Tag Archives: Counselors Audience

Counselors Audience

Beyond the Books

Lynne Shallcross September 1, 2011

It’s a good thing Jodi Mullen didn’t become a counselor exclusively for the compliments.

Mullen, an associate professor and coordinator of the mental health counseling program at the State University of New York at Oswego, recalls working with a 12-year-old European American girl from a middle-class family whose presenting problem, according to the girl’s intake form, was “promiscuity.”

“Promiscuity is one of those words that means different things to different people,” says Mullen, who coauthored the book Counseling Children: A Core Issues Approach with Richard Halstead and Dale-Elizabeth Pehrsson, published earlier this year by the American Counseling Association. “In this case, her mother indicated she meant that her daughter had had intercourse with at least four boys in the last two months, and those were [just] the ones she knew about. There were actually three more, my client later disclosed, all within the last two months. My first thought was, ‘Yikes!’ I was very worried about this girl, and I wasn’t sure I could really help her. I knew I could lecture her about her behavior, but I also knew that would not be helpful [because] I am sure others had already done enough lecturing.”

It was a tough start to counseling. The girl didn’t want to talk to Mullen, draw or create anything in the sand tray. Instead, she wanted Mullen to listen to the music on her MP3 player. “That’s what I did for our first three sessions,” says Mullen, a member of ACA. “At the end of the third session, I asked if she could make a playlist or soundtrack to help me understand what the last two or three months had been like. She responded with, ‘You are so weird, and your hair is messy.’ I replied, ‘True. See you and your playlist next time.’ She ‘whatever’ed’ me, rolled her eyes and left.”

But at the next session, the girl arrived with a CD comprising 14 songs and titled “How I Screwed Up My Life.”

“We listened to each song,” Mullen says, “and then all on her own she said, ‘I am going to bring another CD next week. This one is going to be “How I Turned My Life Around by Talking to a Weirdo With Messy Hair.”’ Perfect.” The girl followed through, making the CD and doing the work that the inspiring songs implored her to do.

Halfway across the country in Texas, it’s a cautious 8-year-old girl whose growing separation anxiety eventually pushed her to refuse to go to school who sticks out in Brandy Schumann’s mind. The girl’s family walked on eggshells around her, leaving home as little as possible and hiding any changes in their schedule that might alarm the girl, says Schumann, an ACA member who runs a private practice in McKinney. When the girl refused to attend school, the family began home-schooling her.

After about 10 sessions of play therapy and a number of consultations with the girl’s parents on how to create a more predictable environment, Schumann says the girl’s anxiety decreased and she began taking more risks. “She agreed to join a social skills group, something she adamantly had refused previously,” says Schumann, an adjunct professor at Southern Methodist University who has also worked as a school counselor. “She continued to make progress, taking increased risks and seeking connection with peers.”

As the girl improved, she forged new friendships and survived stressful childhood experiences, including getting braces and having friends move away, with a manageable level of anxiety. Now 9 years old, she is registered and excited to attend public school this fall.

Simply listening and making a genuine effort to understand the girl’s feelings and situation were key to helping her, Schumann says. “I let her set the pace. I provided the environment — an accepting place where someone understood what it was like for her [and] where it was safe to be vulnerable. That facilitated her natural progression toward growth. She no longer had to adamantly refuse something in order to convey how overwhelmingly stressful something was. I also taught her parents how to provide these same qualities to her.”

From promiscuous preteens and anxious elementary schoolers to college students struggling with relationships and mental illness, counselors who work with students of any age encounter a host of complex issues. In a demanding and rapidly changing culture, school, college and community counselors play an integral role in helping struggling students overcome issues and move toward personal growth.

A scary world

Unfortunately, the anxiety Schumann’s client felt is becoming more the norm for elementary- and middle-school-age students, Schumann says. Her practice has seen many young children who met the criteria for generalized anxiety disorder, including two different second-graders just recently. Schumann’s practice has also worked with young clients presenting with mutism, adjustment disorders, phobias and some obsessive-compulsive traits, all related to anxiety. “We have kids dealing with a tremendous amount of stress,” she says.

Today’s children and young adolescents are struggling with complex issues, Mullen says, and a common theme seems

to be instability. “Their lives are unstable because a parent is drug addicted or incarcerated, or because they just moved, or Mom was deployed — again! — or they didn’t make the soccer team, or because they are not ready for all the changes that come with being a sixth-grader,” she says.

Pehrsson, associate dean and professor of counselor education at the University of Nevada, Las Vegas, likewise reports seeing children more frequently diagnosed with anxiety as well as depression. Children are dealing with and experiencing so many issues today, she says, including war, frequent moves, homelessness, immigration and time spent alone as parents and caretakers work longer hours or multiple jobs in the face of mounting economic pressures. It all adds up to today’s kids having to deal with more than children in the past did, Pehrsson says. “The unabating recession and lingering wars have impacted homelessness, stress, addiction issues and more,” she says. “These two things alone have [increased] the magnitude of what they are experiencing.”

“Additionally, as schools continue to emphasize testing scores, school pressures continue to rise,” says Pehrsson, a member of ACA and the Association for Child and Adolescent Counseling, an organizational affiliate of ACA. “For many children, the schoolroom is often a place of fear and failure. This, and all the normal transitional and friendship/social issues that children struggle with, adds additional burden.”

Schumann agrees that young clients’ anxiety often stems from pressure to succeed and achieve in school. She adds that this stress is oftentimes imposed unintentionally by the school atmosphere, by parents or by the children themselves. In many instances, the kids are consumed with worry about what will happen if they “mess up” at school, Schumann says.

The solution for anxiety-filled students includes counselors working with parents, Schumann says. “Part of it is just helping them understand the child’s world as the child experiences and understands it. It’s helping them get back in touch. Do you remember when a test on Friday or the invitation to a party was the biggest stressor in your life? [Parents] can’t imagine being worried about a spelling test when they have a mortgage to pay.”

When it comes to anxiety and a host of other issues, working with the parents can be hugely beneficial to kids, Schumann says. “Parents often parent the way they were parented, or they parent in reaction to the way they were parented,” she says. Parents have usually reached a wall by the time they determine to seek counseling for their children, so they are also more open and responsive to listening to new ideas. Even so, Schumann emphasizes to parents that her guidance is not a criticism of what they have been doing and points out that perhaps their particular child’s needs require a new set of skills. Schumann’s practice also offers two-way mirrors so counselors can watch a parent and child interact — or a parent can watch the child and counselor interact.

Counselors and parents alike must trust the pace and readiness of an anxious child instead of pushing the child into situations or environments that the child is cautious of, Schumann says. “Instinctively, when adults experience children as anxious, they attempt to minimize the child’s distress, sometimes hiding information about stressful events — say an upcoming dentist appointment — in an attempt to lessen the amount of time the child is anxious,” she says. “In contrast, children with anxiety need more preparation, not less, for transitions and events. They seek predictability and structure that comes from information and knowing what’s coming up. Adults can better serve the child by validating the child’s experience of the world, understanding the child’s perspective and conveying to the child a belief that he or she can handle it.”

Schumann, who is also a registered play therapy supervisor, says her approach to working with children in general is to use play therapy. Play is a child’s natural language, she says, so asking children to engage only verbally is akin to requesting them to speak solely in a language that is foreign to them. When a child is struggling with anxiety, Schumann respects that child’s pace in play, works on simply being present with the child and anticipates that it might take the child a little longer to build a relationship with her.

Mullen is also a proponent of play therapy with younger clients, as well as other options such as drawing, music and writing. She emphasizes, however, that all counselors should secure appropriate training and supervision before using play therapy interventions.

Facebook, fights and feeling fat

Counselors point to technology and social media as another issue that greatly affects younger students. “Cyberbullying and lack of privacy has unfortunately become the norm,” Pehrsson says. “Technology can foster connection, but not always in a healthy way. Children are inundated with technological input, and deciphering the good from the bad, the true from the false, is often missing.”

“In short,” says Halstead, a professor and chair of the Department of Counseling and Family Therapy at Saint Joseph College in West Hartford, Conn., “children are struggling with all the issues that children have always struggled with, but today there is a layer of technological complexity that has served to challenge children in ways that one could not have imagined a decade or two ago.”

“I have found that children who have access to various forms of social media technology are able to engage in peer-to-peer [interactions] nonstop,” continues Halstead, a member of ACA and the Association for Counselor Education and Supervision, a division of ACA. “These children have precious little social downtime, so for social circles that trend toward the dramatic and hostile, there is little opportunity to gain distance and perspective.”

Another fairly common issue Schumann sees among elementary and middle school students is behavioral problems, which can vary by age but include things such as being aggressive, hitting or having a low frustration tolerance. “What we typically see is that children escalate in order to be understood,” Schumann says. “They’re frustrated because they’re trying to communicate something and they don’t feel the environment understands.”

“Typically, caregivers discipline in a way that sets them up against the child,” she continues. “The resulting power struggle can escalate to even more behavior problems.” Schumann points parents and other caregivers to research on limit setting that aims to understand the initial desire, intent or feeling of the child, that allows the child’s expression to occur in an acceptable manner and that allows the parent to align with the child, jointly looking at the problem. “Because the child feels understood, he or she does not need to escalate in an attempt to communicate their point to the parent who previously didn’t understand,” she says.

Body image is another common concern that often begins at a very young age, Schumann says. Her counseling practice runs social skills groups for kids, and in response to the question “If you had one wish, what would it be?” Schumann has heard children as young as second and third grade say they didn’t want to be fat. The group setting is very helpful to kids with body image concerns because it allows them to learn vicariously from each other’s strengths while taking on different — and hopefully healthier — perspectives, Schumann says.

No matter the issue, Mullen says counselors can be most helpful by creating an atmosphere in which kids and teens feel accepted and free to be themselves. “This might sound easy, but it’s not,” she acknowledges. “Youngsters recognize helpers as adults, and in the youth culture, helpers are often categorized as authority figures. In order to create a safe atmosphere, counselors need to be as nonjudgmental as possible, while simultaneously being able to use gentle confrontation to facilitate and develop problem-solving and coping skills that will last well beyond the actual clinical interventions employed.”

In accord with the guidance Schumann gives to parents, Mullen says counselors must be careful not to minimize their young clients’ worries. “Sometimes, the problems this age group deals with can seem trivial to an adult. For instance, when a 9-year-old boy is devastated because he is not on the same basketball team as his best friend. The key here is that he is devastated,” Mullen says, “and in order to have any credibility with him, one must come to understand and appreciate how badly he feels and communicate that understanding to him.”

Although school counselors generally have the most direct access to young clients, other types of counselors can also serve as valuable partners in helping children and adolescents to navigate life’s challenges. As a private practitioner, Schumann says she has a much smaller counselor-to-client ratio than school counselors do, which allows for more in-depth services and, potentially, more contact with a child’s caregivers. “Community counselors are not bound by [education association] standards dictating the type of service to be provided or limiting the number of sessions,” she points out. “Also, since someone brings a child client to each session, community counselors typically have more contact with caregivers, adding an additional point of impact.” On the other hand, Schumann says, school counselors play a particularly important role because they “reach the children who may not have someone in their lives who cares enough or knows enough to get outside help.”

Schumann also sees great benefit in community and school counselors collaborating in the best interests of children. When a school counselor has been in contact with one of her young clients, Schumann seeks consent to consult with the school counselor. “School counselors can offer an objective perspective of the child’s functioning in a structured setting and with peers,” she says. “Sometimes caregivers resist the idea of disclosing information to anyone at the child’s school, including the school counselor, for fear of their child being labeled or stigmatized. I work with them to understand the significant support, services and sensitivity that can be experienced by the child when his or her environment is aware of his or her needs.”

Striving for independence

Sure, high school means football games and prom, but it also means a buildup of pressure to make big life decisions, says Raychelle Cassada Lohmann, a school counselor at Hilton Head Island High School in South Carolina. “I think high school students face the unique issue of feeling pressured into knowing exactly what they want to do with their life,” she says. “That’s a pretty big burden to be lugging around at the age of 17 or 18. In education, we instill what we know best for postsecondary planning — more education. Some students may not be ready for that road. Many parents have high expectations and of course want what’s best for their child, but sometimes I ask myself, ‘At what cost?’”

Lohmann, a member of ACA and author of the books The Anger Workbook for Teens and Staying Cool …When You’re Steaming Mad, says relationships take on a whole new meaning in high school, with both friendships and romantic relationships being made and broken. “Emotions are more intense at high school,” she says. “There are a lot of firsts — driving, job, loves, etc. And when

an emotion is new, it feels raw when it’s experienced for the first time.”

As teens are forging their own identities, they may stray from their parents’ expectations, Lohmann says. With teens pushing to gain autonomy and parents trying to hold on to their control, it’s not uncommon for the two parties to engage in a spirited bout of tug of war.

One exercise Lohmann finds helpful with kids struggling for increased independence is to have them identify what they have control over. She asks students to write down everything going on in their lives and to put an “X” on the items they have no control over. Together, they review the list and Lohmann asks the students to rank how much the things they have control over affect them on a scale of 1 to 10.

“Now we can address the things that are in their control to change and develop an action plan, beginning with the first thing on their list,” Lohmann explains. “With the ‘out of my control’ things, we work on coping strategies. This strategy helps teens feel more empowered to conquer the things that are affecting their life. Plus, it helps them understand that sometimes in life there will be things that happen that are out of our control. It is at this point we learn to cope with what’s going on around us and keep moving in a forward motion.”

Certain issues, such as forging an independent identity, are age-old, but today’s teenagers are also being bombarded with new issues that previous generations never encountered. “The biggest, fastest change hitting the teenage population right now is the use of technology,” says Lohmann, who is also a member of the American School Counselor Association and the National Career Development Association, both divisions of ACA. Lohmann points to studies from the Pew Research Center showing that 75 percent of teens have a cell phone, 88 percent of those with cell phones text, and 73 percent of teens use a social networking site.

One obvious issue strongly connected to technology is cyberbullying, says Lohmann, who adds that schools need to address the problem because, even if the threatening texts or Facebook posts are sent from students’ homes, the stressful interactions return to school with the students and negatively affect the educational environment. Another potential problem she points out are students’ digital footprints. Students often don’t realize that what they do online can become searchable by college recruiters and even potential employers.

Lohmann says a school counselor’s role when it comes to high schoolers and technology is working with students to learn how to behave online. “As counselors in the school system, we have to educate the teens about what they should be putting up on the Internet,” she says. Lohmann sometimes asks her students to Google themselves and says they’re often surprised at what they find captured online.

Educating parents on understanding technology and encouraging them to work constructively with their teens can be helpful as well, Lohmann says. She offers the example of parents who discover their teenager is being cyberbullied and react by telling the teenager he or she can no longer use the computer. In the future, instead of reaching out to his or her parents for help, the child might stay silent, reasoning that being disconnected from the lifeline of technology is an even worse scenario than being bullied, Lohmann says.

The “fierce employment situation” in today’s economy is another hurdle for high schoolers, Lohmann says, because it’s impeding teens from finding the jobs that were more common in years past. Because students are having trouble getting the experience they used to receive through part-time or summer jobs, Lohmann says it’s important for counselors to assist them in finding unpaid internships, job shadowing experiences or other opportunities for work experience.

Likely also due in part to the unsettled economy, Lohmann says more high school students are looking at the possibility of attending technical colleges or two-year community colleges upon graduation instead of four-year colleges and universities. “By being familiar with the options that community colleges offer, counselors can help students gather the information they need to make a well-informed decision,” Lohmann says. “Admission to most community colleges is a simple process, but it doesn’t just stop there. Community colleges have a host of programs, including college transfer, remediation and career-technical. Counselors need to understand the array of opportunities that community colleges provide so they can help students make a well-adjusted transition into the program of their choice.”

Lohmann’s general advice to other counselors working with high schoolers is to remember that these students want to be respected and heard. Counselors should also aim to assist these adolescents in learning to be assertive and in understanding that their feelings do count and matter, she says. Lohmann tries to teach her high school students how to voice their opinions while simultaneously remaining respectful of other people and their feelings.

One significant benefit of being a school counselor, Lohmann says, is that it makes her accessible to students in a way that minimizes the stigma. “They can say they have a problem with their schedule and [then] tell me all about their home life,” she says. “That’s a privilege that school counselors have — we can really be there for the kids. They can seek us out when they need us.”

A time of transition

On campuses nationwide, college counselors almost always report that anxiety and depression are the top two issues with which students are struggling, according to Trey Fitch. An associate professor of counseling at Troy University in Panama City, Fla., Fitch says those two issues apply to traditional college students as well as to nontraditional students. He also says the prevalence of anxiety and depression among college students is not new.

Students ages 18 to 22 face numerous identity development issues as they make the transition from family life at home to independent living at college. “People associate that transition [with being] very stressful,” says Fitch, a member of ACA who coedited the book Group Work and Outreach Plans for College Counselors, published this year by ACA, with Jennifer L. Marshall. At that age, Fitch says, the brain is going through a major stage of development. Add to that a combination of neurological, physical and social changes, and the result can be anxiety and depression. But older, nontraditional college students often deal with anxiety and depression as well, Fitch says, because they’re generally facing “role overload” and trying to squeeze school in between family responsibilities and jobs.

A cognitive behavior approach has proved effective with clients with anxiety and depression, Fitch says, because it helps them adjust the maladaptive thinking patterns believed to be at the root of those two issues. “It has a lot to do with how people talk to themselves,” he says. For example, a student might think that because he failed a test, he’ll never graduate. The counselor’s role, Fitch says, is to help the client change his thinking and come up with a more realistic appraisal. “Although I’m disappointed about the results, I can do better next time, and it doesn’t mean I’m going to fail the class or that I’m a bad student,” Fitch says. “Sometimes [counseling is about] redirecting them back to seeing how they lack balance.”

Kenneth Jackson, director of the Purdue University Calumet Counseling Center in Hammond, Ind., echoes Fitch, saying that anxiety and depression are among the most common issues on his campus. In addition, he says, a good number of students come to the counseling center with personality disorders, eating disorders and substance abuse issues. Jackson likewise points to cognitive behavior theory and techniques as being helpful in addressing such issues, but adds that the humanistic aspect of being genuine with clients is also essential.

Often, Fitch says, there is a correlation between anxiety and depression and relationship issues, whether with family members, romantic partners or friends. Traditional college-age students generally find many relationships changing, he says.

These students are generally not in long-term relationships at this point in their lives. Their core social groups are evolving even as they’re separating from family members by living at college.

Fitch recommends using narrative, cognitive behavior or family systems approaches with college students struggling with relationship problems. The approach often needs to be brief, he adds, because college counselors aren’t usually able to see students on a long-term basis. Regardless of the approach, it is important to focus on breaking negative patterns, he says. It can also be helpful to focus on students’ strengths and those times when the problem did not exist. This often means examining their patterns of unhealthy relationships as well as their strengths in relationships, he says.

Group interventions can also offer a viable option for meeting the needs of college students, Fitch says, particularly when the school’s students greatly outnumber the school’s counselors. When Fitch worked as a counselor at Texas A&M University-Commerce, he says the counseling center offered different types of groups as well as outreach programs on topics such as stress management and career development.

Off campus, community counselors also need to be knowledgeable about the issues that college students face. For the past few years, Schumann has noticed an uptick in the number of college students who come in for counseling while they’re home on summer break. Common issues for which they’re seeking help include anxiety, academic pressure, trouble balancing their personal and academic lives, and body image concerns. “The transition of becoming quasi-adult is a lot for [college students] to handle sometimes,” Schumann says.

With college-age clients, Schumann focuses on being present and working to genuinely understand and validate their feelings. She often uses a combination of talk therapy and activity therapy, which can include sand tray or the expressive arts. In the past, she has also researched the counseling resources on her clients’ campuses and provided the students with information for getting help once they returned to school.

Emerging issues

The most surprising trend Jackson has seen of late on his campus is the rise in the severity of mental illness that students are experiencing, as well as the number of students requiring emergency hospitalizations for safety reasons. Fitch supports that observation, saying that more college students today have to be hospitalized, are seeing psychiatrists and are on medications. “It could be that there’s more stress in today’s society, it could be poor coping skills or it could be that we’re recognizing it more,” Fitch says. “My guess is it’s a little bit of all three.”

Considering the increase in severity of mental health issues among college students, Fitch urges college counselors to be vigilant, to be knowledgeable of community resources and to develop relationships with community providers, including crisis counselors, psychiatrists and contacts at area hospitals. “When these issues pop up, that’s when you have to reach out,” he says.

Fitch also notes a new trend — more combat veterans returning to college and university campuses. College counselors might be tasked with helping these veterans deal with post-traumatic stress disorder, reintegrate into the community and understand what’s involved in the shift between combat and academics. He recommends that college counselors seek additional training in preparing to work with this special student population and points out that the Department of Veterans Affairs offers educational opportunities for counselors.

Financial pressures are also increasing for students. Jackson, a member of ACA, NCDA and the American College Counseling Association, a division of ACA, says many students on his campus are seeking higher education later in life, meaning they are more likely to be under financial strain caring for children and/or elderly parents and working a full- or part-time job while going to school.

Fitch also notices the economic pressures burdening today’s college students. “As a teacher, I have a lot of students who come to me with their academic problems, but the real problem is financial,” he says. “They have to work an extra shift and they can’t make it to class, or they have to withdraw because they can’t afford it.”

In these tough economic times, Fitch tells counselors to help college-age students prioritize. “The counselor can help them set priorities when they’re in crisis,” he says. “Helping them with decision-making and priority setting are two of the most important things.”

In recent years, college counseling centers have grown more similar to community clinics, Fitch says, departing from the role of helping students solely with academic and relationship issues. That means college counselors must be properly prepared to deal with a wider variety of student problems than in the past. For that reason, Fitch urges college counselors to be active in their professional organizations, to earn continuing education credits, to keep up with the literature and to do whatever else they can to keep learning. “My biggest tip right now would be the need for extra training,” he says, “because there are so many issues now that we didn’t deal with 20 or 30 years ago.”

ACA Resources:

For more information on student issues, check out these books published by the American Counseling Association. To purchase any of the titles, visit the ACA online bookstore at counseling.org/publications or call 800.422.2648 ext. 222.

  • Counseling Children: A Core Issues Approach by Richard W. Halstead, Dale-Elizabeth Pehrsson and Jodi Mullen
  • Group Work and Outreach Plans for College Counselors edited by Trey Fitch and Jennifer L. Marshall
  • Cyberbullying: What Counselors Need to Know by Sheri Bauman
  • Suicide Prevention in Schools:
  • Guidelines for Middle and High School Settings, second edition, by David Capuzzi
  • Solution-Focused Counseling in Schools, second edition, by John J. Murphy
  • Youth at Risk: A Prevention Resource for Counselors, Teachers and Parents, fifth edition, edited by David Capuzzi and Douglas R. Gross
  • Active Interventions for Kids and Teens: Adding Adventure and Fun to Counseling! by Jeffrey S. Ashby, Terry Kottman and Don DeGraaf
  • Assessment and Intervention With Children and Adolescents: Developmental and Multicultural Approaches, second edition, by Ann Vernon and Roberto Clemente

Lynne Shallcross is a senior writer for Counseling Today. Contact her at lshallcross@counseling.org.

Letters to the editor: ct@counseling.org

A new voice on the Hill

Heather Rudow August 4, 2011

(Photo by Heather Rudow) ACA Member Gregory Pollock prepares to lobby elected officials at the Institute for Leadership Training.

Gregory Pollock appears calm as he begins a long, sunny walk toward Capitol Hill, but he admits the idea of lobbying elected officials in a matter of hours has got him nervous.

“I’ve written letters and made phone calls to state congressmen before,” he says, “but I’ve never done something as big as this. It takes it to a whole other level. The last time I was even in DC was when I was 14 for a family vacation.”

The most vivid memory the Ohio native recalls from that previous trip is spotting the late Sen. Ted Kennedy. But today, Pollock and nearly 140 ACA branch, division and region leaders from across the country are heading straight to the source of national legislation to talk about important issues facing counselors and their profession.

Some of the counselors will be asking their senators and representatives to reauthorize the Elementary and Secondary Education Act, but Pollock, the government relations chair for the Ohio Counseling Association, will be tackling Senate Bill 604, the Seniors Mental Health Access Improvement Act of 2011. The bill will allow licensed professional counselors to be covered under Medicare, and it is something Pollock has passionately lobbied for in years past.

A professional clinical counselor for the past 15 years, Pollock says there have been many instances in which he has finally begun to make progress with a client but he has had to suddenly stop seeing them because they turned 65 and Medicare won’t cover their counseling visits. He says it’s detrimental to his clients’ mental health as well as to the counseling profession.

“They finally begin to feel that comfort and they begin making progress, and then it’s disrupted,” he says. “I think the reason I care so much about this is because I’ve seen the inequities firsthand and it’s really, really frustrating.”

Which is why, even as the Capitol building’s iconic dome looms in front of him, Pollock says he is ready to push his nervousness aside and speak out about a cause he believes in.

During his day on the Hill, Pollock meets with representatives for Sen. Sherrod Brown and Rep.Steven LaTourette and has what he considers to be varying degrees of success with each. But the experience has left him invigorated, he says, and perpetuates his desire to advocate for for counselors at home and across the country. Pollock said he is also looking forward to giving a confidence boost to other counselors who haven’t tried lobbying before and who, like him, might be nervous about it.

“Now I can go to them and say, ‘I’ve done this, and you can, too,'” he says. “I can tell them I’ve been there before and it’s not so scary.’”

Pollock says it’s important for all counselors to get involved in order to make positive changes for the profession, even if it’s just joining an organization like ACA and keeping up to date on current events.

Recently, he says, a counselor asked him if she was covered under Medicare— the exact fight he has been involved with for the past three years.

But what Pollock says he has learned the most from his experience on Capitol Hill is that every action taken by a counselor to get his or her voice heard counts, and it doesn’t have to be at a national level.“If all the counselors in America wrote one, heartfelt letter to their local elected official about the importance of Medicare coverage for counselors, that would be at least 200,000 letters. Can you imagine what we could accomplish?”

For more information on S. 604 and other current issues, visit ACA’s public policy page.

Heather Rudow is a staff writer for CT Online and Counseling Today. Contact her athrudow@counseling.org.

The challenge of diagnosing ADHD

Mike Hovancsek August 2, 2011

I remember sitting in Ms. Smith’s sixth-grade class, in full daydream mode, as she droned on and on in the background. Suddenly, Ms. Smith declared, “Now that I have explained this assignment, I want you all to get right to work on it.” My classmates immediately started working diligently at their desks with paper and pencils.

I had no idea what the assignment was because I had been daydreaming through the entire explanation. Trying to remedy the situation, I walked up to the teacher and whispered, “I don’t understand what we are supposed to be doing.” Ms. Smith immediately became irritated. This was not the first time I had asked her to repeat instructions.

“I just spent several minutes explaining the assignment. Weren’t you listening?” she demanded in an angry whisper.

“Oh, I was listening, but I don’t think you explained it very well,” I whispered back in a sad attempt to deflect the blame.

“OK, I’ll explain it one more time, but that’s it!” Ms. Smith hissed in an impatient tone.

Standing up close to Ms. Smith, I took in details about her that I had never noticed from my desk. I could see her scalp through her curly blond hair, and she had an alarmingly large nose. Even worse, she had huge pores. “Man,” I thought, “you could actually store things in there!”

Just as this thought occurred to me, Ms. Smith said, “There, now I have explained the assignment to you twice. You should be able to do it perfectly at this point.”

As I walked back to my desk, I realized I had not heard a single word of Ms. Smith’s explanation. I had been too busy admiring her pores. I returned to my desk and drew pictures until it was time for recess. It was many years before anyone suggested that I may have a form of attention-deficit disorder.

In Essential Psychopathology and Its Treatment (2009), Jerrold S. Maxmen, Nicholas G. Ward and Mark Kilgus estimate that 5 percent of Americans have some form of attention-deficit/hyperactivity disorder (ADHD), which is more than 15 million men, women and children. These numbers are slippery, however, because ADHD often goes undiagnosed or misdiagnosed.

Many challenges exist when it comes to getting a proper diagnosis for ADHD. I will examine several of them in this article and provide some suggestions that can help improve diagnostic accuracy.

Attention-deficit/hyperactivity disorder is a misleading term. People who have this disorder might actually have very intense focus when they are interested in a particular topic, sometimes spending countless hours engaged in a favorite activity. This presentation is at odds with the attention-deficit part of the term and can cause diagnosticians to erroneously rule out ADHD as a diagnosis. Also, many people have “ADHD, Predominantly Inattentive Type,” which often does not include hyperactivity among its features. In fact, a person with that diagnosis often has hypoactivity.

In other words, a person with ADHD may have moments of excellent attention and absolutely no symptoms of hyperactivity — behaviors that completely contradict the very title of the disorder. In an attempt to remedy this, Edward M. Hallowell and John J. Ratey, in their 1995 book Driven to Distraction, suggest it would be a good idea to change the term to Attention Inconsistency Disorder.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) can be misleading when it comes to ADHD. The writers of the diagnostic manual seem to imply that only children have this disorder. They list ADHD in the “Disorders Usually Diagnosed in Childhood” section, and the descriptive criteria include statements such as “Often leaves seat in classroom or in other situations in which remaining seated is expected.”

Only about one-third of children with ADHD grow out of the disorder. The rest take it into adulthood. In addition, a lot of people are not properly diagnosed until adulthood, when they may have symptoms that look different from the ones described in the DSM. Adults with this disorder might be quick to get angry or frustrated, often start projects and then abandon them to start other projects, self-medicate in an attempt to manage their symptoms or have a history of underachievement despite possessing a significant amount of talent and enthusiasm.

There is no valid test for ADHD. This is a really interesting issue. As mentioned earlier, many people with ADHD have very good focus when something interests them. As a result, they may get curious when you present them with a test. In those moments, their attention increases and they perform like people who do not have ADHD.

To complicate matters further, pharmaceutical companies created some of the ADHD scales. One test in particular has been the subject of lawsuits because it is suspected of being designed to provide marketing information to drug companies. Counselors might want to question any scale developed by people who profit from an affirmative result. If tests are used at all for diagnosing ADHD, it is important that counselors take the results with a grain of salt and consider them as only one of many available pieces of diagnostic information.

People with ADHD are not always the best historians. They may report that they don’t have a problem in one area or another, when the people around them might tell you something very different. Diagnosis is best when it combines feedback from family members, school records, records from past therapists and the client’s own self-reporting. It is also helpful to get to know a client over

the course of a couple of sessions before making a diagnosis because the client may behave differently or recall different information from one session to the next.

Several disorders (for example, bipolar disorder) look quite a bit like ADHD but require a very different course of treatment. Those other diagnoses must be ruled out before assuming that a hyperactive and/or unfocused person has ADHD.

Environmental and circumstantial factors can mimic ADHD symptoms. We live in a society that bombards us with far too much stimulation, much of it competing for our attention at any given moment. We might also have past traumas that distract or upset us. Relationships can have a similar effect. The chaos of office politics or a dysfunctional family, for example, can reduce focus and create mood instability. Rule out these factors by seeing whether the ADHD symptoms are present in different environments and whether they have been present since childhood.

Certain people could receive secondary gain from this diagnosis. For example, a teacher having trouble managing the behavior of a particular student might feel more comfortable attributing the problem to ADHD rather than to his or her own classroom management skills. In addition, clients might falsely present with symptoms of ADHD in hopes that it will increase their odds of receiving disability benefits or other entitlements. Be sure to consider possible secondary gains that clients might experience before making your determination.

ADHD has a high rate of comorbidity, which can confuse matters. People with ADHD might also have substance dependence, depression, anxiety and/or learning disorders. It is easy to diagnose clients with these more obvious disorders while missing the underlying ADHD. A mindful, informed diagnostician will keep an eye out for contributing/coexisting factors, including ADHD.

Substance addiction/dependence can disguise or mimic ADHD. As just mentioned, it is easy to be distracted by the issues associated with addiction and to miss the underlying ADHD, which can be a significant contributing factor to the addiction. Conversely, people who are using or in withdrawal from substances often exhibit anxiety, hyperactivity or distractibility that mimic ADHD. In the case of substance abuse/addiction, it can help to delay the diagnosis of ADHD until the client has experienced several months of sobriety.

Diagnosis is complicated by the fact that some medications used to treat ADHD have a high abuse potential. This could possibly motivate some clients to feign ADHD in order to get drugs. At the same time, people who legitimately have this diagnosis might be denied treatment by mental health professionals who suspect these clients are drug seeking. It is important to consider both scenarios when making diagnostic decisions.

Diagnosis potentially can lead therapists to overpathologize their clients. The goal of diagnosis is not to condemn a person or to give him or her an excuse to fail in life. The goal is to identify the most effective treatments available to help a client address identified problems.

Hallowell and Ratey argue that it may not be accurate to refer to ADHD as a “disorder.” For example, the very elements of ADHD that disrupt life can also cause a person to be spontaneous, creative, intuitive and intelligent. When clients learn to manage the dysfunctional elements of ADHD, they can then also benefit from its positive elements. It is important to identify, celebrate and access these strengths as part of treatment. u

Mike Hovancsek is a supervising professional clinical counselor in Ohio. Contact him at therapy@ohio.net.

Letters to the editor:
ct@counseling.org


 

Seeing potential, not disability

Lynne Shallcross August 1, 2011

When Chad Betters wants his students to grasp what it means to have a disability, he shares the story of a former client. The woman had been a nurse for 19 years but developed an allergy to latex as a result of her work.

“By developing this condition, the client not only had to adapt vocationally, given that she could not safely work in any health care environment due to the utilization of latex in many of the medical supplies present, but also had to make drastic changes in her life, including modifying her home, her vehicle and even her wardrobe due to the presence of latex components. She also had to learn to be mindful of her environment when out in public because sitting in a restaurant with balloons in the vicinity could trigger allergic symptoms,” says Betters, an assistant professor of rehabilitation counseling at Winston-Salem State University in North Carolina.

After working with Betters, the client was admitted into a legal training program and found work as a paralegal. She had learned how to manage her disability and became an advocate for health care professionals with latex allergies. “It’s a story I share with my students, and it tends to open their eyes to the magnitude of the impact of a disability,” Betters says.

Rehabilitation counseling is a well-established but sometimes misunderstood part of the counseling profession. “Everyone assumes we’re substance abuse counselors,” says Betters, a member of the American Counseling Association and the American Rehabilitation Counseling Association, a division of ACA. “And while we work with individuals with substance abuse issues because [they are] a disability, we work with all disabilities across the board.”

Carolyn Rollins, associate professor in the Department of Counseling and Educational Leadership at Albany State University in Georgia, has also heard the assumption that rehabilitation counselors focus on one specific area, such as substance abuse. But disability comes in a variety of forms, says Rollins, who is a past president of ARCA.

For example, she says, a rehabilitation counselor might help a student with a disability to get the accommodation he or she needs, whether that means taking a test in a quiet environment or using a computer with voice capabilities. The counselor’s role, Rollins explains, is to take a physician’s or other evaluator’s recommendation of what accommodation is necessary and to assist the school or other institution in implementing that accommodation for the client.

According to the ARCA scope of practice, “Rehabilitation counseling is a systematic process which assists persons with physical, mental, developmental, cognitive and emotional disabilities to achieve their personal, career and independent living goals in the most integrated settings possible through the application of the counseling process. The counseling process involves communication, goal setting and beneficial growth or change through self-advocacy, psychological, vocational, social and behavioral interventions.”

Tyra Turner Whittaker, a professor of rehabilitation counseling at North Carolina A&T State University, notes that the number of people with disabilities is vastly increasing, particularly as the baby boomer generation ages and as more veterans return home with disabilities incurred during military conflicts.

Rollins adds that improvements in medical care are allowing greater numbers of people to survive life-threatening situations, but many times, these individuals are left with disabilities. It’s no surprise then that the role of rehabilitation counselors is growing ever more crucial, Rollins says. “A person’s ability to function independently can be enhanced by the knowledge of rehab counselors.”

Employment … and much more

One of the primary goals of rehabilitation counseling is to help clients become gainfully employed, says Amos Sales, professor in the Department of Disability and Psychoeducational Studies at the University of Arizona. As a minority group, 13 percent of people with disabilities live at or below the poverty line, and two-thirds of people with disabilities are unemployed, according to Sales. Of those who are employed, only one in four is employed full time. “You can imagine what that does to a yearly income,” Sales says.

Carrie Wilde, president of ARCA and former chair of the Counselor Education Department at Argosy University in Tampa, Fla., says although the roots of rehabilitation counseling are in helping clients find employment, that isn’t the sole focus. “Now counselors are taking a more holistic approach,” she says. “How are clients doing socially, educationally, how is [a disability] affecting their relationships? It’s not just vocational.”

Whittaker, a member of ACA, adds to that point. “In the past, unfortunately, what happened in the field of counseling [was that] people tended to view rehab counselors as just employment specialists [rather than] counselors who have an expertise in employment,” she says. “For the most part, rehabilitation counselors share the core counseling training that most counseling students have, along with additional training in employment and in the medical and psychosocial aspects of disabilities.”

Rehabilitation counselors assist clients with reintegrating into the community, whether the individuals are dealing with a disability they were born with or one they experienced later in life, Wilde says. She previously worked with clients who had brain injuries, using a holistic approach that encompassed working through the clients’ perceptions of themselves with the disability, adjusting to the disability, improving their self-confidence and becoming more socially comfortable. Wilde says a holistic approach to rehabilitation counseling can also include working with the client’s family members, friends and other support systems.

The issues clients bring with them to rehabilitation counseling are wide ranging, Sales says. In many cases, clients are still working through personal and emotional issues related to having a disability, he says, so a counselor’s training in establishing a relationship while demonstrating empathy and positive regard is crucial.

On the employment end, counselors might work collaboratively with the client to investigate what he or she wants to do, Sales says, possibly by administering a personal interest test. If it becomes evident the client needs retraining or additional education to obtain employment, he says those services can be provided through the state-federal vocational rehabilitation services program, which was set up through the federal Rehabilitation Act.

Employment services with rehabilitation counseling clients might begin with an assessment, which may be administered by the counselor or by someone else, depending on the scope of practice in the counselor’s workplace, Wilde says. After reviewing the assessment of the client’s abilities, she says the rehabilitation counselor might offer the client employment services, such as working on interview skills, or send the client to another agency for additional training or services.

Rehabilitation counselors often work with potential employers or the client’s coworkers as well, she adds, helping to set up accommodations for the client in the workplace. The counselor’s level of involvement in the workplace largely depends on the client’s ability to articulate his or her needs to the employer, Wilde says. “We as rehabilitation counselors do not want to add to the stigma that may already be associated with a disability,” she says. “The more we can have clients do for themselves, the less disruptive it is.”

In working with an employer, the rehabilitation counselor’s goal is to find out what can be changed in the client’s environment or support system to allow the individual to do the work, Wilde says. For example, if an employee was injured and can no longer handle heavy lifting, a rehabilitation counselor might work with the employer to modify the person’s job description. Wilde had one client who couldn’t bend well because of a disability, so she collaborated with his employer to make adjustments to the equipment with which the client worked.

The economy remains a complicating factor, Betters says. “Individuals without disabilities are having trouble finding employment,” he says. “When there are disabilities, that just compounds it.”

Whittaker offers a recommendation to counselors providing vocational counseling to rehabilitation clients. “Truly listen to the client’s story — where they’ve been and where they hope to go,” she says. Clients often want to share their backgrounds as well as their future aspirations, she explains, and counselors should show the patience to first listen before assisting clients in meeting those goals.

Returning power to the client

Sales views people with disabilities as an oppressed minority group — a group that “experiences a particular need to feel more power in their lives.” Giving power back to individuals with disabilities is such a passionate topic for Sales that in 2007 he wrote a book about it: Rehabilitation Counseling: An Empowerment Perspective, published by ProEd and available through ACA.

“They have been denied power throughout their lives,” Sales says of clients with disabilities. “They have dealt with the medical model all their lives where they’ve been told what they can do and cannot do. Because of mobility issues, they’ve been denied access. All of those things feed into being in a lower power position. They come to counseling with a need to be more empowered.”

Ironically, the field of rehabilitation counseling had very paternalistic beginnings, Sales says, with counselors viewed as the “experts” who would determine vocational goals for clients. Thankfully, times have changed, he says, and today there is a greater push toward client empowerment.

The first step rehabilitation counselors can take in empowering clients is to assume the role of partner rather than of expert, Sales says. That’s a paradox in the counseling profession, he says, because counseling students work hard to become knowledgeable about all sorts of emotional issues and how to overcome them. “But where you subtly cause problems and actually oppress clients is by making decisions for them, by moving them more toward the counselor’s own thoughts and opinions,” he says.

If the counselor acts as the expert, Sales warns, clients are more likely to make choices on the basis of what they think the counselor wants them to do rather than on what they believe would be in their own best interests. “If they’re comfortable with you and they are seeking advice, that’s good,” he says. “But if you move them too quickly based on your thinking and expert knowledge, that’s not good.”

To create a more empowering counseling process for persons with disabilities, Sales offers several recommendations, including responding to the individual instead of the disability and using the Rogerian approach of empathy, congruence and positive regard. Try to put as much power as possible back into the clients’ hands, he advises counselors, and support clients in assuming more power over their own personal change as well as over their environment. Depending on the individual issues and needs of each client, rehabilitation counselors can use a wide range of effective counseling theories and approaches, but Sales says feminist theory pairs particularly well with an empowerment approach.

Rollins is also an advocate of empowering clients. “Rehabilitation counseling is a profession in which we strongly believe in the autonomy of the client, and the client’s role in the process is very important,” she says. “The client ought to be able to have a role in the outcomes of the treatment and to define [his or her] own needs.” Clients should be actively involved in the rehabilitation process, Rollins says, and counselors should work from a strengths-based model, with the counseling relationship building on the assets the client brings to the table.

Earlier in her career, Wilde remembers empowering a 32-year-old client who was rebuilding his life after a self-inflicted gunshot wound to the head. The client was living in a nursing home when Wilde began working with him, but after approximately two years of rehabilitation counseling, the man found employment and began living on his own again. “It was the belief that he could do more for himself that got him out of the nursing home,” Wilde says. “Empowering clients to do more for themselves and feel good about themselves is central to rehabilitation counseling.”

A complicating factor

For about three years, Betters has been researching the relationship between disability and obesity. The nation’s waistline is growing, and that can complicate the situation for people with disabilities, he says. “As our country is becoming more and more a victim of the obesity epidemic, we are going to have to accommodate this in what we do as rehabilitation counselors because it is multiplying, compounding and increasing the magnitude of disability that clients are bringing to the table.”

Advancements in health care have helped minimize obesity’s effect on mortality, which is positive, Betters says, but the flip side of the coin is that obesity is increasing morbidity, making it more of an issue within rehabilitation counseling. Obesity can complicate rehabilitation after a person suffers a disability, and it can also stem from incurring a disability.

Betters points to research showing that people who enter workers’ compensation programs after an injury come out with higher body-mass indexes than before they began. “Those individuals are then at a greater likelihood of sustaining a re-injury,” Betters says. “It’s almost a downward spiral.” The American lifestyle already promotes obesity, Betters says, and when someone has a disability, lack of activity, dietary changes from a tighter budget and mental anxiety only increase the likelihood of the person becoming obese.

The implication for rehabilitation counselors, Betters says, is that job placement for the client becomes even more difficult. The more limitations a person has related to obesity — such as fatigue, taking diabetes medication or dealing with orthopedic pain because of weight — the harder it becomes to find a suitable employment match. Betters adds that individuals who are obese also face greater employment discrimination. “Obesity’s implications compound everything,” he says.

The obesity epidemic isn’t going to drastically diminish anytime soon, Betters tells rehabilitation counselors. In fact, data points to it getting worse. “As rehab counselors, we can’t expect clients to come in the door with a game plan that they’re going to take responsibility to manage [their weight] or have an action plan during rehab,” he says. “Rehab counselors didn’t sign up to work as nutritionists or exercise trainers, but we need to start including those aspects at least in the discussions if it’s relevant.”

Does Betters recommend that rehabilitation counselors address the issue of weight with clients, even though it remains something of a taboo topic? “If it’s going to prohibit or limit their employability, my position is yes,” Betters says. “It should be treated as any other issue, concern or obstacle in the client’s return-to-work process.”

Although rehabilitation counselors aren’t experts in diet and nutrition, Betters suggests opening the discussion by asking clients how obesity might be impacting their disability. Rehabilitation counselors may also be able to assist clients by making appropriate referrals. For example, although it isn’t the norm, Betters says some workers’ compensation systems are providing gym memberships to clients to assist them with weight-loss efforts.

Working together

All counselors, regardless of specialty, can benefit from understanding the work of rehabilitation counselors, Whittaker says. “All counselors will encounter individuals with disabilities at some point, whether the disability is physical, cognitive, mental or developmental in nature. My suggestion would be to have compassion. Often due to burnout or dealing with our own life issues as counselors, the level of empathy toward others can be adversely impacted. It is vital for all counselors to fight for [clients’] opportunities as you would fight for your own children or parents.”

Whittaker thinks all counselors should have at least one course that focuses on disability issues but also believes that each counselor should operate within his or her own scope of practice. “If a private practitioner has a client with a disability who presents with issues beyond their scope of practice, I would definitely say refer the client to a qualified rehabilitation counselor,” Whittaker says.

If a mental health counselor is working with a client who has an identified disability and isn’t progressing as well as he or she should and the reasons why aren’t apparent, Rollins recommends consulting with a rehabilitation counselor. “Rehab counselors and mental health counselors work well together,” she says. “They can work on a plan to advance the client’s goals. The rehab counselor also might be able to come up with other sources of support for that person.”

Other counselors may also find a rehabilitation counselor’s expertise particularly helpful when trying to determine if a disability exists. Although certain physical disabilities are easy to discern because of the presence of wheelchairs or crutches, Rollins says many clients struggle with “invisible” disabilities that counselors might not readily identify in the absence of client disclosure. “Consequently, some dimensions of the client’s behavior or issues may be unclear and remain unexplored,” she says. “The counselor may view the being unmotivated or uncommitted to treatment, lazy or unwilling to fully engage. Some disabilities may be undiagnosed, or the social stigma attached to some disabilities can affect a client’s willingness to disability. A rehabilitation counselor will identify clues from the client’s history, as well as behaviors that may suggest the presence of a disability, even though the client has not disclosed. … The rehabilitation counselor will then explore the impact of the disability issues and assist the client in addressing those issues to reduce their impact in successfully resolving the counseling issues.”

Counselors who don’t specialize in rehabilitation counseling would also benefit from understanding the state-federal vocational rehabilitation services system to properly prepare to help clients with disabilities who are seeking employment and other supports, Betters says. Many counselors don’t realize the vast amount of resources within the system, he says. If the issue is related to finding, maintaining or advancing in employment, the system can provide assistance with medical concerns, education, transportation, retraining and much more.

Above all else, Betters says, it’s important to recognize clients as individuals with disabilities, not disabled individuals. “They’re capable of doing almost anything if they have the appropriate accommodations,” he says.

Sales agrees. “You can become more preoccupied in understanding the disability than in understanding the person,” he says. “Be very cautious to not address the individual as their disability.”

Wilde’s most valuable lesson learned as a rehabilitation counselor was to let clients take the lead. “My clients have taught me so much,” she says. “They are the experts on their experiences, so I take my lead from there. I’m there to challenge them and support them, but it’s looking at what the client has to offer, seeing beyond the disability and seeing the potential for what they’re able to do. It’s a privilege to work alongside clients as they go through that process.”

Branching out

Employment isn’t an issue only for rehabilitation clients — it’s also an issue for rehabilitation counselors. To help new rehabilitation counseling professionals looking for work or even seasoned professionals seeking something new, Tyra Turner Whittaker, a professor of rehabilitation counseling at North Carolina A&T State University, offers a rundown of job opportunities for those trained in rehabilitation counseling.

1) One major employment option, Whittaker says, is working for a state agency, whether it’s a state vocational rehabilitation agency or a state agency for the blind or deaf and hard of hearing.

2) Look into opportunities with the Department of Veterans Affairs.

3) Because rehabilitation counselors have special expertise in career and employment counseling, they can consider working as a career counselor or employment specialist, Whittaker says. “You can use that knowledge and skill set to help individuals find careers or assist companies in executing their employment development programs, which are desirable services in this current economic climate.”

4) Work as a vocational expert on behalf of insurers, defendant or plaintiff attorneys, or through the Social Security Administration. “Similar to medical experts utilized in the legal system, vocational experts offer vocational professional expertise on the impact of a personal injury on the claimant’s future earning capacity,” Whittaker says.

5) Addictions counseling is another option for counselors trained in rehabilitation counseling, Whittaker says, although rehabilitation counselors might need additional licensure and/or training in addictions counseling depending on their state’s requirements. North Carolina A&T offers a certificate program in rehabilitation counseling and behavioral addictions. The program provides specialized training to rehabilitation counselors in the areas of alcohol and drug abuse, gambling addiction, sex addiction, eating disorders and criminal behavior.

6) Life-care planning is yet another option. “This is an area of specialty in rehabilitation in which the counselor works with people with catastrophic injuries or illnesses,” Whittaker says. The counselor’s role would be to develop a care plan that delineates every specific need the individual has or will have, along with the cost of those needs from the point of injury through the remainder of the client/claimant’s life.

7) Finally, Whittaker points to disability management as a rewarding employment option. Rehabilitation counselors would have the opportunity to work with an employer in the areas of disability intervention and prevention within the workplace.

To order a copy of Sales’ Rehabilitation Counseling: An Empowerment Perspective (order #72868), visit the ACA online bookstore at counseling.org/publications or call 800.422.2648 ext. 222. The cost is $39.95 for ACA members and $49.95 for nonmembers.

Counselor’s best friend

Lynne Shallcross

Cynthia Chandler has a secret weapon in her counseling toolbox. He’s furry, has four legs and facilitates breakthroughs with clients that Chandler suspects would not happen otherwise. His name is Rusty, and he’s one of Chandler’s cocker spaniels.

Rusty might not be able to talk, but there’s no doubt he connects with people, says Chandler, professor of counseling and director of the Center for Animal-Assisted Therapy at the University of North Texas.

Chandler, who is also one of the facilitators of the American Counseling Association’s Animal-Assisted Therapy in Mental Health Interest Network, recalls one boy with whom she worked when doing volunteer counseling at a local detention center. The boy had anger-management problems and often got into fights, and he wouldn’t respond to any of the counselors at the detention center.  When Chandler showed up with Rusty, however, the boy quickly gravitated toward the dog.

At the request of the detention center, Chandler, along with Rusty, began conducting counseling sessions with the boy. Chandler allowed the boy 10 minutes of play with Rusty, followed by 20 to 30 minutes of counseling and then another 10 minutes of play. During the counseling segment of the meetings, Rusty would rest his head on the boy’s lap.

Rusty’s presence seemed to enable the boy to interact with Chandler. “He just opened up to me like you wouldn’t believe, and he wouldn’t open up to the other counselors at all,” she says. “So it was Rusty who built the relationship.” There was a scientific reason behind the boy’s ability to transfer the connection he felt with Rusty onto Chandler, she says, and one that went much deeper than forming a cute, cuddly bond with a dog.

After Chandler got one of her cocker spaniel puppies in 1999, she noticed how people at the park or on the street would approach and ask if they could pet her dog. Eventually, it clicked for Chandler that if her dog made people feel comfortable enough to approach a stranger, the technique might prove useful in her counseling work as well, serving as an effective icebreaker to lower clients’ anxiety levels. After reviewing the available research, she realized her observation only touched the surface.

Science has provided a psycho-physiological explanation for why humans and certain animals feel so comfortable together, says Chandler, the author of Animal Assisted Therapy in Counseling, published by Routledge and due out in its second edition in September. Dogs, cats, horses and humans are all mammals and share the same social response system, she explains. Social contact, especially positive physical contact, releases a pleasure hormone called oxytocin, which has a healing, calming, soothing effect.

“That’s fantastic for a client who’s anxious and nervous and has difficulties in forming social relationships,” Chandler says. Anyone who has lost trust in other people, such as emotionally troubled kids who feel betrayed and abandoned, can benefit greatly from contact with a therapy animal, she says. Chandler references studies conducted in hospitals that show that patients who receive visits from pets heal faster, require less pain medication and have less scar tissue than those who don’t.

“This is the most important point that people need to understand — it’s a science,” Chandler says. “Up to this point, a lot of people have not really understood the science behind it and why it’s so powerful. It’s the release of oxytocin, [which] actually heals the body. It’s not just cute and fun; it’s science. Animals are here to stay in therapy if people embrace the science.”

In the case of the boy at the detention center, Chandler explains that oxytocin was being released as he interacted with Rusty. Because Chandler was present as this was happening, the boy was able to connect her with Rusty and bond with her, as well. “We cannot forget the science behind [animal-assisted therapy],” she says.

An instant connection

Amy Johnson, who facilitates the ACA Animal-Assisted Therapy in Mental Health Interest Network with Chandler and also directs the online animal-assisted therapy certificate program at Oakland University, has always loved dogs and children. Spending a week at one of the first “dogs-in-prison” programs for youth and witnessing how the kids’ tough exteriors melted away while interacting with the animals inspired an idea in Johnson, who is also a certified dog trainer. In 2005, she started an organization called Teacher’s Pet: Dogs and Kids Learning Together, which pairs at-risk youth with hard-to-adopt shelter dogs for training.

Teacher’s Pet operates in a school for students who are emotionally impaired and in three juvenile facilities for court-adjudicated youth. The organization also runs a summer camp for middle school students and a program for kids with autism on the Oakland campus in Michigan. The average length of each Teacher’s Pet program is 10 to 12 weeks, meeting twice per week for two hours each day. In the juvenile facilities in particular, the kids feel an immediate connection with the dogs because they share similar situations, Johnson says. “It’s kids with behavior problems and dogs with behavior problems, kids who are locked up and dogs who are locked up.”

The students are tasked with training the dogs to get them ready for adoption. The first hour of each session usually involves psychoeducational work with the students, with Johnson teaching them how to understand the dogs’ body language. Dogs and humans have very similar body language and expressions, Johnson says, so this exercise also assists kids in reading other people’s body language and understanding their intentions. Talking about the dogs’ lives, including whether they’ve been abused, neglected or put up for adoption, often opens up opportunities for Johnson to talk with the students about their own life experiences, which frequently mirror those of the dogs.

During the second hour of each session, the kids train the dogs, which is also effectively teaching the kids how to act and how not to act. For example, Johnson tells the kids that if they’re sitting on the ground, the dogs will view them as peers rather than as leaders. She instructs children who have low self-esteem that the dogs won’t respond to them if they’re hunched over and quiet. “Even if you don’t feel like you know what you’re doing, act like it,” Johnson tells the students. “Raise your voice. Stand up straight.” In the process of training the dogs, she says, the kids are “practicing better ways of interacting with others while getting feedback from the dogs.” Working with the dogs helps the kids to develop empathy, patience and impulse control, while also giving them a confidence boost, Johnson says.

Johnson describes the experience of a girl in one of the detention facilities who had some traits of borderline personality disorder. Both the girl’s mother and grandmother had lost custody of her, and at the detention center, she was prone to fights. The girl was participating in the Teacher’s Pet program and, one day after she got into more trouble, Johnson went to talk with her. “She really didn’t want much to do with me,” Johnson says, “so I changed the subject and asked her to tell me about the dog program. She said she didn’t want to talk about it, and she didn’t want to be in the program anyway. I knew what was coming even before the girl said it. She said, ‘I don’t want to be attached to that dog and have it taken away from me.’”

Johnson told the girl she was doing something wonderful for someone else by getting the dog ready for adoption and that through her own selflessness, she was helping others. The girl continued with the program, and when it came time for the dogs to “graduate,” she predictably expressed some sadness — but not because the dog she had trained was leaving. Instead, she was worried that the dog would think she had chosen to abandon it. “That was the first time I saw empathy with her,” Johnson says. “I attribute a large part of that to her working with the dog. I truly don’t believe we would have been able to make progress with her in that area without the dog.”

The Teacher’s Pet dogs assist kids in building empathy and perspective-taking, Johnson says, but the program also helps them learn to handle loss because they can’t keep the dogs after they train them. Johnson talks with the kids about their feelings when the dogs graduate. “It gives them a dry run through other losses they’ll have,” she says. “It gives them the skills to know how to deal with it.”

One student who had been removed from his mom and siblings was preparing to say goodbye to his dog. “He told me afterward, ‘It let me know that I can say goodbye to someone I love and it’s not the end of the world. It’s OK that I was with him only a short period of time, but I can love him forever,’” Johnson says. “If I had said cognitively, this is what we’re going to work on, it wouldn’t have been the same as experiencing it.”

A comfortable relationship

The most popular place to utilize animal-assisted therapy in counseling is in schools, Chandler says, “probably because that’s the most awkward social age for humans.” Kids from kindergarten on up can benefit, she says, both in special populations and in mainstream populations. She adds that research has found kids are more focused and better behaved in the classroom when an animal is present.

A school counselor might have a dog that kids can come in and pet, and while they’re there, the students can talk with the counselor about things that may be bothering them. It helps to normalize the experience of going to see the counselor, Chandler says, and interacting with a pet tends to calm kids.

A second likely place to incorporate animal-assisted therapy is in private practice, Chandler says. A client would come to see the counselor, and a pet would be present, whether a dog, a cat, a bird or another animal. The interaction could include nondirective activities, such as the client simply holding or petting the animal while talking to the counselor, or it could be more directive, such as asking the client to work with the animal to perform a command, which helps to build social skills and self-confidence, Chandler says.

Whether in private practice or in schools, animals help adolescents feel more comfortable with the counselor, Johnson says, because the animals deflect attention away from the client. In many cases, she says, young clients will watch how the dog interacts with the counselor. If the counselor is nice to the dog, Johnson says the kid might think, “Maybe she’ll be nice to me” or “She must be a nice person because the dog likes her.”

Kids can also project through the animals, Johnson says. “If the kid’s been abused, the counselor might say, ‘This is my dog. Do you know he had been abused when we first got him? What do you think he worried about most while living there?’

“‘Oh, I bet he was really scared, like he never knew when he might get hit,’ the kid might say. They’ll project their own feelings onto the dog.”

Horses can be utilized in private practice as well, Chandler says, although clients would most likely visit some kind of therapy ranch to work with them. “It’s not just about horseback riding,” Chandler says. “Before they ride, the client has to form a relationship with the horse. Everything the counselor does is motivated toward the client building a relationship with the animal, and that helps build the relationship with the counselor.”

Children with autism can often benefit from animal-assisted therapy, Johnson says. Working with an animal provides these children a safer audience on which to practice basic actions such as giving and receiving feedback and maintaining eye contact, she explains.

That holds true for a variety of other clients as well, Chandler says. “Mammals provide great practice for developing skills with humans,” she says. “The relationship with the animal is simpler for the client, and once they develop it with an animal, they can transfer that over to humans.”

Animal-assisted therapy is also utilized in nursing homes, detention centers, prisons and hospitals. According to Chandler, studies have shown that in prisons that incorporate animal-assisted programs, inmates’ self-esteem goes up, while behavior problems go down, and the tendency to return to the judicial system after release is greatly reduced.

Animals provide a safe release for people, Johnson says. “Humans don’t tend to always be trusting of each other. With a dog or other animal, you can go and hug them and sob. They won’t judge or tell anyone.”

Taking the plunge

Counselors interested in integrating animal-assisted therapy into their work have to do their homework, Johnson and Chandler say. Not every client will be comfortable around an animal, Johnson cautions, whether due to fear, cultural differences or allergies, and counselors should never push hesitant clients to work with therapy animals. Chandler adds that counselors should also screen clients to ensure they are emotionally ready to interact with pets appropriately rather than being aggressive or abusive.

On the flip side, counselors must be certain that their animal doesn’t pose any type of danger to clients, Johnson says. For example, even if a client gets angry or yells, the animal shouldn’t startle and react aggressively. Chandler advises that both the animal and the counselor should receive proper training. She points to the Delta Society, which offers individuals the opportunity to obtain registration as a pet partner. The person goes through a minimum of eight hours of training, while the pet has to pass a standardized 30-minute assessment. Therapy Dogs International offers an assessment for the pet but doesn’t provide training for the handler, which Chandler says is important.

Coverage for liability is another important piece of preparing for animal-assisted therapy. Because Johnson’s students train the dogs, she maintains dog training liability insurance on top of her counseling insurance. If a dog is certified through the Delta Society or Therapy Dogs International, those organizations offer liability insurance options as well, Johnson says. In addition, she asks her clients or parents of clients to sign a liability waiver as well as a waiver stating they won’t harm the animal and will behave appropriately around it.

Chandler also recommends that counselors pursue additional training in animal-assisted therapy. Her program at the University of North Texas and Johnson’s program at Oakland University both offer distance-learning opportunities.

Counselors should always be thinking about the animal’s best interests, Johnson adds. Be sensitive to recognizing when the animal is tired, she says, and avoid raising its stress level.

To counselors considering animal-assisted therapy, Johnson says it goes far beyond just having a dog in the room. “It requires having goals and objectives and utilizing the animal as a specific part of treatment,” she says. “Once you have goals, there should be a specific modality to obtain those goals, consistency of treatment, measurement tools and evaluation. For example, if you’re working with a child on social skills, it’s much safer to practice those skills with a dog. For a client who needs a good cry, it might feel less awkward for him or her to hug a dog as opposed to sitting across from someone in silence. Animals offer an opportunity for skin contact, which releases oxytocin, reducing blood pressure, heart rate and decreasing anxiety. When stress is lowered [and] anxieties are reduced, it allows for a safer, more open setting for the client to speak openly and freely.”

 

The ACA Animal-Assisted Therapy in Mental Health Interest Network is an electronic mailing list that offers counselors a chance to ask questions, obtain resource ideas, share literature, problem-solve and more, Johnson says. Visit counseling.org for more information (use the link to “Interest Networks” at the bottom of the page), or e-mail Holly Clubb at hclubb@counseling.org to sign up.