactions in a symbolic way that is not as fearful as traditional talk therapy.”
  • Have the client make a scene in the sand or draw a picture of something scary and then talk about feelings. “Then do whatever you want with the picture to get rid of the feelings,” she says.

One major difference in treating trauma as opposed to other issues is that the potential for primary or secondary traumatization and compassion fatigue in counselors is very high, Webber says. “Counselors’ greatest asset is our empathy. It is also our greatest liability. Counselors may show signs of traumatization, experience fear and pain and personal distress by their exposure to the client’s trauma story.” Counselors can combat compassion fatigue and traumatization in part by developing and following through with a self-care plan and by taking time for rest and relaxation, she says.

Treating trauma can also resurrect a counselor’s own traumatic experiences, Webber says. She recommends that counselors do their own trauma work with a trained therapist before working with others. If counselors are impaired or vulnerable, she adds, they should refrain from treating trauma clients.

Those risks aside, through her years of treating trauma, Webber says her faith in humanity and in counselors’ ability to help has been strengthened. “Trauma is the ultimate existential challenge to continue living in spite of horrendous and unspeakable pain and sorrow. We are all in this world to help each other. Our greatest tool is our person, and our greatest gift is to walk with someone on his or her path to recovery.”

Helping the helpers

When it comes to the relationship between first responders and trauma, Brian Chopko says guilt plays a leading role. A counselor and assistant professor in the Department of Justice Studies at Kent State University at Stark, Chopko vividly recalls one client in her early 50s who responded to an emergency but ultimately couldn’t save the lives of two people. “She tried so hard to save them that she was almost killed herself,” says Chopko, explaining that the first responder sustained a serious injury during the rescue attempt. The woman then developed PTSD following the event.

“One of her main complaints was guilt — guilt that she didn’t do enough to save these two people,” says Chopko, a former police officer and a current volunteer deputy sheriff. He asked the client to rate her guilt on a scale of 1 to 100, with 100 being the worst. “One hundred,” she responded.

Chopko used a variety of techniques, including prolonged exposure therapy, to help the first responder think differently about what had happened. What turned the tide for the client was an empty chair technique in which they addressed how the victims would feel about her rescue efforts and what they might say to her. “That was a breakthrough moment,” Chopko says. “She told me in the next session that that moment in therapy changed her life. It felt like 1,000 pounds off her shoulders.”

People respond differently to trauma, Chopko says, so the crucial role of the counselor is to discover how a particular trauma has affected a particular client. People can go through the same event and have two totally different experiences, he says. After identifying the guilt from which his client was suffering, Chopko and the first responder were able to find success in treatment. After their work together, the client reported her guilt had dropped from 100 to a 2 or a 3.

While trauma affects people in different ways, Chopko says first responders undoubtedly deal with more than their fair share of it. Chopko, who teaches courses and does research on mental health issues in the criminal justice system, particularly post-traumatic stress experienced by first responders and victims of crime, recently conducted a study of 186 police officers throughout Ohio. He found that 17 percent of the officers were displaying probable PTSD symptoms. An additional 10 percent, while not meeting the criteria for PTSD, were displaying post-traumatic symptoms that were still considered significantly distressing. “More than a quarter of all police officers were currently experiencing significant or severe post-traumatic distress,” Chopko says. “Lifetime prevalence rates are much higher.”

“First responders commonly experience traumas as a routine part of their job,” Chopko says, including witnessing scenes of threatened or actual deaths or injuries from accidents, crimes, disasters, fires, suicides and hostage situations, to name a few. “In addition to viewing dead bodies and terrible injuries, first responders often have to put their hands on and handle the mangled and dead bodies,” he continues. “First responders are also often themselves put in life-threatening situations, such as the firefighters who run into a burning house to save others at great risk to themselves or the police officer who has a gun pointed at him, is involved in a shooting or is involved in a high-speed chase.”

Traumatized individuals are having a normal response to a very abnormal situation, Chopko explains. People who experience a traumatic event are expected to display post-traumatic symptoms and distress, he says. The variable is how long the symptoms and distress will last. For some, it is only a few days; for others, it may be a lifetime. First responders and others who have experienced trauma can get stuck in the fight-or-flight response, Chopko says. “This response helps you immediately survive the life-threatening event. Because the event is so overwhelming, however, the mind and body get stuck in that response. This is why people experience the hyperarousal symptoms — the mind is always waiting for that next terrible event to occur. The memories of the event never get sent into the long-term storage of memory.”

Chopko uses the analogy of a frozen computer. “If you type too many commands into a computer at once, what happens? The computer will freeze up and get stuck. The trauma is so overwhelming, the mind can’t process the horror of what occurred.”

Although survivors of trauma might not want to relive the experience and may avoid talking about it, that strategy won’t work over the long haul, according to Chopko. “People avoid thinking about the event because it produces more symptoms. In the short term, this strategy works by not inducing more severe symptoms. The problem is, this just reinforces your need to keep avoiding the memory to reduce symptoms, and this does not give the brain a chance to process the memory and put it into long-term storage. In the long term, avoidance has the paradoxical effect of making the symptoms worse.”

One of the biggest hurdles to helping first responders heal is the stigma attached to asking for assistance within the first responder community. “The work environment of first responders is one of a macho nature, where signs of weakness are undesirable,” Chopko says. “Many first responders feel highly uncomfortable seeking help because they don’t want to be viewed as weak by their peers and superiors and therefore suffer in silence.” The best way to address this barrier, he says, is to remind first responders of how normal their feelings are. “This is where normalizing is so important to convey that, ‘No, you are not weak or crazy. In fact, many of the other first responders are also experiencing similar reactions. They are just not talking about it.'”

The good news, Chopko says, is that empirically validated treatments such as prolonged exposure therapy work well at reducing negative post-traumatic symptoms. “This type of therapy is sort of like going back and entering the commands into the computer one at a time so the computer can run smoothly without freezing.” In therapy, the client tells the story over and over again until the symptoms are reduced, resulting in the memory being processed and getting placed into long-term storage, he explains. “In this way, the opposite of avoidance is the key to recovery.”

One intervention developed specifically to help first responders is Critical Incident Stress Debriefing (CISD). With this model, all first responders involved in the traumatic event are brought together afterward to debrief. Although research has not been consistent in showing that CISD is successful in preventing future symptoms, Chopko says it offers counselors a chance to get their foot in the door with first responders. Mental health facilitators can lead the debriefings, emphasize to first responders that what they are feeling is normal and then offer them resources for additional help, he says.

Another way for counselors to reach this population is to get involved in programs that train first responders in mental health issues or crisis intervention. If a counselor presents the training, he or she might be able to provide an additional training segment on post-traumatic stress, Chopko says, thus beginning the normalizing process for first responders.

Most people experience only one or two traumatic events in their lifetime. The challenge for first responders, Chopko says, is the sheer number and wide range of traumas they will experience, with a cumulative effect taking place over the years. While it is very difficult for first responders to avoid that circumstance completely, Chopko says, counselors can teach them healthy behaviors for dealing with ongoing stress, including relaxation techniques, breathing exercises and physical exercise. Counselors should emphasize to first responders the importance of practicing those techniques throughout their careers, not just in moments of crisis, Chopko says.

Trauma on the battlefield

With simultaneous combat zones in Afghanistan and Iraq, there is no shortage of soldiers who have endured traumatic experiences. Trauma can appear at a soldier’s every turn, says David Fenell, professor and chair of the Department of Counseling and Human Services at the University of Colorado at Colorado Springs. Among the examples are repeated exposure to life-threatening combat, witnessing the death or wounding of a comrade, an attack by an improvised explosive device or being assigned to duty in which the soldier is responsible for assisting the wounded.

A retired colonel in the U.S. Army Reserve Medical Service Corps, Fenell deployed to both Iraq and Afghanistan to provide mental health services. One of the most important tasks for counselors treating veterans is to think of the trauma as an opportunity for the client to grow and develop, says Fenell, a member of ACA. “This positive view will be very helpful to the client. I frame the symptoms as normal reaction to abnormal circumstance and avoid pathologizing the client. Too many counselors conceptualize normal stress reactions to threatening situations as PTSD. This is a mistake.”

Fenell believes ordinary stress reactions are being misdiagnosed as PTSD among military personnel, which can have a detrimental effect. “The mainstream press has made a huge issue of the mental health concerns of returning warriors,” says Fenell, who served as chair of ACA’s Special Committee on Military and Veterans Affairs. “The military has responded and, in some ways, (that led) to the diagnosis of choice being PTSD, with traumatic brain injury a close second.” Treatment through the Department of Veterans Affairs becomes easier to obtain when the PTSD diagnosis is given, he says, but the diagnosis isn’t always a good thing. “When people are treated as if they are dysfunctional, they become dysfunctional. When people are treated as normal people in the process of getting better, they are more likely to get better.”

That said, Fenell emphasizes that he does not disregard the diagnosis of PTSD. “PTSD is real and can be devastating to those who experience it and those who are close to them,” he says. “If my positive strength-based approach is not effective, I can move to more traditional approaches or refer.”

Fenell says the sooner trauma therapy can begin, the better — as long as the client is able to begin reprocessing the events and the feelings associated with them. “Again, I reassure the client that he or she is experiencing normal reactions to abnormal circumstance and that we will get through this confusing time together. It is a health-based, rather than pathology-based, way of working with the client.”

Fenell offers a few tips for working with members of the military affected by trauma:

  • Establish a relationship based on trust. “My military background is invaluable in this regard with combat veterans and their families,” Fenell says.
  • Normalize the symptoms.
  • Engender hope. “This is crucial,” he says. “Too many civilian therapists communicate pessimism to clients nonverbally when dealing with combat trauma.”
  • Ensure that the client accepts and begins to believe that he or she will improve with time and supportive therapy.
  • Engage the family in treatment. “The family often begins acting differently around the traumatized client, and this typically makes the client feel worse rather than better,” Fenell says. “Get the family on board and in treatment with the client so that all are emphasizing a strength-based, ‘this will get better’ mind-set.” It’s also helpful to collaborate with the client’s military unit so that it will be positively involved as well, he says.

The greatest challenge for counselors, Fenell says, is being comfortable with the client’s tragic experiences while still expressing empathy and engendering hope. Counselors should be psychologically healthy and well grounded and able to enter the world of the client without being overwhelmed by it, he says. “Psychological health, personal resiliency and lots of experience help.”

But, he cautions counselors, don’t become immune to your own feelings. “The counselor must be able to express accurate empathy without becoming so overinvolved that therapeutic perspective is lost. Losing perspective and feeling too much, or becoming detached and not feeling at all, can happen to some therapists when dealing with the pain associated with trauma cases over a long period of time.”

A less safe place

One of the things that makes a traumatic event such as the school shootings at Columbine or Virginia Tech so hard to handle is that violence has invaded a safe place, Webber says. “Schools are safe places, homes away from home, full of fun, football pep rallies and friends. It is unimaginable that kids and teachers could be killed in their school. More unbelievable and terrifying is that at Columbine and other schools, they were killed by students.”

In the microcosm of a K-12 school community, traumatic events can take different paths based on who is affected and how many students are affected, says J. Barry Mascari, assistant professor and chair of the Counselor Education Department at Kean University in New Jersey. “Too often, schools treat everyone as if they are impacted to the same degree and inadvertently bring more students into the complex mix than is necessary,” he says.

“Many students may not know the victim and would not have any impact but feel guilty or think they should be more upset. This needs to be normalized,” Mascari says. “The small minority that is impacted also needs some triaging, because some simply need psychological first aid to help them normalize what they are thinking and feeling. Others may need more direct follow-up because of the closeness to the event or previous trauma. School counselors are in a unique and critical position to help students weather these events and are especially critical in helping administrators manage these crises.”

Recently, federal and state governments have begun mandating response plans, and school counselors should play an important role in developing those plans, Mascari says. “When I directed the plans for a large city school district, we did everything from sharing building plans to meeting with the counselors so they understood their role in the response plan. Our school counselors played a critical role in initiating a response.”

Webber says returning to routine — reopening school and restarting classes — as soon as possible is important. Sharing should be encouraged in classes rather than large assemblies, she adds, because counselors and teachers can more readily identify those who might need additional support in smaller settings.

At a university, where there is less structure and containment, it is more difficult to provide immediate support and contact from teachers and counselors, Webber says. Drop-in centers in dorm lounges, dining rooms and other areas can help to decentralize response efforts.

At schools and universities alike, Webber reminds counselors their role is also one of prevention. “National Suicide Awareness Week is one example,” she says. “After students complete brief surveys, counselors follow up with students whose survey results suggest that they may be at risk.”

After disasters strike

From the recent earthquakes in Haiti and Chile to the 2004 Indian Ocean tsunami to the domestic devastation of Hurricane Katrina, natural disasters can strike quickly, but their impact is often enduring, altering the lives of large groups of people. While those who have lost homes and loved ones are most affected, those trying to help can be greatly impacted as well.

The most significant challenge for disaster responders is secondary traumatic stress, says Cirecie West-Olatunji, an associate professor of counselor education and coordinator of the mental health track at the University of Florida. Responders may begin to experience symptoms similar to those exhibited by the disaster survivors, she notes. “This is why self-care is an important part of disaster training,” says West-Olatunji, an ACA member who participated in a recent ACA podcast on the earthquake in Haiti. “Disaster mental health counselors who do not know their limitations and do not have a plan for resilience during service provision can become liabilities during deployment.”

The second most significant challenge is cultural competence, says West-Olatunji, who represents the Association for Multicultural Counseling and Development on the ACA Governing Council. “Given the rise in disasters globally, counselors are likely to be deployed to geographic areas where the cultural mores differ from their own. Thus, they need to exemplify cultural competence that reflects responsiveness and expediency in service provision.”

In the aftermath of Hurricane Katrina, many mental health professionals were sent to the Gulf Coast to help, but some were asked to return home because of a lack of cultural competence, West-Olatunji says. “When counselors lack cultural competence when responding to disasters, they can sometimes aggravate existing symptoms. Culturally competent mental health disaster counselors are able to identify community strengths and mechanisms for healing. They are also able to incorporate community knowledge into their work and expediently apply that knowledge in their interventions.”

West-Olatunji, who lived in New Orleans for 14 years and raised her children there, recalls an experience in the aftermath of Hurricane Katrina in which her knowledge of the people and community became a lifeline. She was working with first responders from the area and their families, who were living temporarily in intact communities aboard cruise ships off the coast of New Orleans. While she was there, people were beginning to move off the ships and into trailers, but many were very resistant to the idea.

Tasked with providing communitywide intervention, West-Olatunji knew from past experience that the people of New Orleans were social. She wanted to get them more comfortable with the idea of moving into the trailers, so instead of sitting inside one of the models and waiting for people to come in and ask questions, she took a chair and sat outside. She spoke to people passing by as if she were sitting on her front porch, and then she’d invite them in. As they sat inside the trailer with her, West-Olatunji remembers, they could see it wasn’t so bad. “That’s an example of using knowledge of the community … as a vehicle to get them where I want them to be,” she says.

Cultural competence is also important in working through the aftermath of a disaster with clients one-on-one, she says. “It is important for counselors to honor the ways in which individuals are coping with their trauma and to acknowledge ways in which they define healing. Counselors often want to bring their own concepts of healing to trauma-affected communities, leaving out the idea that counselors can effectively co-construct solutions with their clients.”

Cultural sensitivity is especially important when it comes to religious beliefs, Zalaquett adds. “Clients’ religious interpretations of their ordeals may conflict with the counselor’s interpretation of the situation,” he says. “Nonetheless, we should not challenge clients’ deep religious beliefs. Helping victims process feelings of guilt and responsibility is one way in which we could serve them better.”

Following the American Red Cross disaster mental health model means the bulk of mental health services are provided only after first responders have addressed more immediate needs, West-Olatunji says. At that point, counselors should look to the most resilient community members. “Counselors can assist by working with the less vulnerable individuals first to help stabilize the community and utilize the most resilient individuals in restoring normalcy to the community,” she says. “Further, disaster mental health counselors can serve as consultants to civil employees, educators and religious and community leaders in providing information on mental health recovery. Oftentimes, individuals will seek assistance from leaders in their own communities before approaching mental health professionals.”

Disaster counseling is very brief in nature, West-Olatunji says, with most sessions conducted in field-based settings. “Any individuals who require more conventional services are referred to existing services in the community,” she says. Another way for counselors to help in the aftermath of a disaster is by providing services to first responders, who are particularly vulnerable to secondary traumatic stress. Counselors from farther away can pitch in by providing assistance to counselors in the affected area, West-Olatunji says. “The most valuable support can be in the form of outreach trips with advanced counseling students, practitioners and counselor educators to provide relief, consultation and training to the affected community of counselors.”

When one works with adults affected by a disaster, West-Olatunji says restoring regularity in their daily activities is important. “This intervention aids in the recovery process in that it reestablishes some predictability to their lives. An example would be attempting to eat meals at prescribed intervals on a daily basis or going to bed at the same time each evening. Ritualizing the daily routine is helpful in restoring a sense of safety and grounding individuals in reality.” She adds that encouraging clients to engage in reflective or meditative activities can also be helpful, as can participating in communitywide or family rituals to aid the grieving process.

When it comes to children, West-Olatunji says it’s important to allow them to tell their stories about the disaster. “Some common interventions with children involve the creative arts,” she says. “Asking children to draw their stories can be a powerful tool that allows them to have a voice and also serves as a platform for therapeutic activity. Other pediatric counseling techniques include working with sand trays, dramatic play, Popsicle stick doll construction, the use of proverbs and mutual storytelling.”

While disasters bring death, destruction and heartache, West-Olatunji says the greatest lesson she has learned about trauma is an optimistic one. “People are much more resilient and psychologically hearty than I imagined. They have taught me a lot about the capacity of the human spirit.”

ACA Resources

  • Terrorism, Trauma and Tragedies: A Counselor’s Guide to Preparing and Responding, third edition (order #72892), can be ordered directly through the ACA online bookstore at counseling.org/publications or by calling 800.422.2648 ext. 222. The cost is $29.95 for ACA members and $39.95 for nonmembers. The book, edited by Jane Webber and J. Barry Mascari, features chapters written by Webber, Mascari, Carlos Zalaquett and David Fenell, among many others.
  • Disaster Mental Health and Crisis Stabilization for Children (order #78205), a live demonstration DVD presented by Jennifer Baggerly and produced by Microtraining and Multicultural Development, may also be ordered directly through ACA. The cost is $149.
  • ACA also offers a Traumatology Interest Network so counselors can share experiences, ask questions and offer tips and techniques for treating trauma. For more information, contact the interest network’s facilitator, Karin Jordan, who has been working in Haiti, at kj25@uakron.edu, or Holly Clubb of ACA at hclubb@counseling.org.

 

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Letters to the editor: ct@counseling.org

Inviting families into the support circle

Stacy Notaras Murphy April 14, 2010

It was 25 years ago when Bette Stewart’s husband was diagnosed with a mental illness. “I felt angry and alone, like my life was coming apart at the seams,” she recalls. “I asked the psychiatrist for help. I know now that if (my husband) was an alcoholic, I would have been referred to Al-Anon (an organization that offers help and support to family members of problem drinkers). But the doctor knew of no place to send me.” Fortunately, Stewart found her way to a support network run by the National Alliance on Mental Illness (NAMI), an organization that serves individuals and families impacted by mental illness via education programs and political advocacy. Today, she coordinates NAMI support groups throughout Maryland.

“These families (who have a loved one with a mental illness) are dealing with trauma. We’ve lost a person whom we cared so much about. That person is very different now. It’s like losing a part of yourself,” Stewart explains. “We don’t let people grieve that publicly. Families often have bad experiences with therapists who don’t take the time to hear all sides of the story.”

Families face substantial adjustments when a loved one is diagnosed with a mental disorder, be it getting accustomed to the side effects of medication or the lifestyle changes needed to maintain emotional stability. Yet many family members find themselves cut out of treatment plans, particularly if the diagnosed individual is an adult. As a result, the families of those who are mentally ill may feel isolated and alone as they struggle to make sense of the changes. In such situations, therapy or support groups may be beneficial, but many in the counseling profession are unaware of how to reach beyond their clients to those family members in need.

“I think it’s a training issue with clinicians. They aren’t trained to work with families of adults (who have been diagnosed with a mental illness),” Stewart says. “They’ll think, ‘My client doesn’t give me permission to speak to his family.’ But if clinicians are trained with the belief that families are beneficial to the (mental health care) consumer, part of the counseling goals can be connected to the family. Once the provider is out of the picture, that family is still there.”

Joyce Burland experienced this challenge in her own life. Her sister was diagnosed with schizophrenia in the 1960s, and her daughter was diagnosed with the same condition in 1980. “We were given no professional advice in 1960, and nothing had changed in 1980. I thought, ‘This can’t go on.’” So Burland, a psychologist, joined NAMI and wrote the curriculum for a course that would help family members find information and support. NAMI now offers the free peer-education program, Family-to-Family, in all 50 states. Burland currently serves as director of NAMI Education Training and Peer Support programs.

“I was convinced that family members who had lived the experience could be very good teachers,” Burland says from her Santa Fe, N.M, home. “We estimate that 225,000 people have taken the 12-week, free course to learn about what is happening to the person they love — what kind of illness they have, what the lived experience is and how to be an effective and active advocate for their family member in treatment. These are things you do automatically if you get diabetes, but it’s not automatic in the mental health field.”

An educational endeavor

NAMI’s Family-to-Family program takes a largely educational approach to supporting family members. The groups, led by former participants who have been trained as presenters, feature information sharing on a variety of topics, including diagnosis, medications, current research, community resources and mental health care advocacy. Group members also hear about the lived experience of those with mental illness and are prepared to face the possibility of crises and relapse scenarios. The program also covers self-care awareness and coping strategies for the group members themselves.

“The incidence of mental illness is very traumatic for the family,” Burland says. “You could see someone who is healthy in May be psychotic by December. We try to help families see that this is as traumatic as a flood or an earthquake.”

Opening themselves to therapy or a support group may not be easy for family members. Some have soured on the thought of therapy or counseling after trying to secure care for their loved ones. Describing the support group community as a “secret society,” Burland explains that it may take years for certain individuals to willingly go to a meeting where they might be identified as having a family member with a mental illness.

Stewart adds that mental health care providers may have little understanding of the complicated support needs of clients’ family members. “Some of the assumptions are that (mental health care) consumers don’t have families, or that families are part of the problem or that families aren’t going to be interested,” she says.

Stewart works as a training specialist at the University of Maryland School of Medicine’s Evidence-Based Practice Center in Baltimore. She has been involved in a study measuring the efficacy of the Family-to-Family program that reflects the lack of awareness in the provider community. Her hope is that more clinicians will consider how helpful an informed family can be to a loved one’s overall progress.

“By involving families in treatment, everyone benefits. The more families understand what’s going on, the easier it is to respond in a more appropriate, compassionate and understanding way,” Stewart says. “Sometimes families feel extremely isolated, and it’s beneficial to know that other families experience the same situations. Together, families can learn skills to work more effectively with their family member.”

She mentions the example of one Family-to-Family participant, a man in his 80s who had been locking horns with his mentally ill son for more than 20 years. When the son turned up every holiday in dirty clothes or with body odor, a fight would inevitably result. But the course provided the father with some insight into the challenges of personal hygiene for someone with his son’s diagnosis.

“During a class he sobbed, ‘Why didn’t someone tell me this before? We could have avoided so many miserable times.’ Later, he described the first happy holiday dinner in years because he understood that the best his son could do was to be there on time. They could deal with the fact that he had dirty clothes, whereas before, (the father) would just get angry. People are never too old to learn something that will benefit them,” Stewart says.

The counselor connection

When NAMI was established 31 years ago, its original purpose was to make up for the lack of support and information offered to families by the medical community. As such, some NAMI members carried a reasonable amount of guardedness concerning providers, who for years had created a perception that clients’ mental illnesses were generally connected to poor parenting and childhood abuse.

It’s no surprise that when family members felt marginalized and blamed for their loved ones’ struggles, they were wary of interacting with the professional community. But with a better understanding of the biological factors involved in mental illness, some mental health advocates suggest that today’s providers can do much to repair the divisiveness of the past by taking on family support initiatives. Among the benefits to counselors are introducing their traditional services to a new audience and deepening their understanding of the impact of mental illness on the family.

Betsey Neely began looking for mental health resources when the youngest of her three adopted children was showing signs of conduct disorder in school. An Atlanta attorney and single mother at the time, Neely found a local NAMI chapter and took part in Burland’s Family-to-Family course.

“It was the most helpful thing I found anywhere for dealing with a child with mental illness problems,” Neely says. “After that, I was trained to teach Family-to-Family. I taught that for several cycles and really saw how much the family members appreciated and needed the support. When I finally retired from being a lawyer, I decided to go to graduate school for professional counseling.”

While pursuing her degree, Neely, an American Counseling Association member, devised a support group for her practicum at a community mental health center. “I saw there was no help for the families, and I got reenergized,” says Neely, who currently runs a consulting practice that helps clinicians learn how to be better witnesses in legal proceedings.

“I think the time is right now to bring providers into this education movement. There are educators and providers who would be willing to cooperate with NAMI as a family advocacy group, to bring the best of both worlds together,” says Neely, who adds that the waiting lists to join some advocacy-related support groups can be long. “We just don’t have enough volunteers to offer as many (support groups) as are needed, and clinicians can be trained by NAMI and other groups to really understand members’ needs.” Specifically, NAMI’s Provider Education course and a similar program offered by the Depression and Bipolar Support Alliance (DBSA) both feature the perspective of the “mental health consumer” and teach non-blaming ways of reaching out to families and clients.

“I would not say that providers can always do a better job (of leading support groups), because unless you can make the experience useful and relevant to the family that’s suffering, all the education in the world gets you nowhere,” Neely says. “But I do think providers could do an excellent job assuaging the guilt feelings and helping families keep balance in their own lives.” She adds that trained counselors can understand group processing in ways that peer educators may not, thus allowing counselors to help move the sessions toward more productive outcomes.

Likewise, Jessica Swope, a psychology associate with Psych Ed Coaches in Alexandria, Va., believes her professional training lends itself to attending to subtle group dynamics. She currently facilitates a free monthly support group for parents of children diagnosed with attention-deficit/hyperactivity disorder through CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder).

“As therapists, we have the basic therapeutic training in empathy and listening skills — being able to distill what’s being said, getting to the core of it and feeding that back. Having someone skilled in that way in the room can help move the conversation forward so there can be room for more emotional processing,” Swope says. “I am trained to be attentive to all members’ needs, to be tuned into what’s happening with the group members who are talking, as well as those who are not talking. You are able to take the temperature of the group as a whole and steer the conversation in response to that.”

“A trained therapist who doesn’t have the experience of a family member with that particular issue can be useful because that one person is in the room not thinking about things through the lens of their own experience. Therapists are able to provide a sounding board where people can really be heard,” she notes.

Swope also appreciates the value of camaraderie within the group. “That’s the nice thing about having parents dealing with these issues at all stages. The leaders listen for misinformation, and we might tweak or make additional suggestions, but there’s a lot of learning and information sharing taking place.”

Neely emphasizes the importance of showing families they are not alone in their struggles. “Parenting was the hardest thing I’ve ever done — much more difficult than any employment I’ve ever had as an attorney. There is so much personal trauma that comes from that and guilt that gets in the way. I was a single mother with three kids acting out all the time, and I think there are just a lot of people in that dilemma.”

Empathy, not revenue

This type of group work is probably not the space for counselors to make financial gains; these families are often struggling to make ends meet already as they fund their loved ones’ care. Swope says providing pro bono support services fulfills her ethical requirement to be of service to the community.

Highlighting the distinction between support groups such as the one she runs and therapy groups, which have more psychological aims, she notes, “These are people who are spending a lot already on finding the right type of care for their loved ones. It’s important for people to have a place to go where they can get resources (and) support, have their batteries recharged (and) where they don’t feel like it’s a drain in any way.”

Stewart echoes this thought. “Many families don’t have money to put toward treatment and therapy. Sometimes they just need a basic understanding of what’s going on, what happened to my son or daughter. In this difficult financial time, I hope more providers will think of referring people out to what’s available in their own communities. But if providers are interested in learning ways to really work professionally with families, rather than traditional ‘family therapy,’ I hope they will consider learning about family psychoeducation approaches.”

Indeed, psychoeducation can be the key to reaching this population. Counselors may find members of support groups are more interested in learning about their loved ones’ illnesses and how they can help, while less interested — at least initially — in processing the emotional toll of the diagnosis on the family. At the same time, firsthand knowledge of how mental illnesses impact families can deepen both a counselor’s empathy and case conceptualization skills. Provider education programs are offered through a variety of organizations, including NAMI, DBSA and the Substance Abuse and Mental Health Services Administration.

Swope has also found that spending time listening to support group members describing their experiences has enriched her individual work with AD/HD children and adults. “I’m fairly new to working with this population, and my experience has largely been through my clients. This group work is a good way to fill out the picture for me as a clinician,” she says. “I think (support group work) would be useful for anyone looking to develop a niche practice. It’s a service but also a way of deepening your knowledge as a practitioner. It’s very useful for me to learn from the parents.”

Stacy Notaras Murphy is a licensed professional counselor practicing in Washington, D.C. Contact her at snmurphy@verizon.net.

Letters to the editor: ct@counseling.org.

Learning the ropes of rural counseling

Jonathan Rollins

Fans of TV sitcoms may fondly recall Cheers as the friendly neighborhood bar in Boston “where everybody knows your name.” The regular denizens of Cheers descended the stairs to be enveloped by an unwavering sense of camaraderie.

Of equal appeal to these characters, however, was the fact that the bar served as a refuge from the outside world. In truth, outside of a close network of other regulars, relatively few patrons of Cheers “knew their names.” The bar offered a certain sense of anonymity — a place where most other people wouldn’t possess any knowledge of their personal histories, their past mistakes, their baggage, their quirks. Even psychiatrist Frasier Crane frequented Cheers to escape his problems and, in some instances, his clients.

Contrast that with the environment encountered by counselors who work in rural areas, where the phrase “everybody knows your name” is oftentimes a truism, not just a homey slogan. This life-in-a fishbowl aspect of rural counseling offers unique challenges that encompass ethical decision making, boundary issues and counselor self-care.

For instance, says Lauren Paulson, a licensed professional counselor and American Counseling Association member who has conducted research on the topic, counselors in rural areas face greater pressure than their suburban or urban counterparts to serve as role models for clients, even when the counselor is not working. While Frasier Crane could step into Cheers without giving it a second thought, Paulson says drug and alcohol counselors who work in rural areas might question the advisability of having a glass of wine at a local restaurant. “A lot of the (rural) counselors I have talked to said they felt they needed to go out of town before they could truly let down,” says Paulson, a visiting assistant professor at Allegheny College and an adjunct professor at Edinboro University, both in Pennsylvania.

“You’re kind of on display when you’re a counselor in a rural area,” says Dorothy Breen, an ACA member who moved from a metropolitan area just outside of New York City 23 years ago to take a job at the University of Maine. In addition to being an associate professor at the university, Breen maintains a home and a private counseling practice in the western part of the state, which is much more rural in nature than the comparatively cosmopolitan university town of Orono (population 9,114 at the 2000 census). “The rural setting really influences my work and my life in a lot of ways,” says Breen, who is conducting research on rural counseling during her sabbatical from the university. “I constantly have to be aware of the ethics and boundary issues at play — at the gym, at the bank, in church, at school, in the grocery store. It’s easy to find myself … right next to one of my clients (in the course of doing everyday activities).”

Culture shock

Though the concept of multicultural competency has steadily taken on more import for counselors, both Breen and Paulson say there is a general lack of information about rural culture and rural counseling in the professional literature and in graduate counseling programs.

“Knowing your culture. That’s something that gets stressed to all counselors, but not all counselors understand that there is a distinct rural culture,” Paulson says. “At the same time, it’s diverse. Each rural culture is unique. Most counselors have been trained from urban models, and these counselors can experience culture shock as they try to make their way in the rural community without knowing how to ‘speak the language.'”

“It’s not just a matter of providing counseling in rural areas,” Breen advises. “It’s a matter of providing rural counseling. Rural counselors often need different treatment suggestions and face different considerations (than their colleagues in urban and suburban environments).” For example, she says, in an urban area, a counselor might encourage a depressed client to get out of the house and visit an art museum. “But that’s not always available in a rural area. Instead, it might mean going to a school basketball game — the very central part of social life in some rural communities — or doing something active, such as getting out in the woods.”

It is essential that counselors practicing in rural areas understand and respect their clients’ cultural values and beliefs, many of which revolve around family, Breen says. For instance, Breen provides counseling services in a rural school because the area where she lives doesn’t have school counselors. In encouraging students to pursue their education past high school, she has learned the importance of involving families in these discussions. In many cases, these students will be the first in their families to attend college. Sometimes, Breen says, the parents are worried about who will take care of them if their sons or daughters leave the rural community and decide not to return. Other times, students voice concerns that they will not be accepted back fully into the culture even if they want to return after college.

Another difference in rural counseling is the strength of the connection between the counselor and the community, says Breen, who adds that this is simultaneously one of the most positive and most challenging aspects of being a rural counselor. “You really do get to know people, and they depend on you,” she says. “You’re not just the counselor there; you get involved in the community. If you weren’t involved, you wouldn’t be able to be the counselor because they wouldn’t trust you. You’re seen as the person in the community to go to for all kinds of things, and that’s a different kind of lifestyle. You need to be able to balance being available to people with maintaining boundaries and having personal time.”

“Knowing that’s the way it is — being on stage all the time — is important before making the decision to practice in a rural area,” she continues. “It comes as a shock to many urban counselors.”

Ethical uncertainties and other challenges

Working as a counselor in a rural area, “You have to be a generalist,” Breen says. “You have to be prepared for everything.” But that reality can also leave rural counselors questioning whether they might be working outside their scope of practice. “The difficult part when considering counselor ethics is that some people in rural areas won’t get the help they need because a specialist isn’t available,” Breen says. “So the question becomes, do you, as a counselor, try to help them instead to the best of your ability?”

Paulson says rural counselors oftentimes must use creative problem solving to make up for a lack of resources, including in the areas of support and supervision. She encourages these counselors to be deliberate in “setting up sidewalks.”

“That means using one of the strengths of their tight-knit rural communities and forming collaborative networks,” she says. “It’s crucial in a rural area to form relationships with the local general practitioner, other mental health professionals, school counselors and other disciplines.” She also recommends that rural counselors make use of peer networking and supervision and take advantage of opportunities to connect with other colleagues at conferences, through professional associations and through online directories. She would like to see the profession develop a central network to allow rural counselors to connect so they could provide support and guidance to one another.

In Breen’s case, there are no doctors or similar professionals in her town. Instead, she collaborates most closely with a local pastor in discussing certain clients. Breen emphasizes that she always obtains signed permission from clients before working with the pastor, but because they generally view Breen and the pastor as primary caretakers of the rural community, clients normally welcome the collaboration. “We’re all there is here, and we try to help people get their needs met the best we can,” Breen says.

Paulson says that’s one lesson some counselors in urban and suburban areas could most benefit from learning from their colleagues in rural areas — making the most of all the resources immediately available to them and building connections with other professionals.

Counseling students and counseling professionals considering the possibility of practicing in a rural area should give serious forethought to how they will navigate the fishbowl aspect of living and working in a small community, especially as it relates to boundaries, privacy, confidentiality and other facets of professional ethics, Breen says. “I’ve handled that by being pleasant but saying very little about myself out in the community. I keep a pretty low profile. Part of it is just having the confidence not to have to talk about myself and being comfortable letting clients see me as I am — for example, in my workout clothes with my hair pulled back — when I’m not in the office.”

If counselors are constantly on display in rural communities, so too are their clients — and their potential clients. “As a counselor, you have a lot of information about members of the community, so you have to think about how to handle that,” Breen says. “In fact, you have a lot of information about your clients before they even start talking to you. As a counselor, you have to be careful, because that information might not be correct, or it might not be the client’s perspective. … I do not talk about myself very much (out in the community). I also do not talk about other people. I think it’s so important to not get into general gossip (as a rural counselor). I truly avoid that because I don’t want to give the impression that I would spread around any information I might have.”

Although counselors are taught to protect client confidentiality, the rural communities in which counselors work might not carry that same expectation, Breen says, and that can be a challenge. “In a rural area, people are very open in some ways. They will very innocently talk about things openly because they assume that everyone else knows already.”

Breen gives an illustration of a typical dilemma that a rural counselor might encounter. While eating at a local restaurant with her family, the counselor is approached by a mother who mentions some problems her child is having. Even though the mother has shared details of the situation in front of the counselor’s family, “My husband and daughter have to accept that I can’t say anything else about it to them,” Breen says. “It’s important for counselors to talk with their family ahead of time so they understand what your job is like and what your professional ethics are. But can you expect your children to keep things confidential when a client or a client’s family or a member of the community has shared details openly in front of them? This is a challenge. While in rural areas, some people may tend to not care about confidentiality, it is important as a professional to do my best to maintain confidentiality.”

Recommendations and considerations

In many cases, Paulson says, rural counselors experience feelings of professional isolation because they do not have easy access to supervision, training, consultation or networking opportunities. Combine that with often heavy caseloads and the daily struggle to navigate boundary issues and maintain some sense of privacy within close-knit communities, and rural counselors can face increased risk for burnout, she says.

That’s why Paulson, who wrote her dissertation on supervisors working in rural areas, continues to conduct research on strategies to help rural counselors compensate. “I love working and living in a rural area, and I wanted to provide ways to support these counselors and enhance the services they provide to their communities,” says Paulson, who is helping to implement a pilot study in her county on providing supervision to mental health workers in rural areas.

Paulson and Breen both acknowledge that rural counselors often have to sacrifice half or even full days of work to access supervision and training. Paulson recommends that these counselors use technology to access webinars and online training whenever possible, in addition to pursuing training opportunities at the local, state and national levels. Both counselors would also like to see the profession do more to provide continuing education that focuses specifically on rural aspects of counseling. One educational resource that Paulson recommends is the electronic Journal of Rural Community Psychology (marshall.edu/jrcp/).

At the individual level, Breen encourages rural counselors to engage in what she terms “self-study.” In an article on professional counseling in rural settings for the ACA publication VISTAS: Compelling Perspectives on Counseling 2005, Breen and Deborah L. Drew offered questions counselors can use to engage in self-study and better understand their unique experiences. Among the questions:

  • In what ways does the rural setting help your counseling practice?
  • In what ways does it challenge your practice?
  • How does it change your work?
  • How does it change your concept of the role of a counselor?
  • How does your rural professional role challenge your personal life?
  • What can you draw upon from your training that focuses on rural counseling?
  • What kind of training do you need to look for that focuses on rural counseling?
  • What kind of support do you have that focuses on rural counseling?
  • What kind of support do you need to look for that focuses on rural counseling?

“Self-study is part of making sure that you’re adhering to professional ethics the best you can given the environment,” Breen says. “It’s also helpful in understanding your need for renewal and relaxation. It’s very important as a rural counselor to take care of yourself. That might include yoga, working out or making sure to schedule that time to snowshoe or play golf. In rural areas, being outdoors is a way of life, so take advantage of it.”

Paulson also emphasizes the need for rural counselors to be intentional about practicing self-care. “It’s about making sure you’re balanced in your life and allocating time for yourself,” she says. Among her suggestions for counselors on the personal development front:

  • Develop a personal wellness plan
  • Spend time with friends and family
  • Travel
  • Exercise and watch your nutrition
  • Develop your spiritual life

Although rural counselors can face unique challenges, Paulson says, it’s important for them to focus on the many positive aspects of where they work and live, including the slower pace of life, the peace and beauty of their surroundings and the rich, deep relationships they develop within their communities.

Breen, Drew and Mikal Crawford recently surveyed counselor educators to find out if their programs prepare students for rural counseling. They are in the process of analyzing the data and will interview some of the counselor educators as follow-up. Breen believes it would be wise for graduate programs to offer a course on rural counseling. “Even if graduate students are not planning to work there, they might have a client from a rural area, and it’s important to understand the culture,” she says. But to truly understand it, she adds, students and counselor educators also need to experience it. “It’s about encouraging them to get out in the rural communities and observe, to go to the ballgame, to go to town meetings, to do an internship in a rural area. Simply acknowledging that rural counseling is different is a start. But we need to prepare students to be generalists who are able to deal with a wide range of issues. We need to train students to take care of themselves and advocate for themselves and teach them what it might mean to live the rural lifestyle. And we need to train students in ethical decision making so they are better prepared to handle some of the issues they will face in rural areas.”

Speaking of teaching, rural counselors might have a few lessons they could pass on to their colleagues practicing in more populated areas, Breen says. “Other counselors could benefit from rural counselors’ understanding of their community — learning not just what is told to them in session but what life is really like for their clients and neighbors.”

Jonathan Rollins is editor-in-chief of Counseling Today. Contact him at jrollins@counseling.org.

Time to celebrate

Richard Yep April 1, 2010

Richard Yep

Each April, we celebrate Counseling Awareness Month. Rather than a single day on which elected officials pass a proclamation or make an announcement at a meeting of the city council, we feel that counseling is so special, so profound and so important to society that it really deserves more than just one day and more than one single action!

On the American Counseling Association website (counseling.org), you can find a list of tips and suggestions for celebrating Counseling Awareness Month, either as an individual or as a group of professionals (or both). This is the time of year to blow your own horn. Not because you are bragging (which is also OK), but because it is critical at this time to let our society know that the counseling community is well-educated, appropriately trained and ready to help with those obstacles and life challenges faced by individuals, couples, families, teens and others. Click on our home page link to Counseling Awareness Month, and you will be able to download “Public Awareness Ideas and Strategies for Professional Counselors.”

Here are a few ideas. Perhaps you can gather with your local group of professional counselors and plan something for April that will call attention to the good things that you do. You can volunteer to do something that demonstrates counselors’ helping nature (such as house building with Habitat for Humanity or taking a group to work at a local food bank) or perhaps provide handouts at the local mall or farmers market about how counselors can help individuals.

Some of you might choose to provide pro bono workshops at a community center or another gathering place on issues of concern to those who live in your town or city.

Also take some time to download our series of “Counseling Corner” columns that explain to laypeople what counselors can do to help their clients and students. If you are interested in these columns, go to counseling.org/Publications/CounselingCorner.aspx. Please feel free to use them in your community!

If you work in a school or community agency, let others know that your facility exists and what it is you do, even as you continue maintaining the confidentiality of your students and clients. There are many possibilities during Counseling Awareness Month for publicizing the good that counselors do. For those of you who are able to “celebrate,” please e-mail me and let me know what you did!

I want to personally thank the thousands of professional counselors who made plans to attend the ACA Annual Conference & Exposition in Pittsburgh in March. Our cosponsor, the Pennsylvania Counseling Association, has done a terrific job as our partner. From feedback heading into the event, I know that our attendees appreciate the networking, education and connections with resources that are always evident during our time at the conference. And, you know, it is never too early to start planning for next year, so I hope as many of you as possible will consider joining us at the 2011 ACA Annual Conference & Exposition that will be held March 23-27 in New Orleans!

Please contact me with any comments, questions or suggestions that you might have via e-mail at ryep@counseling.org or by phone at 800.347.6647 ext. 231.

Thanks and be well.