Monthly Archives: August 2010

Men Welcome Here

By Lynne Shallcross August 25, 2010

 

If you think barbershops are all about haircuts and shaves, take a closer look.

For African-American men in particular, barbershops often serve as epicenters of culture, community and camaraderie. Debra Johnson is hard at work adding counseling to that list as well. Her approach works in part because, for most of these men, the barber chair is a lot more inviting – and a lot less intimidating – than the therapist’s couch.

Johnson, a counselor and founder of Changing Generational Legacies LLC, makes monthly visits to local barbershops near her Columbia, Md., consultation practice. When she began dropping by a few years ago while working for a government agency, Johnson was keenly aware that men – especially Black men – do not generally embrace counseling. So Johnson ditched her counselor name tag, picked up a blood pressure cuff and headed off to meet the men on their “turf.”

Johnson, who is also a nutritionist, makes the trips with a nurse, offering free blood pressure checkups to the barbershops’ clients. Many men in the Black community know someone who has suffered a stroke, Johnson explains, so they view the checkup as beneficial and normal. But oftentimes, she adds, the checkup also doubles as a makeshift counseling session. “Being an African-American woman myself, I know that counseling is just taboo [for African-American men],” says Johnson, a member of the American Counseling Association. “So I’m not going to go in and say, ‘I’m going to provide you these counseling services.’ I can’t go in as a counselor.”

The blood pressure checks are performed in a room separate from the rest of the barbershop clients, giving Johnson the opportunity to talk one-on-one with the men about stress, poor diet and anything else that might affect blood pressure. As the conversations get rolling, many of the men open up. On a recent trip, Johnson and the nurse found that one man’s blood pressure reading placed him in the risk zone for a stroke. Because they keep track of previous blood pressure readings at the barbershops, Johnson knew the man hadn’t previously been in the stroke zone. She asked him what had changed, and the man revealed he was under a tremendous amount of stress, including facing eviction from his home.

After Johnson and the man chatted for about 20 minutes, the nurse suggested they recheck his blood pressure. To their surprise, it had dropped back down to normal. “Even for me, it was a ‘wow’ moment,” Johnson says. “He was just as stunned.”

The client went back into the main room of the barbershop and shared what had just happened, helping the other men begin to see the connection between releasing life’s stressors and good health, Johnson says. “Through that process, I’ve really learned that Black men are hurting, but they don’t have a safe place to share that pain. Vulnerability is not embraced, for Black men or for most men.” Johnson adds that a number of men from her barbershop trips now make the trip to visit her – as clients of her counseling practice.

Johnson might slowly be creating counseling converts among barbershop customers, but getting men engaged in the therapeutic process remains a challenge for many in the field. “There is a large body of research that shows men are less likely than women to seek many forms of support, including counseling and many forms of health services,” says Mark Kiselica, vice provost and professor of counselor education at the College of New Jersey. “This hesitance to seek assistance is a contributing factor to some of the problems that are more common in men than in women.” Men are less likely to seek mental health services when they are in distress, Kiselica says, and experts suspect that is a contributing factor in boys and men being more likely to commit suicide.

In fact, men seek counseling services at about half the rate of women, says Travis Schermer, an outpatient therapist at Mercy Behavioral Health’s East Liberty Center in Pittsburgh. Compounding the problem, he says, is that men are in a sort of crisis of meaning and identity. A lack of models of masculinity, the loss of career-based identities, emotional isolation and the use of nonrestorative behaviors such as drug and alcohol use and pornography all point to a crisis of meaning, Schermer says. “What men are supposed to be and how they’re supposed to be has become less clear,” says Schermer, an ACA member who is also an instructor at Chatham University and a doctoral candidate in counselor education at Kent State University. “It’s really a struggle of identity in a lot of ways.”

Toughing it out

Although men are less likely to seek counseling, they’re just as likely to continue treatment once they’re there, says Schermer, adding that the reasons men tend to avoid counseling aren’t crystal clear. “Some have conjectured that the process of counseling is antithetical to masculine ways of being, while others have conjectured it has more to do with the discourse occurring in the masculine community concerning counseling,” he says. “I believe it’s a mixture of the two. Counseling does not typically honor a masculine way of being, which is commonly more action oriented. In turn, there are barriers that many men perceive from other men, such as a social stigma about attending counseling that is enforced through shame and prejudice. Combined, these elements depict men as viewing counseling as uninteresting and as socially undesirable.”

Peter Kleponis, assistant director of Comprehensive Counseling Services and the Institute for Marital Healing in West Conshohocken, Pa., says pride plays a role in keeping men away from counseling. Many men don’t want to admit they have a problem in the first place, he says, while also pointing to socialization and the male problem-solving nature as primary reasons why men avoid counseling. Women are more relational, Kleponis says, and tend to look to others for help when they have a problem. Men, on the other hand, believe they have to find the solution on their own. “We men were raised to think we have to solve our own problems and pull ourselves up by our bootstraps, so to speak.”

Kiselica agrees that socialization plays a role in distancing men from counseling. “The more traditional a man is, the less likely he is to seek help from others,” says Kiselica, a member of ACA. “He’s raised to think he should ‘tough it out’ on his own.” But while acknowledging that traditional masculinity is a viable factor, he contends research has overemphasized this aspect and believes a few other factors deserve increased attention.

“Too many clinicians assume that the reason some men don’t go for help when they are in trouble is because they don’t want help,” Kiselica says. “That assumption is often erroneous and simplistic.” Many men are simply too overwhelmed to get help, he explains, pointing out that they might come from families with multiple problems, be experiencing poverty, have low educational levels or have fragile family structures. Another factor is the fear of being judged. “There are some populations of men who are very accustomed to being judged,” Kiselica says. “They feel they’re going to be blamed for problems before their side of the story is even told.” Teenage fathers, with whom Kiselica has worked for 30 years, are prominent among this group, as are fathers of children in the welfare system, incarcerated fathers and fathers of color. “We really need to rethink the way we think about boys and men and how we try to help them,” Kiselica says. “The reason I’m accentuating this is that most of the people who write about men situate the problem within the man. Professionals need to think more complexly about boys and men – that’s my primary message.”

Research on male sexual development resonates with Mark Freeman, who runs a counseling and consulting practice in Winter Park, Fla. One model of development from researchers D. David and R. Brennan highlights four “rules” that men and boys learn through cultural and family development. Although simple, Freeman says, the model makes a lot of sense when considering the divide between men and counseling. The first rule is “no sissy stuff. You’re undermined and ostracized for any sign of femininity. Talking about your feelings one-on-one with another human being is in that realm,” says Freeman, a past president of the American College Counseling Association, a division of ACA.

The second rule is “the big wheel.” With this rule, what counts is how much a man can accumulate in terms of wealth, status, success and other related measures. The third rule – “give ‘em hell” – teaches men to be daring and aggressive and to take risks. The last rule is to “be a sturdy oak.” This rule includes a measure of toughness, Freeman says, and tells men that they should be self-reliant and shouldn’t show their feelings or emotion. “All four of these rules are completely antithetical to opening yourself up to another person in a counseling center,” says Freeman, who directed the counseling center at Rollins College for more than 20 years. He estimates that during his time at the college, there were three to four female clients for every male client who sought counseling.

A targeted approach

Masculinity, fear and cultural “rules” could all be keeping men away from counseling, but Kiselica suggests counselors themselves might inadvertently be putting up “No Men Allowed” signs. “What’s overlooked is that mental health professionals tend to not know how to do male-friendly outreach and male-friendly engagement strategies,” he says. “They don’t know how to recruit men for services or how to engage them once they get in, despite their best intentions.”

Only by designing and providing services that appeal to men will they actually be drawn in, says Kiselica, adding that his years of work with teenage fathers has taught him that lesson quite clearly. “If you say you have a counseling program for teenage fathers, they won’t come,” says Kiselica, author of When Boys Become Parents: Adolescent Fatherhood in America. On the other hand, offering help related to finances, getting a job, legal questions about paternity or questions about being a father will resonate with that population. “If you construct the services to have what young men are looking for, you can join them at those points where they want help and then bridge from there to other issues in their lives,” Kiselica advises.

That mentality is applicable to all men, not just teenage fathers. “You have to design the services to fit the males you are targeting,” says Kiselica, who also coedited Counseling Troubled Boys, published in 2008 as part of a series of books about counseling boys and men. Simply offering counseling services and expecting men to show up won’t get counselors very far, he emphasizes. “You have to gear it toward what is the salient service for them.”

Advertising your services in a different way can also help. As part of his practice, Freeman offers executive coaching services, which he finds to be much more appealing to men. “I can reach men much easier because they’re all interested in leadership development. But to be honest with you, the work is very similar [to counseling].” The approach proved effective on a college campus as well, says Freeman, who taught a course on leadership while working at Rollins. Because the course had the word leadership in the title, more male students signed up, Freeman says, but the content was more “feminine,” touching on human relations and interpersonal skills. “You have to present it in such a way that it fits with those four rules [mentioned earlier],” he says. “If you’re talking about leadership development with men or boys, that’s the ‘sturdy oak’ – it doesn’t look like ‘sissy stuff.’ I build their trust by not violating one of the four rules. You still get to the same place where they can be vulnerable and open up.”

For his practice, Kleponis, an ACA member who partially specializes in men’s issues, creates marketing materials that feature a masculine look, are written from a masculine perspective and refer to things that will speak to men, such as sports or fixing an engine. But marketing materials and brochures are only marginally effective, Kleponis says, so he also advocates partnering with local men’s organizations. Many of Kleponis’ clients are Catholic, so he incorporates Catholic spirituality into the therapeutic process when applicable and has also partnered with local clergy, the Knights of Columbus and an organization called the King’s Men that assists men struggling with addictions to pornography.

A plan of action

Once men make their way into therapy, counselors say the next hurdle is getting them involved in the therapeutic process. One of the biggest mistakes counselors make right off the bat, Kiselica says, is sticking with tradition. “Counselors stay in their offices and expect men and boys to open up and spill their guts,” he says. “This is inconsistent with the ways boys and men naturally form their friendships. When boys and men form friendships, they do things together. They’re often very active. They talk about personal things in the context of instrumental activities.”

For example, boys might play a video game side by side, or men might work together on a car. While engaged in those activities, Kiselica says, they are more likely to have very personal conversations. The talks might not be as deep or as lengthy as conversations shared by women, but men gradually get to know each other in this manner, Kiselica says.

What does this mean for counselors? Embrace men’s active side, Kiselica advises. For example, go to a basketball court and shoot hoops while you talk. With the permission of parents, Kiselica has taken some of his young male clients fishing. Counselors who can’t leave their facility should still explore options for doing something active with their male clients, whether it’s taking a walk or playing checkers, Kiselica says. “Boys and men often relate to each other while they’re immersed in an activity, and if counselors can do this, they’ll help boys and men to open up.”

At one of the workshops he presents, a school counselor told Kiselica she was having trouble getting boys to come to her office. He suggested she buy a Nerf basketball hoop and put it on her door. Not too long after that, he received a letter from the counselor. “The boys were now fighting to go to her office,” Kiselica says. The counselor found that she could learn all sorts of important information about what was going on in the school – not necessarily by talking with the boys, but just by listening as they shot hoops side by side.

Kleponis also encourages counselors to take note of the way men relate over activities. Even though he can’t take to the ice with a client, if Kleponis finds out the man follows the Philadelphia Flyers, he’ll talk hockey with him to build rapport. “It helps develop a sense of trust,” he says. “It’s not really therapist and patient; it’s just a couple of guys. And that’s where they will open up. From there, I can move into whatever the problem issue is.” Kleponis recommends male therapists for male clients, particularly if the client is dealing with a sexual issue. Otherwise, he might be more hesitant to open up, Kleponis says.

“While I think there are many similarities between my approach with men and women, I do make special considerations with men,” Schermer says. “Oftentimes with male clients, I will spend much more time building rapport. I will take time to honor what is often an initially positive presentation. It’s not uncommon for men to present with ‘nothing wrong.’ This is an aspect of themselves, one that they often need to present to the world in order to perform their masculinity.” Often, it’s through honoring that story that trust and rapport is built, Schermer says. “With women, I find I gravitate more toward the problem initially. With men, I will spend time in a positive space that is close to the problem. We’re almost like base jumpers standing on the edge packing our chutes. We’re talking about the jump, i.e. the process of counseling; about great jumps in the past, i.e. times that we’ve been successful before in and out of counseling; and sharing some anxiety about the jump, i.e. worry about facing these issues. When we feel strong together, we’ll take that jump. It’s never my decision to jump. I just sit on the ledge waiting for them.”

A big part of masculinity, Schermer says, is the assumption that men are supposed to be strong, in control and have it all together. When men arrive in counseling, they’re struggling with an image of themselves as not being in control, he says. Sometimes, the counselor will initially hear a positive presentation – the client will talk about all the positive things going on in his life. The important thing, Schermer says, is for the counselor not to react in a challenging way. “We need to honor their positive presentation as being a ‘true’ aspect of themselves and not a denial of the problem.”

Once a client begins sharing some of his struggles, Schermer recommends incorporating action-oriented elements into the therapeutic process. Talk with the client about the action steps he’s going to take, Schermer says, because planning that out feels powerful and instills a sense of moving forward. “Men do feel a bit more invited into the process when you say, ‘It’s collaborative. We need to figure it out together. It’s a team approach.'”

Kleponis concurs, saying a team problem-solving approach can go a long way with male clients. He assures his male clients that, together, they’ll get to the root problem of what’s going on by brainstorming, doing some problem solving and coming up with a solution.

Freeman recommends starting with the cognitive rather than the affective realm. He might help a client look at how a negative belief is obstructing his ability to succeed in his marriage or how he can change certain behaviors to become more successful at work or at home. Men respond well to solution-focused work, Freeman says, so keeping the conversation goal-oriented and focused on what the client wants to achieve will help keep male clients engaged.

Avoid asking too many questions initially, Kiselica says. Instead, begin by talking to a male client about his interests and try to relate to those interests. Many boys and men have previously been forced into counseling when they got into trouble, so they might associate a barrage of questions with being interrogated by an authority figure such as a principal or a corrections officer, Kiselica explains.

Another good rapport builder? “Inject humor,” Kiselica says. “Guys use humor as a way to express affection and to form bonds with other men.”

More than meets the eye

One of the more common presenting problems among male clients is anger, Kiselica says. “Men and boys tend to be either forced or pushed to go into counseling for anger-related problems or some sort of disruptive behavior. So, on the surface, that’s often the presenting problem.” But the situation is typically more complicated than that, he says. “It could be that the man is experiencing extreme pressure at work, he may be feeling that he and his wife are incompatible in some way, or it could be that he has suffered some trauma in the past that he’s never had an opportunity to deal with.” Kiselica says an estimated 400,000 boys nationwide are the victims of some form of abuse or neglect each year. It’s also estimated that 15 percent of adult men in the United States experienced some sort of sexual abuse as boys. “So you always have to try to bear in mind there may be more than initially meets the eye [with the presenting problem],” he says.

Kleponis says pornography addictions are another common problem among male clients. When he began working as a counselor more than a decade ago, most of the client addictions he saw were to drugs and alcohol; now, he says, 90 percent of the addictions he encounters are to Internet pornography. Many men also struggle with selfishness, Kleponis says. “That’s one of the biggest problems in relationships and marriages.”

For clients with pornography addictions, Kleponis uses a traditional 12-step program. But for the issue of selfishness, he uses positive psychology. Positive psychology is based on research findings that people who practice virtue on a regular basis are psychologically and emotionally healthier. Kleponis helps clients set up action plans that include picking two virtues and practicing those virtues every day. In doing this, Kleponis says, clients oftentimes receive a positive reaction from their significant others, children and coworkers. “Hopefully they begin to see that practicing virtue is much more beneficial than the vice, so they’ll profit more from it.”

Issues of meaning are also common for men, Schermer says. Men labor to connect with others emotionally, he says, often wrestling with emotional awareness and to find the language to communicate effectively. Although men often are good at expressing their emotions through behavior, Schermer says he frequently works with men to connect in ways that are also meaningful to others, not just to the man personally. That might mean learning to say “I love you” instead of just showing it behaviorally, he says.

Part of Schermer’s work with male clients involves finding models of masculinity. One surprising model who often comes up is Mr. Rogers. Clients see him not only as masculine, Schermer says, but also as a man who was very emotionally aware and present with others. Schermer helps clients identify significant men in their own lives and then delve into what it meant for those individuals to be men and how they showed their masculinity. This process helps clients recognize the qualities they picked up from others and also creates awareness that how they act will impact other people’s lives. For example, a client might come to understand why he believes that “real men” don’t talk about their feelings and how that belief is hurting his wife. “It creates this sense of agency,” Schermer says. “[Clients say], ‘If I knew that this would happen, I would never have let it happen.'”

No matter the presenting issue, Kiselica says counselors should use a positive masculinity approach. “The very first thing across all of these [issues] is searching for and affirming male strengths,” he says. For example, if Kiselica is working with a client who is a father, he’ll ask the client to share how he tries to be a good father. “I identify a really worthy strength and then help him to maximize his potential in that strength and remove barriers to it,” Kiselica says.

Kiselica adds that counselors should affirms men’s practice of “action empathy” because many men demonstrate their care for others by actively doing something for them rather than verbalizing that care. Group therapy is another good option for men, he says. “If you devise the [counseling] program to appeal to men, engage him in a male-friendly manner and affirm his strengths, he’s then more likely to trust you with a very vulnerable topic,” Kiselica says. “All of this work that I’m talking about gives you currency with men. It allows you to earn their trust and delve into topics they might not otherwise explore.”

Know thyself

Speaking generally, gay men are less hesitant than other men to get involved in counseling, says Leslie Kooyman, an assistant professor at Montclair State University in New Jersey who spent almost 10 years in private practice. “I think the difference is that it depends on where a male is with their masculine identity and their feminine identity.” On the masculine side, men tend to be more distant, rational and logical and less relational, says Kooyman, an ACA member who is a gay man. “Men in general are not conditioned to express feelings or even identify feelings,” he says.

The reason gay men might be more open to counseling, Kooyman says, is because they have already dealt with feelings that are different from the “norm.” These individuals had strong emotions growing up, often feeling isolated or different, he says, so they are more accustomed to feeling vulnerable and expressing feelings as adults.

Counselors who want to work with gay male clients should get involved in gay-friendly community organizations, whether through membership, volunteering or giving presentations on topics such as substance abuse, Kooyman says. But before these clients walk through the door, it’s important for counselors to understand their own sense of sexuality and how they feel about homosexuality, Kooyman says. “If you’re not really comfortable with gay men and gay male culture with your own values, then it’s going to hinder the process,” he says. “Even a gay counselor working with a gay client has to be comfortable with his own identity and know himself. That’s the first part – know thyself.”

The second part, he says, is being very familiar with sexual identity models, such as those developed by Vivienne Cass and Richard Troiden. Beyond that, counselors need to understand the client’s external culture – what this man’s career, family and sexual life are like in relation to being gay. The question to explore, Kooyman says, is “What does being gay mean to him?”

The coming-out process, intimacy, isolation and relationship issues are all common topics with gay male clients. Isolation is often a result of the stigma attached to being gay, Kooyman says, so an important task for counselors is getting these clients more engaged in the community and perhaps connecting them with people who might be struggling with the same issue. With intimacy issues, Kooyman says counselors should know the sexual identity models and then explore with the client where he is within the stages of identity development. Addressing intimacy might mean helping clients identify both their own feelings and those of a partner to see what needs are being presented and how to deal with those needs, Kooyman says.

Getting gay men involved in the therapeutic process depends largely on the counselor’s ability to explore the client’s culture and worldview in a positive, nonjudgmental way, Kooyman says. Don’t make assumptions, he emphasizes, and be open enough to share what knowledge you have of his culture as a counselor. Show the client you understand the context of the world in which he lives, Kooyman says.

As a counselor who works with gay men, Kooyman says it can be exciting to partner with clients who are willing to be a bit more creative. “The societal expectations have already been broken,” he says. “They’re often not as married to the societal expectation of gender. They seem much more open to explore who they are as a person rather than trying to fit a mold.”

The importance of trust

“There’s a lot of stigma associated with seeking out a counselor,” Johnson says of the African-American community’s relationship with counseling. For men, in particular, seeking professional help is seen as a sign of weakness, so the likelihood of a Black man picking up the phone and calling a therapist is very slim, she says. “It’s odd and almost rare when a man calls on his own who has not been mandated [by the courts],” says Johnson, who has been doing advocacy work specific to African-American men for six years. Most of the male clients Johnson sees have come in because their wives or significant others asked them to participate in couples counseling.

Many African-American men would much sooner seek help from a pastor at a church or an elder in the community than reach out to a counselor, she says. “When you’re dealing with African-American men, there’s this whole historic perception that exists that they’re strong and they can handle all things. For some people, help is seen as positive, but for an African-American man, the word help can be viewed as a weakness for him.”

Lack of trust is reason No. 1 that African-American men steer clear of counseling, Johnson says. “Trust is the absolute biggest issue. They don’t trust systems, period.” Although the Tuskegee syphilis experiment happened decades ago, the memory of it is still prevalent in the Black community, she says. Many African Americans don’t trust the medical community, Johnson says, and fear that any information collected will be used against them.

Heading out to the barbershops has allowed Johnson to reach more African-American men, but she admits that earning their trust has taken time and patience. Trust is built gradually and depends heavily on following through on promises. “They are very used to being misled,” she says. “When I say, ‘I’m coming to the barbershop,’ I’m there.” Johnson recommends that other counselors follow her model and go wherever the men are, whether that means traveling to barbershops, building partnerships with churches or using other creative approaches. In each case, it’s essential that the counselor bring a service the men feel they need. For Black men, Johnson stresses, that’s not going to be counseling. Instead, offer something that will resonate with them as being necessary, and then use that as a springboard to respectfully provide counseling-related services.

Upon finding the “in” and connecting with potential clients, Johnson recommends adding coaching aspects to the treatment. “I find traditional counseling is not as effective as counseling in addition to coaching. Coaching doesn’t feel as much like ‘Someone is taking care of me [and] asking me questions about my deeper feelings.'” Coaching gets clients more involved through action-oriented questions, Johnson says. Questions might include “How do you see yourself?” and “What challenges are you facing?”

But don’t assume that all clients know what to do, Johnson cautions. For example, she says, a counselor might ask a client what it means to be a father, but the client might not be clear on the meaning if his father was not present and he lacked a positive male role model in his life. A counselor’s role, Johnson says, is to help clients work through the issue and figure out what is preventing them from being what they envision.

One issue many African-American men present with is oppression, even though they rarely use that word, Johnson says. Being overlooked for a promotion at work is one example of a significant stressor. Money is another. This can involve not only the stress related to being a provider but also distrust or stress over getting a fair deal at a bank or business. Johnson says her clients also struggle with the many instances in which others are distrustful of them, such as when women clench their purses in the elevator or cross the street when an African-American man is approaching. Regardless of whether the woman crossed the street for a completely unrelated reason, perception is reality for African-American men, Johnson says.

Johnson is a firm believer in the power of the mind, so when confronting issues in session with clients, she likes to use cognitive restructuring. “I believe if we change how we think, we’ll change what we do,” she says. Once her clients realize they can change their thoughts, their stress levels often decreases. Johnson asks her clients to focus on what they are doing that is not giving them the outcome they want. “They may be in some cases the victim, but if they’re here in counseling, then we need to move beyond that,” she says. One sentiment Johnson hears from clients at times is, “The Man always has his foot on my neck.” She advocates an active approach in response. “When I hear that, I say, ‘If the Man has his foot on your neck, then you’re lying down. Get up.'”

Counselors can’t expect to sit back silently and simply listen when working with African-American male clients, Johnson says. These clients often feel as though no one understands them, so it is important for counselors to engage with them, she explains. “Allow them to talk, but when they stop talking, it’s important to paraphrase. Make sure you’re getting – or not getting – what they’re saying. They like being asked. It’s empowering.”

Counselors might have to be creative to pull in these clients initially, but once they figure out how to reach them, Johnson says, the payoff is big. She notes a higher percentage of her male clients show up for counseling sessions than her female clients. “[My male clients] realize, ‘Wow, I can use this, and this is really working for me.’ But you’ve got to get them in. You can’t wait for them to come to you.”

 

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Letters to the editor: ct@counseling.org

(Psycho)social networking

Stacy Notaras Murphy August 24, 2010

How long does it take for you to return a phone call?

Do you have a waiting list?

Would you ever slide your fee?

Do you keep up with clinical literature?

Do you have leather furniture in your office?

These are just a few questions that, when answered honestly, could provide insight into a person’s psychotherapy practice. It might sound personal, perhaps even argumentative, but knowing details of the way others run their practice is vital to providing appropriate referrals to your clients.

Many counselors in private practice focus on their own answers to such questions, particularly when cultivating a network of contacts to boost a caseload. But the flipside of this knowledge is just as important. If you have a strictly vegan client who is uncomfortable touching leather, it might be useful to know the decorating choices of the psychiatrist or acupuncturist whose skills complement your counseling work with that person. Likewise, it might help to know how much time those referrals can offer and for what fee so you can assure your client that you have made a careful, well-researched suggestion. Best practices dictate that counselors offer multiple names when asked for a referral, and this requires some advance footwork.

“Do your homework. It is well worth the time invested to survey a few of your colleagues or other health-related professionals regarding referrals for at least the most common issues,” says Deborah Legge, an American Counseling Association member in private practice in Buffalo, N.Y., who also works as a private practice mentor. Specifically, she advises that counselors build relationships with attorneys, primary care physicians, neurologists, nutritionists, massage therapists, support and therapy groups, inpatient facilities and other specialists, such as those for eating disorders, addictions, family therapy and couples work.

“Remember that you are your client’s advocate,” Legge says. “There may be times when you and your client recognize the need for a second opinion or an additional care provider. Your client may be intimidated or afraid to speak up, but you can’t be. It is up to you to help your clients find a voice and get their needs met.”

Scouting for names

“It really comes down to whether I’ve had some experience with the person,” says Ruby Blow, an ACA member who owns Development Counts in Atlanta. “For example, when I’m referring to another counselor – I’m seeing a couple and want to refer one person out for individual work – I would refer them to a therapist whom I’ve either worked with in a setting before and had consultation with, or someone I’ve supervised or taught, or someone whom I know of their clinical skills set, character and ethics.”

Blow recently sought out and invited to lunch a psychiatrist whose location is close to her practice. She explains that she doesn’t believe simple proximity is a sound enough reason to make a referral. Before deciding she would be comfortable referring her clients to him, Blow also wanted to learn about his clinical philosophy. “I don’t presume that because someone has the right letters behind their name, it means they’re practicing competently and ethically,” Blow says.

“I believe it’s hard to refer to somebody for therapy if you’ve never met them or worked with anyone who has worked with them,” explains Lynn Grodzki, a psychotherapist and business coach for therapists based in Silver Spring, Md. “In the mental health profession, we’re often only really comfortable giving a referral to someone we know personally or whose work we know well. Often that means one or two degrees of separation at the most.”

Grodzki, whose latest book is Crisis-Proof Your Practice: How to Survive and Thrive in an Uncertain Economy, describes this work as building your own Rolodex. “You can start to identify who is the best at whatever skill. Who do you hear is at the top of their game? Psychiatrist, massage therapist, couples therapist – set a time to meet up. The nice part about that is that you do get to meet this person, and it can be the start of a mutual relationship.”

Grodzki recommends that counselors ask members of their supervision groups for their preferred providers, listen to their clients’ suggestions and join related professional organizations. “I know therapists who do a lot of couples work and divorce work and have joined professional mediation organizations for just that purpose,” she explains. “All of this is to say that I think we need to be connected. We need these networks to be able to serve our clients well and also to feel like we’re in community with others.”

What to say

When asking other practitioners about their practice, Grodzki recommends explaining your intent right up front and using a slightly modified version of the so-called “elevator speech.”

Grodzki suggests saying, “I’m a therapist, and I’ve heard your name several times before. I need a psychiatrist to refer to, and I would like to talk with you briefly to make sure that I understand how you work.” Relevant questions might touch on the psychiatrist’s approach to medication and whether he or she is willing to work with a client’s current counselor on a treatment plan. It’s also helpful to learn how the practitioner prefers to be contacted and what the expected lag time is before a reply is made, she says.

Grodzki adds that a personal relationship with the referral source can help down the road, perhaps during coordinated treatment. “I’ve made referrals that don’t work out well at all. I had one where I became alarmed at the amount of medication being prescribed, and I urged the client to get a second opinion,” she recalls. “Working at cross purposes is not uncommon.” With client-approved communication between the counselor and other practitioners, a more comprehensive treatment plan may become a reality.

Licensed professional counselor David Zachau and his wife Diana Santantonio, a psychologist, run a psychotherapy practice in Elyria, Ohio. Zachau, a member of ACA, encourages counselors not to be shy when asking for details about how another clinician runs a practice. “Most of the psychiatrists in our area will have one or two counselors or social workers already in house. New counselors should be aware of the risks of sending a client for medication and then losing the client due to that circumstance,” he says, noting that new counselors may be less comfortable inquiring about this practice.

Santantonio agrees: “You want to refer to a psychiatrist who doesn’t steal patients. You have to be aware that that occurs and follow up. If you do refer a client to a psychiatrist and they end up not coming back to you, touch base and find out what happened.”

Networking goes both ways

“A person who is seeking out a professional network has to have a sense of what they, themselves, are bringing to the table,” Blow says. “In my experience, when I have a person who is newer to the profession contacting me in an attempt to network, that person is often seeking something but seldom offering something. The best thing they can do is develop a sense of what they have to offer.

“When I contacted the psychiatrist, I explained that I have clients who occasionally need med management, [so] I’m offering him something. Certainly there became some reciprocity. The best thing you can do to gain entry into the professional community is to bring something to the table, a willingness to give something of yourself.”

Blow stresses the need for counselors to be both clear and specific about what they have to offer when approaching complementary professionals. “Counselors across the board struggle with identity questions,” she says. “We weren’t intended to be social workers or junior psychologists; we were trained to be more accessible to the community. We can show the benefits we bring to the ’wounded well,’ enhancing relationships, enhancing careers, helping others find more fulfillment. Counselors need to develop a confidence about what it is we have to offer so we have a sense of who we are.”

Blow presents a “Career Awakening” workshop intended both for new professionals and those at the midpoint of a helping career. “I think the main takeaway [from the workshop] is that people need to think about what they’re offering, not about what they want to get,” she says. “If you are offering information or resources, you have a better chance of forming a professional network.”

Santantonio says new counselors who call her seeking work or supervision can distinguish themselves from other mental health practitioners by emphasizing the differential diagnosis experience they receive in counseling degree programs. “Counselors have very sophisticated diagnostic training and should recognize that as an asset,” she advises.

Continuous networking

Counselors can stay plugged into the local provider landscape by skimming neighborhood blogs to see who is being recommended, checking in with local clergy to find out whom they refer to or even asking their personal doctors for ideas.

As part of the intake request, Zachau and Santantonio recommend that counselors request the names of the other practitioners new clients are seeing. Counselors can then use the client’s own experience as a guide for gauging the quality level of other providers.

“You can contact the primary care physician just when you’re starting out with a client,” Zachau says. “Secure the client’s permission first, and then send [the physician] a letter saying you’re seeing the patient for anxiety, or whatever, and that you just wanted to let them know. You can learn a lot about the physician’s practice from interactions with it and from your client’s opinion of it. That kind of sharing of clinical information has the other advantage of increasing the likelihood that the physician will refer back to you.”

Putting yourself in position to observe the clinician’s skills firsthand is another way to learn more about a potential referral source. “Sometimes I do just literally ask about their theoretical orientation,” Blow says. “You’d be surprised that people who work for years say they don’t think much about their theoretical orientations. But mostly what I do is observe. Who is asking intelligent questions at a workshop [or] giving case examples? If I like how the person is describing the work, I ask for their information.”

Joan Phillips, an LPC in Norman, Okla., advises counselors to constantly be thinking about building their networks and looking for clues to the quality of potential referrals. When trying to get a sense of another clinician’s practice style, Phillips says, “I listen to how they present case info if they are at a CEU (continuing education unit) event or training and maybe talk to them during a break about particular cases or ideas. I also ask any counselors I know whom they refer to and why and listen for repeated names or cautions.”

Phillips, a member of ACA, notes that CEU events provide excellent opportunities to see and hear providers in their element and to gain an understanding of how they really work. She makes a practice of inviting professionals from complementary disciplines to speak at her office and then offers CEUs to colleagues to come and join the conversation. (When Phillips sees that a potential presenter’s credentials and content meet Oklahoma’s CEU standards, she contacts the state licensure office with the appropriate information and receives CEU approval documents to distribute to attendees.)

“The guest gets good PR and a chance to share their knowledge. Attendees get a low-cost, quality CEU and access to pick the brain of the speaker. I get the same plus some income, and everyone sees my office and location. We all enjoy the camaraderie and networking, so it’s worked well for me,” she says.

Grodzki adds that the process of building a referral list is never finished. “I see this as an ongoing, lifelong process of building our Rolodexes,” she says. “I’ve been practicing for over 25 years, and I even get stuck – maybe the person I always referred to has retired or isn’t working – so I still have to talk to others.” u

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

A case for personal therapy in counselor education

Amanda E. Norcross August 23, 2010

Among the many factors that influence a counselor’s abilities, I have long believed that personal therapy is the most crucial. I was therefore quite surprised that when applying for my licensed professional counselor intern license, I had to formally appeal for acceptance of five personal therapy credits on my transcript. Through this process, I realized that the value of this vital learning experience is not necessarily recognized across the field, so I am petitioning here for what should be the central place of personal therapy in counselor education.

Some of the reasons I present for personal therapy echo classic arguments put forth since the early days of analytic training. Many of today’s most admired clinicians still emphasize these points. For example, Irvin Yalom in The Gift of Therapy calls personal therapy a tuning of the “therapist’s most valuable instrument … the therapist’s own self.” Other insights stem from my particular experiences and growing understanding of how extensively counselors’ self-explorations influence the clinical experience. Incidentally, all the reasons I present make it clear that personal therapy benefits not only beginner counselors but also all other mental health practitioners regardless of their years of experience.

Increasing empathy

As counselors, we ask much of our clients in the process of therapy. We entreat them to sit with a stranger and, over time, reveal themselves, explore difficult emotions, strive for self-awareness and work to transfer what they have learned to their lives outside the consulting room. This is a demanding, courageous act. How can beginner counselors understand what they are asking of clients unless these counselors have undergone their own therapy?

I believe sitting in the client’s chair weekly – experiencing exactly what it is like to be the client – would greatly increase beginner counselors’ empathy. No other aspect of counselor education provides this firsthand knowledge of the client experience: the frustrations, the successes, the challenges. Counselors who have participated in their own personal therapy will have greater empathy for their clients because they have been there. As the psychologist James Hillman wrote in a 1982 newsletter for the Dallas Institute of Humanities and Culture, “Confronted with the unbearable in my own nature, I show more trepidation – which is after all the first piece of compassion.”

Even if a counselor feels mentally well-balanced, through personal therapy he or she will still learn what it feels like to sit across from a counselor and to be understood (or, just as valuable, to be misunderstood) by a counselor. Whatever the extent of the counselor’s personal issues, the experience of being a client forms an authentic, indelible client perspective in the novice counselor’s mind that balances and augments the counselor-centric perspective.

Increasing patience and tolerance of uncertainty

By becoming clients themselves, beginner counselors gain an inner steadiness that increases their ability to help others. In learning self-acceptance and patience through personal therapy, beginner counselors will find it easier to be patient with clients and to respect each individual’s unique process and pacing. It will also become less of a challenge to tolerate the inevitable uncertainty and ambiguity of clinical work.

In my 2009 master’s thesis research, the clinicians I interviewed said both clinical and personal experiences with uncertainty made it easier for them to tolerate uncertainty with clients. In that vein, I believe undergoing therapy is a personal encounter with uncertainty that greatly increases a counselor’s comfort with not knowing. In the face of clinical uncertainty or client pressure, such a counselor is less likely to hastily intervene or diagnose in an unconscious attempt to run away from his or her discomfort, thus leaving space for the potential of true therapeutic progress. All the clinicians I interviewed said allowing themselves to remain in uncertainty forestalled premature action on their part and allowed unforeseen possibilities to arise.

Personal therapy helps new counselors learn patience and calmness in the unpredictable waters of clinical work. Without personal therapy, I believe counselors are more susceptible to acting prematurely and subverting the difficult and fallow periods so crucial to therapeutic progress. (Counselors must remember, however, that some clients might be harmed by sustained uncertainty and require more structure in clinical work.)

Facilitating therapy

The self-knowledge gained through personal therapy is a vital tool for counselors. One of the less often discussed benefits of this self-knowledge is that it facilitates therapy. Counselors’ heightened awareness of their feelings provides, as Yalom describes, “the best source of reliable data” about clients.

Counselors’ spontaneous responses to their clients are a unique, and sometimes uncannily accurate, window into clients’ experiences. Further, an enhanced awareness of their feelings can help counselors discern projective identification, which is the therapist’s internalization of a feeling the client is experiencing but is not aware of or cannot tolerate. In short, if beginner counselors are not fully aware of and comfortable with their feelings, they lose a valuable resource for understanding their clients.

Preventing client harm through self-knowledge

I believe the self-knowledge gained through personal therapy is also central to a counselor’s ethical responsibilities. The ACA Code of Ethics states that “Counselors act to avoid harming their clients” (Standard A.4.a.) and “Counselors are aware of their own values, attitudes, beliefs and behaviors and avoid imposing values that are inconsistent with counseling goals” (Standard A.4.b.). This suggests to me that self-knowledge is critical to avoid doing harm.

Most essentially, the self-awareness gained from personal therapy provides crucial insight into sources of countertransference with clients. A working understanding of personal behaviors and feelings dramatically increases beginner counselors’ awareness of their unique biases, neurotic issues and blind spots and how these might surface in clinical work. Without such awareness, a new counselor could, unknowingly and with good intentions, respond to clients in a manner that is rooted in the counselor’s own unexamined issues. Having undergone personal therapy, counselors are more likely to recognize, and pause to reflect on, sources of impulses with clients.

Preventing client harm through self-care

Personal therapy is a core component of counselor self-care, which is another means of preventing client harm. Standard C.2.g. of the ACA Code of Ethics says, “Counselors are alert to the signs of impairment from their own physical, mental or emotional problems and refrain from offering or providing professional services when such impairment is likely to harm a client or others. They seek assistance for problems that reach the level of professional impairment.”

Though this ethical obligation is one of the more obvious arguments for personal therapy, my concern is that the climate in the mental health field is such that some counselors seek personal therapy only as a reactive measure in difficult situations.

Requiring therapy as part of counselor education, on the other hand, would teach counselors early in their careers to recognize and cope with difficult personal mental or emotional circumstances and decrease chances that such problems would go untended for long periods. In fact, the level of stress experienced by novice counselors – who are attending graduate school, embarking on a new career path and sitting with therapy clients for the first time – makes the counselor education curriculum an ideal forum for teaching the importance of self-care through personal therapy. Building personal therapy into the educational process would also mitigate any initial tendencies by beginner counselors to casually dismiss the impact of their personal circumstances on work with clients.

Decreasing the stigma of psychotherapy

Counselors are sometimes reluctant to seek personal therapy, worried that it indicates they are less capable or flawed as helpers. We should consider the message this double standard sends to our clients and the public. In the September 2009 New Perspectives column in Counseling Today, clinician Jason King said, “If we refuse to participate in the services for which we advocate and base our career, what example are we setting for society and those marginalized and disenfranchised by oppressive systems? If we fear social stigma of counseling and diagnosis, then we are covertly reinforcing the shame and stigma associated with our profession.”

The experience of personal therapy for novice counselors benefits not only the clinical dyad but also the profession overall because it decreases the stigma of therapy. Emphasizing personal therapy in the educational process would, early in counselors’ careers, instill therapy as an accepted mental hygiene option, thus normalizing it, encouraging them to view it as another available tool and teaching them not to negatively judge its use by other counselors.

Going beyond supervision

In considering the importance of personal therapy for beginner counselors, I want to briefly emphasize that the benefits of personal therapy cannot be obtained through the supervisory relationship. Although supervision is helpful in highlighting and discussing how the counselor’s personal beliefs are impacting his or her clinical work, supervision is a client-focused endeavor. Supervision cannot (and, by definition, should not) function as personal therapy. It cannot provide the thorough attention necessary to fully understand the counselor’s behaviors and beliefs. Therefore, it cannot give the new counselor a true taste of the client experience. Supervision can, however, be facilitated by personal therapy, providing the supervisory dyad with a more solid, broad foundation for understanding the counselor’s experience and countertransference.

Conclusion

I have pointed out some of the key arguments for including personal therapy in counselor education, but these are far from all-inclusive. Neural science research, for example, suggests that it is neurologically important for counselors to have done their own therapy work, as discussed in the book A General Theory of Love.

Given the benefits of personal therapy, I advocate that, at a minimum:

  • The next revision of the ACA Code of Ethics should explicitly state that personal therapy is an ethical obligation.
  • All counseling-related graduate programs should require personal therapy for students.
  • All state licensing boards should accept transcript credits granted for personal therapy. Ideally, all licensing boards should require that applicants have undergone personal therapy to apply for counselor intern licensing.

Without personal therapy, I believe beginner counselors are handicapped – counseling others without knowing the potential impact and resource of their own psyches and applying knowledge without having experienced its truth from the inside out. To be effective, aware and ethical in our work with clients, we must have undergone our own therapeutic work.

Amanda Norcross is an ACA member and an LPC intern working in Austin, Texas. Contact her at amanda@amandanorcross.com.

Letters to the editor: ct@counseling.org.

Men largely MIA from counseling

Marcheta Evans August 2, 2010

This month’s Counseling Today cover story focuses on men in counseling. When I first heard this topic, I just smiled. It reminded me of the many times I have wished that more men were enrolled in my counseling classes.

I walk into my classes at the beginning of each semester and scan for diverse students. Unfortunately, I seldom have a class that includes more than two or three men. I believe having more male counseling students would provide a broader perspective and more diversity of thought to these classes.

The cover story focuses on men in counseling from a therapeutic vantage point. I want to talk about the fact that we need more men being trained as counselors. I sometimes ponder on what we can do to recruit more men into the profession. How can we combat the stereotype that counseling is a profession primarily for women?

I have asked my students why they think more men aren’t sitting in their counseling classes. Their responses have ranged from counseling being a nurturing profession to the pay being too low, from men struggling to be empathic to men not liking to deal with their emotions. Each of these explanations might have some credence, but are we seeing a shift? Are we seeing it become more acceptable, more attractive, for men to enter the counseling profession? Honestly, I am not sure. All I can do is look around and see who is sitting in my class. And for me, the question remains: What can we do to recruit more men?

This is an important question, especially as we look at the challenges faced by men in general and young minority men in particular. We see evidence of more and more men struggling with what it means to be a man. We see men who find it a challenge to relate to the important people in their lives. We see more and more of our minority young men being incarcerated. When these men reach out for help, who is there to provide them with the guidance and support they need? Whom do they see that looks like them? Who can potentially serve as their role model?

Very few male counselors are available who are licensed and in private practice, let alone minority male counselors. This has been a concern for me since the time I worked with children who had been removed from negative home situations – situations that seemingly left them with little chance to survive. What can we do? How do we recruit men into our profession who can meet the challenges of becoming comfortable with their emotions and responsibilities? How do we recruit men willing and able to invest in becoming role models and mentors to a new generation? Are we ethically responsible for trying to recruit all types of diversity – including men – into our counseling programs and graduate education?

I asked a recent college graduate why she thought more men don’t enter the counseling profession. She smiled and replied teasingly, “I can give you one answer: They become psychiatrists.” I chuckled and reflected on her response. Could it be that other mental health fields carry more prestige in the public’s mind? Is the money factor significant enough that counseling is not a first choice for many men? Is the public lacking information about what counselors do and who we are? If so, I challenge us to consider what we can do to change our professional image. What steps can we take to make our profession more attractive to capable, invested men who choose mental health as a career path?

According to the most recent ACA membership statistics, 27 percent of our members self-report as male. I was asked whether this number was also representative of the percentage of males seeking counseling. Honestly, I don’t know, but it seems to me that we need to work on boosting this percentage. What are your thoughts? Share them with me at Marcheta.Evans@utsa.edu.

Hooray for students, keeping new professionals and going green

Richard Yep August 1, 2010

Richard Yep

Over the past few years, the American Counseling Association has been very fortunate in realizing a significant increase in the number of students who have joined our ranks. This is a positive sign that those coming into the profession realize that ACA has services, benefits and networking opportunities for them as they make their way through graduate school. I want to thank everyone who has been responsible for growing our student member population. I am hopeful that our student members and those of you who encouraged them to join will never be disappointed in what we provide.

What keeps me up at night, however, is wondering what will happen when these very enthusiastic, engaged and committed students graduate from their counselor education programs. Will we still be able to count on them to maintain their membership in ACA? Can we compete against the limited dollars new graduates make at entry-level counseling jobs? Will we be able to compete against the mountain of student loans coming due? After so many years of studying, reading and perfecting their craft, will recent graduates think the benefits of an ACA membership are still meaningful?

As noted, this worries me.

Although I believe ACA does offer services, resources and other benefits for those who carry the title "New Professional," I am not sure these recent graduates will feel the same way. We want ACA to be the professional home for all counselors, regardless of specialty or training. We want to make sure students know they are welcome, but we also want them to know they are valued for what they bring to the table while they are in graduate school, as well as when they begin their careers.

Occasionally, I ask readers to share their ideas and suggestions. This month, I am asking for your input regarding how we can best serve the New Professional. Don’t worry about the cost or the practicality; just send me your thoughts. You can e-mail or call me (see my contact information at the end of this column), or you can communicate the "old-fashioned" way with a letter sent to: Richard Yep, ACA, 5999 Stevenson Ave., Alexandria, VA 22304.

I know I will appear biased, but I really do believe that the opportunities and resources ACA provides to students and new professionals constitute an incredible set of benefits at a very affordable price. And when a student or new professional adds a division membership, the deal is even better. I congratulate the volunteer leadership for their ongoing support of those who are new to the profession. Our leaders have been steadfast in ensuring that students and new professionals have a voice in the association and in making the opportunity for membership affordable.

I also want to share something that will impact students and all other ACA members this year. When we can do something to hold down costs, that is a good thing. When we can "go green" and be more attentive to conserving our natural resources, that is also good. When we can do both simultaneously, the benefits are even better. I am pleased to tell you that ACA has made the decision to move to an online voting system this year. This means that rather than sending out 42,000-plus paper ballots and providing a postage-paid return envelope to everyone, members will have the opportunity to go to a secure voting site and cast their votes. Biographical information about the candidates, including their qualifications, will be linked to the online election site so you can decide whom you want to vote for and then take care of this process online.

We want to see as many members vote as possible, so we will still make paper ballots available by request this year for those who would prefer to vote in that manner. The bottom line is that online voting will reduce the amount of paper, printing and postage that we consume. In addition, we think it will be more convenient for members to simply go online and cast their ballots. I will be interested in receiving your feedback.

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 ryep@counseling.org or by phone at 800.347.6647 ext. 231.

Thanks and be well.