Counseling Today, Cover Stories

It takes two (or more)

By Laurie Meyers July 23, 2014

gears_brandingDespite the American tradition of “rugged individualism,” working successfully is rarely a solitary activity. Although counselors are proud of their professional identity and strive to be experts in whatever their specific disciplines may be, there is still room for — even a need for — communication and the exchanging of ideas with individuals from other professions. The counselors in this article have found better ways to serve their clients, as well as significant professional satisfaction, by collaborating with others.

A team approach to teaching social skills

American Counseling Association member Chris Abildgaard has known for a long time that he wanted to help people with autism spectrum disorders.

“The first time I ever worked with a person with autism was in 1998 when I was a junior in college,” he recounts. “I just realized that for whatever reason, I clicked with and understood people with autism.”

That desire to help has taken Abildgaard, a licensed professional counselor (LPC) and national certified counselor (NCC) in Wallingford, Connecticut, from school psychology to private practice to a new multiprofessional collaborative practice that is built around the concept of “social thinking.”

Abildgaard, who specializes in autism spectrum disorders and social cognitive intervention and is certified in behavioral interventions for autism, started his career as a certified state school psychologist, which helped shape his view on collaboration.

“While working in the public schools, that’s really where I got my start in understanding the need to collaborate with other professionals and learn from other fields and disciplines,” he says. “In doing that, I think I have been able to explore different methodologies in terms of what works and what doesn’t work.”

Abildgaard bases his interventions in cognitive behavior therapy (CBT) and social thinking. Social thinking is a methodology developed by speech language pathologist Michelle Garcia Winner that focuses on how human interaction requires thinking about other people and what they might be thinking about us. According to Winner, our perception of what people think affects how we behave, which in turn affects other people’s perception of us. However, some people, such as those with high-functioning autism spectrum disorders, social communication disorder, Asperger’s syndrome, attention-deficit/hyperactivity disorder (ADHD) and nonverbal learning disability, don’t intuitively develop the nuances of social interaction.

Winner developed a curriculum and founded the main Social Thinking Center in San Jose, California, where she now teaches. Professionals in other fields who work with populations with social deficits can receive training in the social thinking method at conferences held at the various Social Thinking Centers nationwide.

“Social thinking incorporates a lot of the principles of CBT and gets to the essential questions like ‘why are we social?’ It really starts to define what social is,” Abildgaard says.

Abildgaard discovered social thinking six or seven years ago when the administration at the school where he was working assigned him to teach a group of four students who had varying presentations of autism and possessed different skill levels. “It was one of the most daunting things I’ve ever had to do because I had no idea what I was doing,” Abildgaard says.

In his search for additional methods to help the students with autism, he came across social thinking. He was so impressed with the treatment framework that it became an essential part of how he counseled, and when he went into private practice, he ended up founding the Social Learning Center, which uses the precepts of social thinking to improve clients’ social cognitive abilities. The center targets and teaches clients:

  • How their social minds work, including why they react and respond the way they do
  • The behaviors that make others feel good and bad
  • How these behaviors are affecting their emotions, responses to and relationships with others in different social contexts
  • The “why” behind the specific, isolated social skill and the reasons it would benefit them to use the skill
  • To consider the thoughts and feelings they create based on their behaviors, whether expected or unexpected

Abildgaard and his clinical staff of social workers, a therapeutic recreation specialist and a speech pathologist, plus interns and clinical associates in the fields of mental health counseling, psychology and related areas, teach those concepts using a variety of methods.

“It starts with learning from clients and their families and then asking, ‘How do we help our clients with social learning difficulties be independent and live in the world that they want to be in?’” Abildgaard says.

The Social Learning Center provides both individual and group therapy. In part, that is because functioning in a group is one of the areas the center’s young clients struggle with most, Abildgaard says.

“It’s very rare that you find people in schools who tackle what it means to be in a group,” he says. “You have to be in groups in class all day, and a lot of our clients don’t understand why they have to engage in these behaviors and why they should care about the kid next to them.”

Another area that typically proves challenging for many of the center’s clients is social interaction and feeling comfortable with others. The Social Learning Center’s team teaches its clients that it is OK for them to feel awkward and uncomfortable in social situations, even pointing out that everyone feels uncomfortable at times. However, the team emphasizes that part of life is learning what to do when we feel uncomfortable.

Many clients with social difficulties can become rigid because of their compelling need and ongoing search for comfort. For instance, Abildgaard says, a child or adolescent might wake up on the weekend and have every moment planned in his or her head. However, this plan may not fit with what mom and dad want to do, and this causes conflict. When this scenario gets repeated, it can lead to the young person being labeled as disruptive, in part because the child or adolescent does not understand, and thus is unable to explain, why he or she is reacting that way. For that reason, Abildgaard’s team works with clients on flexible thinking — understanding that not everything has to be planned out and that it is important to consider the thoughts and plans of others as well.

The center also likes to get its clients out into social settings rather than just having them learn about skills in an office. Abildgaard believes that the more socially oriented training that social workers receive is particularly beneficial for coaxing clients out. For instance, one of the social workers at the Social Learning Center is a proponent of adventure therapy, which aligns with Abildgaard’s mantra to all of his therapists: Get outside with your clients; don’t just sit at the desk and talk about being social.

Abildgaard also describes the involvement of the staff speech pathologist as critical. “I think sometimes we forget that behavior is communication,” he says. “When you are working with a client who has so-called behavioral deficits, some of that involves communication difficulties. Treating the behavioral problems is not just about extinguishing the behavior, but finding a way to communicate those thoughts and feelings in words.”

“I’m also continually reminded that sometimes we take for granted the difference between verbal and nonverbal communication,” he continues. “We don’t just communicate with our mouths, but with our faces and bodies.”

Body language typically clues people in to behaviors and unspoken thoughts, but this is something that people with social difficulties often have trouble interpreting. For instance, they might see a look on someone’s face and think it means the person isn’t interested in what they are saying when, in reality, the person is just thinking about what has been said and how to respond, Abildgaard says.

People with social difficulties also have trouble understanding what their body language is communicating to others. The speech pathologist at the Social Learning Center uses mirrors and videos so clients can see their own facial expressions and body language. This helps them start to learn how their nonverbal behavior affects other people.

“I’ve always thought [that we] need to integrate other disciplines in order to bring about the most effective change and treatment options for people,” concludes Abildgaard.

Helping the severely mentally ill to build better lives

During her more than 30-year career working as a counselor in the city jail system in Kansas City, Missouri, ACA member Nancy White has seen many people who were severely mentally ill cycle through the detention system. Oftentimes, these former inmates ended up in homeless shelters or in and out of psychiatric facilities. This was also the case with many other Kansas City residents who struggled with serious mental illness.

So, when management in the behavioral health department at Kansas City’s Truman Medical Center — where White worked counseling people who were homeless — asked her to help build and manage a new Assertive Community Treatment (ACT) team, she jumped at the chance. ACT is an outpatient treatment approach that provides personalized, comprehensive community-based care for those with serious, chronic and disabling mental illnesses.

Sometimes referred to as Program of Assertive Community Treatment, Mobile Treatment Teams or Community Support Programs, programs that use the ACT model are staffed with a multidisciplinary team of professionals such as counselors, psychologists, psychiatrists, social workers, medical doctors, nurses, substance abuse specialists and others. ACT programs can be run at the state, county or municipal level by mental health centers, private nonprofit or for-profit organizations, outpatient units of hospitals, managed care companies or other providers. The teams offer people with serious and chronic mental illness individualized assistance that includes mental and physical health services, substance abuse treatment, assistance with finding jobs or housing and a variety of other services.

“One of the reasons we [the mental health community in Kansas City] started ACT is that many of our mentally ill citizens were spending time in emergency rooms, the hospital, psychiatric units and jail,” explains White, an LPC who manages the team. “We hoped that by providing intensive services, we could begin to reduce their hospital stays, jail stays and homeless issues.”

The program is able to provide such intensive and personalized treatment because of the low client-to-staff ratio — about one staff member for every 10 clients, White notes. In addition to a psychiatrist who provides about 12 hours of treatment a week, the staff is composed of a registered nurse, two LPCs (in addition to White), two vocational assessment professionals and three dedicated case workers (even though everyone pitches in with the case work).

In addition to the low client-to-staff ratio and the diversity of the staff, it is the focus placed on clients that makes the program work, White says. “When a patient first comes in, we meet with them to find out what their needs are and try to meet [those needs],” she says.

Building the clients’ trust level with the staff is also essential, White continues. “We need to show them what we can do for them before it [the relationship] will work,” she explains. “You have to find a way for this person to trust you so that they keep seeing you. If you say you’re going to do something, do it, or they won’t trust you. I tell my staff to never promise something they can’t deliver.”

Clients are referred from a variety of sources such as jails, psychiatric emergency rooms, drug courts, mental health courts and homeless shelters. Many are referred because of ACT’s contacts in the city.

White still sometimes works at the city jail, and the county jail is housed in the same building, so she has co-workers in both systems. “The ACT program can really be a reentry program for people coming out of jail,” she says.

White has encouraged the director and social work staff in the jail system to refer released prisoners with serious mental illness to ACT for evaluation. She also maintains contact with the physicians at the psychiatric emergency room and sometimes visits inpatients to tell them about ACT.

White and her team have also performed training sessions on crisis intervention at the Kansas City police department so that the officers will better understand people with mental illness when they encounter them on the streets or in jail. She also collaborates with the local mental health court. The staff there will sometimes call her after evaluating candidates for mental health court, and some of these individuals will end up at ACT.

White and the rest of the ACT staff deliver a range of services but start with the basics: food, clothing and shelter. After that, psychiatric care is delivered on the client’s terms. Wherever the client feels safe — whether that is at home, in a park or in another public place, is where the program’s psychiatrist will go. “We have the ability to say, ‘We know that you are frightened to go to a psychiatrist; can he come to you?’’ White explains.

White notes that the psychiatrist’s involvement in the program goes well beyond prescribing medications. In fact, this summer, he has been spearheading a program to get clients involved in gardening. Two of the program’s clients see him for therapy, but they also have regular sessions with the LPCs, as do the other clients.

“Counseling has been particularly important for many of our clients with chronic and persistent mental illness,” White says. “It has given them a chance to form a therapeutic relationship with a licensed mental health professional and has allowed them to talk about things that have happened in their lives — things that I suspect they have never discussed with anyone before.”

Reaching out to clients — getting them involved with and able to take advantage of community services — is a big part of ACT. Much of what White’s team does is possible because of the connections the staff makes in the community at large. For example, the ACT team regularly partners with church programs and food shelters to provide basics such as clothing and food.

“We collaborate with churches for food a lot,” White says. “We have enough of a relationship that if it’s after hours and a client needs food, we can call these places and say, ‘Hey, we know you’re not open right now, but we have someone who really needs food.’”

The team also helps clients find housing. Most clients do not come to the program homeless, but some are in group homes or living with their families and would like to start living independently. Over the years, the team has established relationships with apartment managers in the community.

“Once a client has found a place they want to live, we go with them to check it out,” White says. “If we like it, we may end up referring other clients.”

Team members visit clients regularly in their apartments to check on them. Sometimes while visiting with one client, White says, they run into others and have an additional opportunity to hear how they are doing. Residents and managers of the apartments get used to White and her team being around, so they become a kind of extended family. Clients look out for one another, and the apartment managers also reach out to the ACT team if they are concerned about the well-being of any of the residents.

Frequently, finding a place for the client to live is just the first step, White notes, because many individuals with severe mental illness need help with basic tasks of daily living. “Often they don’t know how to cook, how to clean or do laundry, so we teach them,” she says.

Sometimes the clients even want to go beyond the basics, like with money management. “A lot of clients have what’s called a professional payee. Someone has decided they aren’t able to manage their own money, so the bills are being paid by the professional,” White explains. “So we give them financial education so they can become their own payees.”

Although living on their own is a very important goal for clients, the ACT team also endeavors to get them involved in their communities. They can attend ACT-run substance abuse, therapy and vocational groups, and ACT team members will also take clients out to look for work. The team also finds drop-in centers where clients can be with other people, take classes, join groups for fun, go to a movie or participate in some other kind of outing.

“We’re trying to meet basic needs and help them have a better life, function socially and maybe even have a job,” White explains. “We want to increase their time spent in the community rather than in the hospital.”

“We’re also trying to make it better for their families,” she continues. “By the time a client has gotten so sick that he or she is in jail or in the hospital, the family often doesn’t know what to do anymore.”

To coordinate all of this activity and stay on top of clients’ welfare, the team meets every day to talk about which patients might be doing poorly or need extra help. The ACT team also maintains a 24-hour hotline that clients can call when they need help. “A staff member is always on call, so it’s not a stranger — it’s someone they know,” White says.

Making such a huge difference in people’s lives is rewarding, White says. “There are clients who are so debilitated when we begin to work with them — often still psychotic, very symptomatic — that any little progress is a great thing,” she says.

But the progress can also be dramatic. “I’ve seen some amazing things. To see these people get better instead of seeing them behind bars or strapped in bed is so unbelievable,” White says. “It shows that maybe if they had gotten the right services at the right time [earlier in life], maybe they wouldn’t have had to suffer so much.”

Schooling education administrators

School is an environment in which multiple professionals with varying educational and professional backgrounds — think teachers, administrators and school counselors — must work together. Sometimes, however, these professionals don’t truly understand the role that their colleagues actually play — or are qualified to play. These misunderstandings can negatively affect the relationship between colleagues and, worse, carry over to affect the relationship between staff and students.

That disconnect is something that Summer Reiner, an ACA member, witnessed firsthand during her five years as a school counselor.

“It became obvious to me that most people in the school didn’t really understand what counselors do,” says Reiner, who went on to write her dissertation on teachers’ perceptions of counselors. She found most teachers assumed that all school counselors were mirror images of the counselors they had worked with early in their careers. They had little idea of the specialized training school counselors receive or the breadth of skills and knowledge they possess. And because many school administrators are former teachers, this meant the people who had the most control over how school counselors were deployed to do their jobs often didn’t understand what these counselors could or should do.

When Reiner joined the counselor education faculty at the State University of New York at Brockport as an associate professor and school counseling program coordinator, she decided to take a look at the education administrators’ program to see if she could bring about a meeting of the minds.

“I looked at the administrators’ course work, and I saw that they had no training on any of the other school professionals’ roles,” Reiner says.

They did, however, have a course on program evaluation, and in one of Reiner’s courses, school counseling students develop a comprehensive school counseling program. So Reiner proposed that the two classes hold a mock school board meeting in which the counseling students would present their school counseling program. Because the education administration students were trained in program evaluation, they would evaluate the counselors’ program.

In anticipation of the mock board meeting, Reiner gave a presentation to the education administration class about what school counselors are trained to do and what they are not trained to do so that the administration students would have a frame of reference when they evaluated the school counseling program.

“It became a truly collaborative experience because my students got to have the experience of presenting in a board of education setting, and we had the opportunity to educate the administrators on what school counselors are trained to do and what they should be expected to do,” Reiner says. “And the administrators benefited from being able to put their skill set to the test in terms of evaluating a program and learning how to give feedback.”

At the end of the experience, the counselors-in-training also gave feedback to the future school administrators about how they came across when providing the evaluation.

“They [the counseling students] might give an example like, ‘You know, when you looked over your glasses at me and spoke to me, that was intimidating,’” Reiner recounts. “So it raised awareness among the administrators around how people might be receiving their messages.”

After the mock school board meeting, both sets of students reported feeling that the experience had been very educational for them. In fact, they wanted more. “So, as the years went on, we began to add more and more collaborative pieces to this experience,” Reiner says.

Another major collaborative project is an assignment in which both groups choose a school district and go online to download data about the surrounding community, including school report cards, housing information, prevalence of crime (both inside the schools and in the larger community) and other information. The school counseling students evaluate the data and develop recommendations on what they can do to help address problems in the community, while the future administrators detail how they would want their subordinates to approach the issues.

For example, the school counselors might find that the district has a drug problem and propose starting a drug counseling initiative. The school administrators might want to set up brief educational sessions in small groups that all students would eventually attend. In the process, both groups learn how the other would handle a similar situation. Afterward, they evaluate the ideas and provide feedback to one another concerning why the proposed solutions might or might not be possible to implement, Reiner explains.

Another part of Reiner’s administrator-school counselor collaboration is lesson plan evaluation. School counselors are charged with helping students grow emotionally, socially, academically and developmentally. One of the ways they do that is by coming into classrooms to teach. Although typically a small part of their jobs, it is often the piece weighed most heavily by others, Reiner explains. But given all that school counselors have to learn as part of their training, lesson planning often takes a back seat, so Reiner thinks it is useful for the students to get help from the student administrators, many of whom are former teachers and are adept at lesson planning. The counselors-in-training not only develop lesson plans for the future administrators to read and evaluate, they also “teach” their lesson plans in classroom presentations. The administrators-in-training can then provide tips regarding content and engaging students. On the other side, the counselors-in-training can help the future administrators understand why certain lessons that might be controversial, such as open discussions about sex, are developmentally appropriate and important.

Reiner hopes her collaborative program will be a step toward greater understanding and communication between school counselors and education administrators. She eventually wants to conduct a study of the real-world outcomes of the program to determine whether the lessons stick in the long term or simply raise awareness in the moment.

However, Reiner is pretty confident of the effect the collaborative program is having on her school counseling students. “I think they come out of it feeling much more secure that they know what they are doing and that they are good at it,” she says.

The parent coach

Counselors are no strangers to addressing problematic parent-child interactions, whether as part of family therapy or as an element of counseling interventions with individual child clients. But Meghan Walter, an ACA member and NCC from the Orlando, Florida, area, has found it helpful to take a more hands-on, training-oriented approach by incorporating “parent coaching” into her services.

“Parent coaching is closely related to counseling but is a very distinct, specialized kind of consulting,” says Walter, who now operates a private practice as a parent coach. “Instead of focusing on someone’s background or specific personal issues, we help clients identify their parenting goals and give them tools to reach those goals.”

Unlike counseling, parent coaching is a relatively brief intervention that usually takes three to four sessions, Walter says. She meets with the parents, helps them assess and articulate their parent goals, and then gives them the tools they need to reach those goals.

Parent coaching is a nascent field, and at this time, there is no official license or training requirements to qualify as a parent coach, Walter says. However, there are training programs available. Walter received her online training through a program at Concordia University, which uses the Parent Coaching Institute’s model (see thepci.org/about/training/coachingmodel.htm). “Before you send a client to parent coaching, find out what that coach’s background is,” she advises counselors.

Walter’s interest in parent coaching was ignited during her days as a school counselor. Working with students made her realize that counseling interventions would be most effective if they could be reinforced not only at school but also in the home. However, many school counselors weren’t used to including parents in their counseling programs and interventions.

“School counselors need to learn how to work with parents,” Walter says, “and I realized that we could really benefit from learning some parenting consulting skills.”

Walter started her own parent coach studies and then went on, as an associate professor of counselor education at Stetson University in Florida, to teach future school counselors some of the concepts of parent coaching. She also encouraged them to get further training in parent coaching as a valuable adjunct to their school counselor training.

Eventually, Walter went from just teaching the principles of parent coaching to actually coaching parents herself. Some of her clients come to her directly, but frequently she receives referrals from other counselors who feel she offers complementary services to the counseling they are providing. She is currently working with a couple expecting a baby.

“This couple has a child already, and with that first child their marriage experienced serious stresses,” Walter says. “Now that they are expecting again, they want to [preemptively address] some of the problems through couples therapy.”

Because marriage health affects the health and development of children, the couple is also receiving parent coaching from Walter. “I’m helping them build some skills and to see how couples skills play into establishing good parenting practices,” she notes.

In this case, Walter, who is trained to teach certain Gottman Institute programs, is using the institute’s Bringing Baby Home curriculum. The Gottman Institute is a well-known organization dedicated to researching and teaching methods to strengthen couple and family relationships.

Bringing Baby Home prepares couples for the arrival of a baby by focusing on three major goals: strengthening the couple’s relationship, encouraging mothers and fathers to prepare for the transition to parenthood, and giving expectant parents basic information about infant psychological development and related parenting tips.

“When you have a firm relationship, you are really providing a foundation from which a child can grow and thrive,” Walter says. “You are teaching them relationship building and communication skills and to foster emotional intelligence. This helps children to be able to identify, accept and manage emotions in a socially appropriate way.”

Walter also has clients who come in for parent coaching who need additional help to work on their marriage or receive family counseling. In such cases, Walter maintains a list of counselors she can refer these clients to while she focuses on coaching them in parenting skills. When given permission by these clients, she also discusses certain aspects of treatment with the outside counselor.

Recently, a couple came to Walter for parent coaching to help them manage their relationship with their daughter who has attention-deficit/hyperactivity disorder. The daughter was having problems with her schoolwork, including losing assignments and turning in incomplete work, and the parents wanted help with setting expectations and providing the household more structure.

“As we worked on it, I realized the parents needed couples therapy,” Walter says. “There was a pattern going on between the parents in which the dad would be dictatorial and lay down the rules, but he let the mother be responsible for actually implementing them. This allowed the dad to stay out of it and remain passive and judgmental. This was a long-standing issue between them as a couple.”

In addition, the parents were struggling with another daughter who refused to consistently follow the house rules, such as doing chores and sticking to a curfew. “The mom had a hard time putting rules in place, so part of my work with them was to empower mom and to get the dad involved,” Walter says. “The mom was doing too much for her children and sacrificing a lot of herself.”

One of the things Walter coached the parents on was maintaining curfew. She explained that no matter how reasonable sounding the daughter’s excuses were for being late, they needed to adhere to the time they had agreed to. If the daughter missed curfew, they needed to follow through and revoke her privileges for a week or two. The key for these parents was to learn to set appropriate rules and maintain them, Walter concludes.

In addition, through the combination of parent coaching and couples therapy, the mother eventually realized that she wanted to do some work, even in a volunteer capacity, that would take her outside of the home on occasion.

 

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To contact the individuals interviewed for this article, email:

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

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