Tag Archives: Counselors Audience

Counselors Audience

License portability: One counselor’s journey across state lines

Thomas J. Sherman January 1, 2012

As an existentially oriented counselor, I am well versed in the absurd, but I was not quite prepared for how far my ability to accept it would be stretched when I moved three hours away and across state lines. I graduated with my doctorate in counselor education in May from a well-known university and, following graduation, moved to join my partner who had received an outstanding job in another state. Being a licensed counselor, I assumed it would be easy for me to follow her and get a job practicing counseling. How wrong I was.

In light of the 20/20: A Vision for the Future of Counseling initiative’s “Principles for Unifying and Strengthening the Profession,” I felt compelled to share my story. The fourth principle is “Creating a portability system for licensure will benefit counselors and strengthen the counseling profession.” Through writing about my experience, I hope to help other counselors anticipate some of the difficulties of transferring a license from one state to another and help counseling boards understand the impact of restricting the portability of licenses.

When I graduated with my master’s degree, I moved to a state that did not require a license to practice but did require unlicensed counselors to be under the supervision of a licensed professional. In three years, I completed the 4,000-hour clinical residency, which included 2,000 hours of direct client contact and 200 hours of supervision required for licensure in the state. In June 2010, I passed my state licensure exam while enrolled in my doctoral program. In April 2011, when my partner and I knew we would be moving to a different state, I began reviewing the requirements for transferring my license to the new state.

I was informed that the licensing structure where I was moving was modeled after the state’s social work license, which required even recent graduates to have a graduate license to practice. The requirement for transferring a license is listed as either two years of practice as a licensed counselor or 2,000 hours of clinical professional counseling experience. Despite these requirements being listed twice on the licensing forms, I called the state counseling board to confirm that I met the requirements and was completing the correct forms. After outlining my experience, I told the person at the counseling board that I had held my license in the other state for only one year but that I possessed well over 2,000 hours of clinical experience. The person with whom I spoke at the board notified me that, given my clinical experience, I should be able to transfer my license.

By the end of May, I had gathered the required signatures from my professors and former supervisors, collected transcripts from all of the schools I had attended, written the required check to the board and mailed a license verification form to the state counseling board where I currently held my license so it could sign and return the form to the new state to which I was moving. After waiting several weeks into June, I called the counseling board in the state to which I was moving to see if it had received my licensure verification form. I was told the person with access to the files was on vacation and would “be back sometime next week.” The next week, I called several times before reaching the person with whom I needed to speak, only to be informed that the form had not yet been received. This person also told me that if the form was not received by July 15, I would have to wait until Aug. 15 for the counseling board to review my application.

Having this information, I called my former licensing board to inquire about my licensure verification. A voice mail greeted me, informing me the board had a high volume of applications and instructing me to leave a name and number, which I did. The following day, having not received a return phone call, I called several times until finally reaching an actual human whom I could ask about the status of my license verification. I told this person the check for the verification fee I had sent with the form had been cashed in June, but as of July, my new counseling board had not received the form. This person told me my former counseling board met only once per month and had already convened in June prior to my request being received. I inquired as to when the counseling board would meet next. The response: “Sometime in July.” The person could not provide a date when the board would meet to sign my form.

This raised a second concern for me. Because I had submitted all of my forms in June, I had allowed my license in my former state to lapse at the end of that month, not seeing the benefit of paying for and carrying two licenses in different states. I attempted to call my former licensing board again to determine if this lapse would affect the verification of my license because the board would not be reviewing it until July. Once again, I was unable to reach anyone, so I left my question on voice mail. I never received a phone call. Instead, on July 15 I received an email indicating the board had mailed out my licensure verification. The email didn’t address my question of whether my license was still valid.

After waiting another week, I called my new counseling board to confirm receipt of the licensure verification form. It was at this point I was notified that I did not meet the requirements for transferring my license because I had not held my previous license for two years. I told the person at the board I was getting different messages and asked if I could speak with someone higher up. I was given the number of the board’s director. I reviewed my previous conversations with the director, indicating that someone at the board had confirmed my understanding of the state’s licensure requirements. The director said the expectation was that if an individual had a counseling license for two years, he or she would also have 2,000 hours of clinical practice, meaning that a person was required to have both, not either/or, despite the wording on the forms. I shared that the state where I previously had been licensed required 1,000 more contact hours and 100 more hours of supervision than did my current state’s licensure requirements. I was told I had two options: I could wait for the board to review my application in September and inform me of its decision in October, or I could send in another check, complete a different set of forms and mail back in the application for regular licensure — and still wait until October.

Exasperated, I communicated to the director that I had been unemployed for three months while following the instructions provided by the board to get my license transferred. When told the earliest I would hear whether my forms were correct would be October — another three months away — I asked how the board could justify the delay in responding given that a license is required to practice. The director told me that even if the board had received my application materials in June, they still would not have been reviewed until September. In May and June, the director explained, the board reviewed disciplinary issues that kept its members from approving licensure applications, and then the board was on recess through July and August, despite what the person at the counseling board had previously told me regarding the board’s meetings. For four months (fully one-third of the year), the counseling board did not review applications, and when it would review them, it would take 30 days to respond. Following a response, applicants must still sit for a counseling law exam and/or a licensure exam. I finally asked if I could speak to someone on the licensing board who might possibly give me some concrete answers. The director said she could make the request but added that the board did not usually honor such requests.

As of mid-August, I still had not received a response from the counseling board. In the meantime, I renewed my license in my previous state. It took five minutes to do online, and I received my paper license in the mail within a week. I accepted that, at least for a while, I would have to commute across state borders if I wanted to continue practicing as a counselor.

In October, I finally received my letter from the board indicating that I could sit for the licensing examination within a week. The letter indicated I would need to bring a license to confirm my identity. On the letter, my name was incorrect. When I attempted to contact the person listed on the letter to follow up, I reached her voice mail, which informed me she would be out of the office until after the date of the exam. Through the counseling board’s main number, I was able to reach a person who could correct my name. Finally, at the end of October, nearly six months after I began the licensing process, I received my counseling license in the new state. I am currently working in my former state, but I am going to keep my new license active so I can avoid having to go through the licensing process again just in case I want to take a job in my new state.

As counseling continues to grow as a profession, we need to work on developing common licensure standards. Common standards will help ensure the quality of counselors, protect the public and move us toward developing a shared body of knowledge to foster a unique counselor identity. These common standards will also improve the portability of licenses across state lines. I have a few recommendations from my experience that I hope will help prepare other counselors planning to transfer their licenses.

1) Prepare well in advance of a move, especially given the current economic climate. It was hard having to turn down jobs because my licensure application had not been approved and not applying for other openings while I waited.

2) Make sure that you’re talking to a director or some other officer at a licensing board when transferring your license. Although individuals who answer the phones at licensure boards can seem helpful, they are not always familiar with the intricacies of licensure.

3) Make sure to maintain a record of all of your practice and supervision hours in case you need to resubmit the information if you are unable to transfer your license.

I encourage the continued development of common licensing standards that will increase consistency for insurance panels and assist in legislation efforts regarding counselors. Common licensing standards would help strengthen the counselor identity and continue to validate counseling as a cohesive profession, while also making it easier for counselors to continue to do their good works.

Thomas J. Sherman is a clinical supervisor with the Military OneSource program providing support and resources to active-duty, National Guard and Reserve service members and their families. He is also an adjunct professor in the counselor education program at McDaniel College. Contact him at tom.j.sherman@gmail.com.

Letters to the editor: ct@counseling.org

Reducing excessive anger in adolescents through a martial arts intervention

Isaac Burt December 1, 2011

ACA member Isaac Burt showcases some of the acrobatic moves common in Capoeira.

Picture the following scenario. You are a counselor with less than one year of experience. Recently, an employment opportunity opened up at a school to work with adolescents who have a variety of behavioral issues, including excessive anger. An interview is scheduled, a job offer extended. You eagerly accept.

The first day on the job, you are excited and full of energy, which seems to be a necessary characteristic for a counselor at this school because the clients are extremely energetic. Some are yelling, others are play fighting with one another, while several are running. In fact, one client stands out because he is running toward you. He gets closer, and just before he runs you over, he transforms his momentum into a cartwheel and does a backflip, narrowly missing you. He continues to run after he lands, laughing as he says, “I freaked the new counselor out.”

Once you catch your breath, you continue to be amazed by the energy these clients exhibit. Then it crosses your mind just how energetic you were when you were growing up. As you imagine how difficult it must be for energetic clients to sit through an hour of traditional talk therapy, you begin to wonder: “What can I do to help this kind of client?”

In my role as a counselor, I have worked with highly energetic, excessively angry clients. Therefore, it was commonplace for me to encounter the scenario I just described. Through the years, I learned the importance of creativity in counseling and drawing on the strengths of clients. Many counselors struggle with clients who do not respond well to traditional counseling methods. In turn, these counselors may begin to doubt their abilities. They might feel they are doing their very best, but they are baffled by how to reach these clients. To work effectively with this population, counselors need to create a pro-social environment. A pro-social environment is one that promotes clients’ strengths, wellness, empathetic confrontation and positive role modeling. Counselors must form this environment to communicate to clients what their strengths are in a caring, innovative and engaging way.

In addition to identifying these clients’ strong points, counselors must introduce an intervention that is capable of grabbing — and retaining — the clients’ attention. Traditionally, highly energetic and/or overly angry adolescents do not respond well to canon therapeutic methods. Through experience and research, I have developed a therapeutic martial arts model that allocates to counselors a strength-based modality for engaging these clients. The rationale is simple. With these clients, counselors want to employ a system demanding a high level of physical energy and integrate it with therapeutic principles. The hope is to produce a therapeutic pro-social environment that cultivates change in challenging clients.

Target population: The target population for this intervention is adolescent males or females ranging in age from 11 to 18 who are showing signs or symptoms of engaging in overly angry behaviors, including fighting or bullying.

Description of the intervention: The intervention I use is Capoeira, which is both a unique martial art and an effective form of creative self-expression that originated in Brazil. As described by the group Capoeira Brazil, Capoeira promotes diversity and tolerance, teaches discipline and respect, and assists in developing amazing fitness. Beyond being a form of martial arts, Capoeira is also a pro-social event filled with rich tradition and history.

In Capoeira, there is what is called the jogo, or game. The jogo begins with the students and/or Capoeira instructors playing music on instruments. Several instruments may be present, but the most prominent are the berimbau and not to hit each other. Once practitioners are fully engaged in the jogo, they undertake a series of agile, acrobatic and martial arts movements that create a unique corporal conversation. A story between the two players unfolds, with the music and lyrics dictating the theme and the practitioners developing the narrative.

Capoeira is challenging, but its practitioners can use it as a life tool to grow both physically and mentally. The Capoeira philosophy embodies not hurting the other player while in the jogo, participating fully, encouraging others in positive ways and attempting new alternatives. Learning new ways of behaving while in the jogo and developing perseverance to improve ability are especially encouraged.

Empirical studies have indicated the qualities that interventions must possess to be effective with angry adolescents, and Capoeira’s characteristics align with these qualities. First, a pro-social environment must exist that promotes nonviolence (that is, not hurting the other player). Second, there must be a sense that positive risk-taking behaviors or attempts at new alternatives to normal behavioral patterns are encouraged. Third, there must be consistency and repetition in practicing new behaviors that truly lead to change.

Social cognitive theory (SCT) is the primary theory on which my therapeutic martial arts model is based. Empirical evidence documents the effect of modeling on the behavior of children, adolescents and adults, and modeling plays a large part in this intervention. For example, instructors, assistants and other personnel assume a large responsibility in their roles as leaders, teachers and role models. In addition, a bidirectional effect exists, with the environment affecting the clients (interpersonally and behaviorally) and the clients affecting the environment. The thinking of the participants slowly changes, and as it does, their emotions and behaviors soon follow suit. Research has shown that SCT can effectively change problematic, overly angry behaviors into something more positive.

Managing and delivering the intervention: Adapting a model from Stuart Twemlow and Frank Sacco, a clinical supervisor trained in clinical mental health counseling should provide all clinical oversight. An individual who is highly trained in Capoeira would provide the bulk of the intervention, including daily instruction and delivery of the intervention. For optimal functioning, however, clinical oversight is essential because the clinician provides additional follow-up and outreach to clients. The clinical supervisor needs to maintain ongoing involvement with the instructors, including providing consultation and supervision. Further duties entail the clinical supervisor understanding how to apply the intervention to adolescents (evaluation and counseling). One of the clinician’s primary goals is to ensure that the intervention stays on track. This is not to say, however, that the clinician’s role is limited simply to clinical oversight. One of the benefits of Capoeira is that it may help clients respond better to traditional therapeutic measures. Thus, therapy can conduct simultaneously with Capoeira or afterward, once the client is ready. By remaining heavily involved in the implementation of Capoeira, the clinician retains an idea of the clients’ progression and can recommend or implement additional measures as needed.

Necessary resources: The resources needed for this intervention are very economical. Wide-open areas, including gyms, rec centers or church floors, are examples of locations that could house the intervention. Auxiliary components include crash mats and possibly a small trampoline. Of primary importance are monetary resources allocated to the purchase of berimbaus, drums, tambourines and chimes. Transportation costs are also a consideration. A salary for the Capoeira instructor, including a small stipend for any junior instructors deemed necessary for the project, may need to be established. In some instances, however, instructors may provide their services for free. Helping those less fortunate is a primary tenet of Capoeira. Many instructors adhere to these ideals and provide pro bono services to at-risk youth. Junior instructors may also work pro bono because they need to acquire a certain number of hours of teaching experience.

Necessary training: Instructors in therapeutic martial arts programs have multiple roles as semi-therapists, instructors and disciplinarians. The instructors must be firm while remaining aware of the inevitable lapses and/or shortcomings of adolescents. Training in basic mental health procedures should be provided to the instructors so they do not personalize comments made by the adolescents. Moreover, training assists instructors in not transposing their problems to issues faced by the adolescents. Instructors must be knowledgeable about transference and understand not to take reactions and behaviors of the adolescents personally. Instructors should also understand that these adolescents might sometimes treat them as objects on which to take out their frustrations. Finally, instructors must model behavior that assists in decreasing the adolescents’ mistrust of adults and reducing their excessive anger. The clinical supervisor, who should be proficient in behavioral dynamics and clinical mental health counseling, provides administration of instructor training. As stated previously, a clinical supervisor is imperative to the operation of a therapeutic martial arts model.

Time frame: This intervention is designed to take place twice a week for a duration of two hours at each meeting (for a maximum of 16 hours per month and 192 hours per year). As for follow-up, maintain an open-door policy, encouraging parents, caregivers and participants alike to report back to the clinical supervisor and instructors. Reporting allows the clinical supervisor to see what clinical advantages the program provided and where improvements might need to be implemented. Additionally, reporting helps former clients maintain a connection to the program, and some of these clients may want to give back to the program by providing some form of human resources.

Martial arts can provide energetic, overly angry clients with an exciting, strength-based intervention to promote positive growth. Counselors may be able to utilize the intervention in this article either as an alternative or as an addendum to traditional counseling. With people who do not respond well to standard client-sitting-in-the-chair counseling, martial arts may represent a paradigm switch in how counselors conduct therapy.

“Knowledge Share” articles are based on sessions presented at past ACA Annual Conferences.

Isaac Burt is an assistant professor at Florida International University in the Department of Counselor Education, Leadership and Professional Studies. His research interests entail culturally sensitive treatments for marginalized adolescents, redefining anger management groups and increasing self-efficacy in disenfranchised youths. Contact him at Isaac.burt@fiu.edu.

 

Letters to the editor:
ct@counseling.org

Getting off the couch

Lynne Shallcross

In the world of stereotypes, a counseling session goes something like this: The client lays on the couch, revealing his innermost thoughts to the therapist, who sits in a leather chair, glasses perched low on her nose as she slowly nods and inquires, “And how did that make you feel?”

In reality, though, talk therapy isn’t the only game in town when it comes to helping today’s clients. Active interventions of all kinds are gaining
in popularity among counselors and clients alike.

In D.B. Palmer’s corner of the country, counseling sessions consist of everything from Nordic skiing to yoga to “walking sessions,” which are arranged like any other traditional 50-minute counseling session, except they take place along the 300 acres of trails at Alaska Pacific University (APU) in Anchorage, where Palmer serves as director of the school’s Counseling and Wellness Center.

Palmer, also a private practitioner and member of the American Counseling Association, remembers supervising counseling sessions with a client who was progressing well while engaging in cognitive therapy work with her counselor. “She mentioned one day to her counselor that while she felt competent in her thinking, she felt that something was missing and that she woke up each morning feeling anxious,” Palmer says. “She knew that she was overweight, eating poorly, not exercising and missed doing these things well. She just wasn’t committed enough to go do them herself. While I was supervising the counselor, I mentioned that this client would be a great fit for our walking sessions, and things have taken off from there. She’s feeling confident, losing weight, eating better, sleeping better, and her anxiety about these things is almost gone.”

With the Alaskan wilderness in his backyard, outdoor counseling interventions are a natural fit for Palmer’s work. But counselors who don’t live near rugged mountains or flowing streams shouldn’t automatically feel couch-bound either. Engaging clients in active interventions can take place just as easily inside the office.

Christopher Old, who runs a private practice in Truckee, Calif., entered the counseling profession by way of his background in experiential education. Although he harbors aspirations of eventually working with his counseling clients outdoors, for now, due to potential liability risks and logistics, his active interventions occur inside the confines of his office. Even so, Old finds that active interventions open clients to insights they might not otherwise arrive at through traditional talk therapy alone.

Old recently tried out an activity called “Minefield” with a teenage student client who was struggling to stay motivated and focused at school. On the floor of his office, Old laid out a number of “obstacles” in the minefield that the client had to avoid. Among the ways the client chose to label the obstacles: “showing off for friends,” “not managing time,” “not studying” and “having an angry attitude in class.” Old first asked the client to walk through the minefield with his eyes open and avoid the obstacles. Easy. He then instructed the student to close his eyes and try the process again. Not so easy that time.

When Old asked if the client thought he could walk through the minefield with his eyes closed and still avoid all the obstacles, the boy said no. So, Old said he would give it a try himself. The counselor closed his eyes but then did something the boy hadn’t thought of — asked for help in being guided through the minefield. “It was a total lightbulb moment for ‘Oh, I can ask people for help,’” says Old, a member of ACA. “In past therapy sessions, he had mentioned that idea about asking for help. But it didn’t really register with him until he saw it in action.”

The client took a turn navigating the minefield with his eyes closed while partly relying on Old’s guidance, and he was successful. In subsequent counseling sessions, Old noticed a significant difference in the boy’s behavior and attitude. “He would say, ‘I’ve got this thing I’m trying to figure out. Can you help me?’” Old says.

Active interventions are sometimes criticized for being merely “game playing,” Old says, but as used in counseling, the interventions have intentionality. Counselors who use active interventions also lead clients through processing afterward, assisting them in understanding how to apply what they have learned from the activity to their lives outside the office. To be effective with this approach, Old emphasizes that counselors must choose a particular activity for each client on the basis of the client’s specific needs and situation. “The main idea is that as the therapist, you tailor the activities and the debrief based on what the client is bringing into the session and what the therapeutic goal is for the session,” he says. “It is a very intentional use of activities versus just game playing.”

Seeing behaviors firsthand

As evidenced by Old’s and Palmer’s examples, active interventions can be very effective as part of individual counseling, but they also lend themselves well to group work. The unique benefits of conducting activities with groups are that the clients’ social interactions present themselves and the group members process what is happening and offer feedback, says David Christian, a doctoral student in the counseling program at the University of North Texas.

Christian, an ACA member who has used active interventions with children in a foster home and students at a local high school, says his work falls under the umbrella of adventure-based counseling (ABC), which he describes as the use of active interventions based in experiential learning as typically conducted in groups. “During ABC, the participants exhibit behaviors that are often the reason they are in counseling,” he says. “During the processing time, participants are able to receive feedback from the counselor as well as the group members on how their behavior impacted the group as well as the other individual members. The members are then able to explore alternative behaviors and ‘test drive’ them in future activities.”

Regardless of the age group or the size of the group with which the counselor is working, it is imperative to know about the group members’ needs, Christian says. With groups at the foster home, trust was a big issue with many of the children, so Christian chose activities designed to build trust rather than activities that required a significant level of existing trust to accomplish.

Active interventions allow counselors to experience clients’ behaviors firsthand instead of relying on accounts from parents, family members, teachers or other secondary sources, Christian says. Jeffrey Ashby, a professor in the Georgia State University Department of Counseling and Psychological Services, agrees. For instance, in watching a family interact through the course of an activity, a counselor can quickly see the same processes being reproduced that the family uses outside of the counseling session, Ashby says.

That real-life effect can make activities potentially powerful or destructive, so a counselor must be mindful of that, Ashby says, but at the same time, it’s helpful for the counselor to see the behavior reveal itself in session. “Clients will catch themselves being themselves [during these activities],” says Ashby, coauthor with Terry Kottman and Donald DeGraaf of Active Interventions for Kids and Teens: Adding Adventure and Fun to Counseling!, published by ACA in 2008.

The process surrounding the activity is the most important element to the intervention’s success, according to Old. From the start, he says, counselors must assess where clients are at currently and then, on the basis of that assessment, tailor an activity that will help them get to where they want to be. Before jumping into action, the counselor might choose to “frontload” the activity, Old says, introducing it to clients and describing where the counselor hopes it will lead. “Sometimes the introduction is nothing at all, and I won’t give them anything specific to think about,” he says. “But sometimes, I will. I’ll say something like, ‘Think about ideas surrounding communication when you’re doing this activity.’”

Depending on the intervention, the activity might run start to finish without setting time aside in the middle for reflection, so as not to interrupt the flow of the activity, Old says. In those cases, the counselor and client would debrief afterward. But in other instances, he says, a counselor might jump on an opportunity to shine a spotlight on something during the course of an activity. “Sometimes if [I] see things in the moment — a pattern or a dynamic that has been difficult — I’ll stop them and say, ‘What did you see just happen there? What effect did it have? What were you feeling?’ so that you don’t lose the teaching moment.”

Christian agrees, saying he’s learned not to get so hung up on the activities themselves. If a counselor notices something worth addressing during an activity, he or she should stop the group and talk about it, Christian says. Similarly, if a client has an “aha” moment while engaging in an activity, the counselor should let the client speak up.

Debriefing after an activity includes asking clients about what went on and what they experienced, Old says. “What you focus this discussion on will depend on the goals of the activity — remember the part about intentionality being important — and what happened while doing the activity. So, I will ask the client questions about what doing the activity was like and what was going on for them during the activity. We will talk both about behaviors — ‘What happened?’ — and thoughts — ‘What were you thinking about when you did this?’”

Old will often start the debrief with general questions and then move to more specific ones, especially if he needs to guide the client’s thinking toward the topic at hand. “For example, after doing an activity connected to the theme of reaching life goals, [such as with] the minefield activity, I might ask, ‘How easy or difficult was it to reach your goal in that activity? What made it easier for you or more difficult? What could you have done differently?’ I may also point out specific behaviors I witnessed during the activity and talk about those. For example, if I saw someone give up easily without asking for help, I might ask them about that: ‘What were you thinking about when you decided to give up? Did you consider asking for help at that time?’”

The nature of the debriefing segment might also depend on the counselor’s theoretical orientation, Old says. “For example, a CBT (cognitive behavioral therapy) therapist is more likely to focus on the thoughts going on during the activity. A solution-focused therapist might debrief focused on what worked well during the activity and how to do more of that. A psychoanalytic therapist might ask the client to tie what happened in the activity to what has happened in the past, etc.”

The final part of post-activity debriefing is to generalize the experience, Old says. “In this part of the discussion, I will ask my clients how the ideas learned in the activity can be applied to other situations in their life. For example, if a couple has just done a problem-solving activity successfully and we have discussed what led to that success, I will ask them about other problems in their relationship [to which] they could apply the tools they just learned. We will talk about what that would look like and maybe make a plan to give it a try. This generalizing part of the debrief really deepens the learning from the experience and helps client use what they have learned outside of the office.”

During debriefing, also known as processing or backloading, Christian follows David Kolb’s experiential learning model but adds a “therapeutic twist.” First, Christian discusses with the group what it did and asks the group members to tell him what happened. Next, they explore the “So what?” question. Christian says this question encourages group members to think about why the group did what it did and why things happened the way they did.

Then, Christian asks a final question: Now what? “During this time of the processing, we focus on transferring the new insights, knowledge and understanding to the clients’ everyday lives,” he says. “How is what we learned today relevant to their lives outside of counseling? I rely heavily on my counseling skills of reflection, active listening, summarizing and having established a strong therapeutic relationship with the clients.”

Counseling in the great outdoors

In his work at APU, Palmer’s clients at the counseling center include traditional college-age undergraduates, adult undergraduates, rural Alaskan Natives, graduate students, staff and faculty members, and associated family members of those groups. “It’s a wide population that covers our entire community,” he says.

The array of active counseling interventions Palmer offers is as varied as his client base. In addition to participating in Nordic skiing, yoga and walking sessions, Palmer’s clients can go running with him while they’re receiving counseling or take a retreat to the university’s 700-acre organic farm. In the spring, Palmer says the university will also be initiating a community garden where counseling sessions could take place. Palmer also offers workshops for clients on topics such as art therapy, relaxation techniques and stress management.

The university counseling center offers parent-child activity groups, in which students who are parents can bring their kids and engage together in play therapy activities facilitated by counselors in the gym or outdoors. “Students with children are often swamped with work, responsibilities of parenting and finances, and many Alaskan students are far from home networks,” Palmer says. “These sessions allow parents to reconnect, to learn from counselors and to have a safe place to play with their kids.”

Faculty and staff wellness is also prioritized on campus, Palmer says. Faculty and staff members have access to the same services offered to the students. They also get time off each week to take part in wellness events and programs, including dodgeball, botany walks, snowshoeing, canoeing and more. “APU employees recognize that doing our jobs well means staying fit, and that means mentally as well as physically,” Palmer says. “All staff and faculty are afforded free services through my office, [including] walking, running and skiing sessions.”

Counselors at the university attend and facilitate during university block courses, Palmer says, including a swift-water guiding course, an introduction to wilderness skills and winter leadership skills. In addition, Palmer offers a wilderness therapy retreat series to students and mental health practitioners on topics such as leadership skills, professional counseling skills, and mindfulness and ecopsychology.

All the active interventions Palmer leads through the university are activities he independently offers to his private practice clients as well. In addition, through his private practice, he takes clients on seasonal treks, including sea kayaking, rafting, dogsledding, backpacking and canoeing. Palmer also offers four- to seven-day wilderness/adventure-based counseling treks for individuals, couples, groups and families.

“The range of benefits are very wide,” Palmer says about the treks. “Primarily, we work with a parent and child. However, we are getting more calls for entire families and couples. We work with each family to determine [its] needs and design a custom program. These programs can include options such as dogsled expeditions, rafting or canoeing trips, or backpacking options. Every option is unique, and I pay special attention to the family’s needs and goals in designing each trek.”

An example of a one-session activity Palmer often uses in private practice is adventure hiking. “We don’t plan any particular route, as we’re not running an outfitting business,” says Palmer, whose wife, Greta, is a partner in their practice as a personal fitness counselor and life coach. “We take hikes in our local mountains. Anchorage has lots of mountain trails, and these trails are heavily used by our adventurous residents. We’ll meet up at the trailhead, check our gear, as we’re both responsible for our own gear and safety, and head out for one to two hours of hiking. We can tailor these sessions from mild to extreme difficulty levels, while engaging in our session.”

With most of the activities, including walking, Nordic skiing and trail running, Palmer says the counseling session takes place during the activity. Perhaps surprisingly, Palmer says he hasn’t found the activities to reduce the amount of conversation possible. “In fact, I’ve found that our activities clarify and expand the thinking process and thus, the therapeutic dialogue is greatly enhanced,” he says. “Our active sessions also have the added benefit of adding a construct to our session. With a walking session, the client can breathe the fresh air, reflect on environmental stimuli and notice the interactions that occur around us. For example, if we are walking past a park bench with an elderly couple sitting and talking, the client may reflect on their own parents, grandparents, their marriage, their children and their own hopes for the future.”

Palmer says he merely mentions active interventions as an option for clients rather than having every client engage in them automatically. As more people come to recognize the links between wellness and mental health, clients have also asked him about active options during the intake process or phone screenings.

In addition to his counseling credentials, Christian is a level-one certified challenge course facilitator and has facilitated ABC on ropes courses. Challenge courses can offer therapeutic opportunities for counselors and groups, Christian says, particularly in areas such as life metaphors, goal setting and teamwork. One downside, he says, is that many counselors might not have easy access to nearby challenge courses. Counselors must also complete required training if they want to facilitate on the courses, Christian points out.

Take it inside

Although it can be an advantage to get outside with certain clients, Ashby says that’s not always possible or even necessarily the best strategy in all cases. For instance, in a school setting, he says, going outside is a form of breaking confidentiality. And even in other settings, he says, it can be problematic to go outside because of the difficulty of anticipating how private an outdoor space might be.

Inside Old’s office, he uses another active intervention called “Linked Together” from time to time with pairs of clients. In the exercise, two ropes, each with a loop on either end, are linked. Each person puts one loop around each wrist, and the object is to get the two ropes disconnected without taking the loops off either person’s wrist.

The exercise works on problem-solving and communication skills, Old says, adding that each person can actually complete the task of disconnecting without help from the other person. “It’s a great metaphor to looking within ourselves when we have a conflict with someone else or a problem we’re trying to solve,” he says.

Another activity Old uses in his office is the exercise of juggling beanbags. Teens and kids find this challenge especially fun, he says. “I’ll teach them to juggle and connect it to what they’re juggling in their lives,” he says. Old will also ask reflective questions along the way such as how did you learn to juggle those things and how do you react when you drop a ball?

Old is a big believer in learning by doing, and he incorporates team-building-type activities into counseling sessions to bring the ideas he and his clients talk about to life. “For example, if a couple is talking about trust in their relationship, I might have them do forward and backward trust leans in the session and then process what the activity was like for them,” he says. “What did they feel while doing the activity? What effect did communication have on trust? How do they build trust in their relationship? We then use the activity as a metaphor during our work.”

With groups at the local high school, Christian uses an activity known as the “Name Juggle.” Group members pass tennis balls or beanbags to one another while saying each person’s name. With a recent group, Christian told group members the tennis balls would represent things that helped them to be successful in school. The group had to follow a pattern of throwing to each person in the group, and Christian gradually added more balls into the mix.

Partway through the activity, and without warning the group, Christian brought out a rubber chicken and threw it into the pattern. “People get distracted and the balls go flying everywhere,” he says. “So we talk about what are the rubber chickens in their everyday life? What things distract them in school and cause them to drop the ball, so to speak? It creates a reference point, and in future sessions, you can ask what rubber chicken they encountered and how they handled it.”

Shaking things up

Although Palmer says he still really enjoys traditional talk-based counseling sessions conducted in an office, he believes the potential benefits of active sessions are immense. “Why [engage in active interventions]? First of all, we sit too much,” Palmer says. “The benefits of exercise are not only based in timeless wisdom but also represent the latest in neuroscience. Just 25 minutes of exercise a day provides a significant dose of natural antidepressant within our bodies, not to mention the physical and overall health benefits.”

Outdoor sessions in particular provide a jump-start to clients’ thinking, while also offering them connection to their surroundings, Palmer says. He also believes that getting active and getting outside does much to improve counselor performance and the counselor-client relationships. “[Counselors] are far more perceptive when we get off the chair,” he says. “When I walk with my clients, I feel more connected to their stories. The power differential is shifted. Clients see me in a new environment, one in which I navigate the world alongside them. We share the weather, the sights and sounds, and we connect on a deeper level. Active sessions shake things up.”

Active interventions, including adventure and wilderness therapies, are shown to be highly effective with a wide range of presenting issues, Palmer says, including depression and mood disorders, anxiety, personality disorders, grief and loss, post-traumatic stress disorder, eating disorders and low self-concept, as well as with clients who have experienced abuse.

The counselors interviewed for this article contend that almost any client can benefit from active interventions. Including an activity adds a dynamic to therapy that children and adolescents typically regard as more fun than just talking, Old says, and as a result, they tend to be more willing to engage. On another point of the age spectrum, active interventions can help entice adults to step out of their comfort zones, he says. Active interventions can also provide counselors with a clearer picture of how clients act and interact outside of the session, Old says.

Christian, who frequently works with adolescent males, says active interventions are the best approach he has found for getting through to these clients. Boys are more likely to drop their guard, open up and communicate through their actions rather than solely through talking, he says.

Families can also benefit significantly from active interventions, Christian says. “It’s great to watch families have fun together. I love seeing them interact and learn about each other. Processing is always a powerful experience with families. Families also usually start to incorporate more activities outside of session, which is great for communication, cohesion and trust.”

Palmer says another positive is that the stigma clients sometimes attach to counseling is greatly reduced when sessions don’t center on talking inside an office. “I can meet my clients at the trailhead, on the path [or] at the parking lot rather than at my office under the sign that says ‘Counseling Center.’ For all anyone knows, we’re just two peers taking a walk in the park,” Palmer says.

Taking precautions

These experts encourage counselors interested in using active interventions — whether office-based or outdoor-based — to seek proper training before delving in. “Like any other intervention, the counselor should be competent in the activity utilized and the limitations and advantages of the intervention,” Palmer says. “There are logistical and pragmatic concerns like confidentiality — such as, ‘How would you like to introduce me if we come across friends?’ — but these are also concerns discussed in traditional sessions.”

Palmer is a certified wilderness first responder, but he points out that training is far more than the typical counselor needs to simply take a client on a paved walking path for a counseling session. He does recommend, however, that counselors research their options and consider training with an advanced practitioner.

Old mentions the Therapeutic Adventure Professional Group, part of the Association for Experiential Education, as one option where counselors can seek out workshops and conferences. In addition, he says, Naropa University in Boulder, Colo., offers a master’s degree in transpersonal counseling psychology with a concentration in wilderness therapy.

Christian points to Project Adventure, which he says offers introductory courses in ABC. For those counselors interested in ABC, training in group work is also paramount, he says. As for those interested in challenge course work, Christian encourages them to earn certification through an approved Association for Challenge Course Technology vendor.

Ashby cautions that counselors should also be mindful that, depending on how active an intervention is and where it’s taking place, additional informed consent or liability waivers might be necessary. For the APU counseling center’s walking sessions, Palmer and his colleagues primarily depend on the informed consent document as well as information gathered from intake materials, which inquire about clients’ medical conditions and detail restrictions concerning the activities the counselors offer. “We include the standard doctor clause: ‘Be sure to check with your medical provider if you have questions about whether or not active sessions are appropriate for you,’” he says. For adventure-based treks, Palmer acknowledges that the liability waivers are more complex, but he advises counselors against attempting to jump directly into that level of activity.

When using active interventions, these counselors emphasize that clients’ emotional and physical safety is of the utmost importance. Old cautions counselors to know for certain that each client can be trusted to be safe in the activity before doing it. “If you have a teen who you know will drop his dad on his face in a trust lean, then you don’t do a trust lean,” he says. Old says he always talks with clients about safety concerns before an activity, and he always gives each individual client the option of not participating.

Says Palmer, “For counselor safety and accountability, we utilize a unique call-in system to alert each other that we’re beginning and returning from our active sessions, as well as traveling an established and approved route. Personal as well as psychological fitness is essential. This is not something to just decide to do. I have taken very deliberate steps, researched the broader field, consulted with leaders and built upon over a decade of practice and academic research. Like any new specialty, the new counselor must be aware of the implications upon practice.”

Respecting the entire therapeutic process is also key, Old says. If the counselor fails to choose the activity based specifically on where the client is or doesn’t debrief afterward, the intervention will end up being less powerful, he says.

But for counselors who put the work into researching and training with active interventions and then put them to work in their practice, the payoff can be significant, these counselors say. Beyond improving physical health and fitness for clients, Palmer says active interventions enhance the rapport between client and counselor and promote therapeutic advances. “For some clients, this is one of the only ways to break through depression and anxiety,” he says. “Some clients are so entrenched in behavior and thoughts that keep them in the same place. Active sessions are phenomenal in their ability to drive through these barriers.”

Christian’s faith in the effectiveness of active interventions continues to grow stronger. “Although there is not an abundance of research regarding ABC, given what we know about cognitive development, the effect of exercise on the brain and personal antidotes, ABC proves to be an effective form of counseling,” he says. “Also, you don’t have to go to a ropes/challenge course to do active interventions. ABC is adaptable to nearly every setting. I would love more counselors to learn about it and begin to utilize it.”

Both Palmer and Old are happy to offer trainings to other counselors. For more information or to contact them, visit Palmer’s website at abcfamilytherapy.com and Old’s website at mountainmentalhealth.com.

Walking the Labrynth

Not surprisingly, the campus of Central Michigan University doesn’t feature an ancient outdoor labyrinth. So Michelle Bigard has her clients at the university’s counseling center tap into the therapeutic benefits of a 24-foot indoor canvas labyrinth instead.

Bigard, a counselor and associate professor, describes labyrinths as meditative walking paths that feature a circle to represent wholeness and unity, a spiral to represent transformation and change, and a quadrant to represent order. “So you have change and order in a safe setting, which is why we think it’s such a powerful symbol,” she says.

Historically, there are two main labyrinth patterns: medieval and classical. A classical labyrinth has fewer paths than a medieval labyrinth, Bigard says, so a classical labyrinth can be helpful in moving larger groups through more quickly, whereas a medieval labyrinth can lend itself to a slower, more contemplative walk. Both labyrinths styles are useful in either individual or group work, Bigard says, because they assist clients in slowing down and becoming more self-reflective and self-aware.

The idea is to walk toward the center of the labyrinth, reflecting and remaining open to what thoughts and images come to mind, Bigard explains. When people reach the center, they can stand or sit for as long as they want before walking the path back out and exiting.

Bigard encourages clients to remain open to the experience and to the metaphors that often reveal themselves. “If the narrow turns drive you nuts,” she says, “you can reflect metaphorically on that: ‘Where are the tight turns in my life?’” The hope in doing the exercise, Bigard says, is that clients will learn something about themselves and figure out how to apply that knowledge in their lives.

Whether individually or in a group, after clients finish walking the labyrinth, they can process the experience with the counselor. Bigard says counselors who do labyrinth work ask clients processing questions such as “What metaphors showed up for you? What meaning does this have for you? How do you want to apply what you felt or learned [in the labyrinth] in your life? What’s it like to hear someone else had a similar experience in walking the labyrinth?”

Labyrinth work can be relevant for almost any type of client, Bigard says, but she thinks it’s especially helpful in situations of loss, change, transition and trauma. Among trauma survivors, a spiritual wound and a wound of trust often exist, Bigard says. The labyrinth offers clients dealing with trauma a safe and containing place that is enclosing but not engulfing, she says.

But labyrinth work isn’t beneficial only to clients, Bigard says. It can be useful to counselors in their own self-care as well. Counselors can walk a labyrinth to enhance their stress management, self-awareness and personal growth, she says.

Bigard suggests that counselors interested in leading labyrinth work first try it out for themselves and also undergo training. She points to a facilitation process through Veriditas (veriditas.org) as one option for training.

— Lynne Shallcross

Lynne Shallcross is a senior writer for Counseling Today. Contact her at lshallcross@counseling.org.
Letters to the editor: ct@counseling.org

Professional counselors: Are we too overwhelmed to focus on prevention?

By Mark J. Britzman & Sela E. Nagelhout November 1, 2011

A normal day for a professional counselor too often entails focusing on remedial concerns. So many clients suffer from the aftermath of trauma and violence, while severe mental health concerns such as anxiety, co-occurring disorders and chemical dependency — among other mental health disorders — also necessitate in-depth therapeutic treatment. That reality raises a question. In today’s society, can professional counselors realistically do justice to promoting prevention while concurrently focusing on the priorities involved with clients’ pressing presenting concerns?

There is little debate that each day, professional counselors do their best to help thousands of individuals deal effectively with a myriad of life challenges. Counselors earn their character stripes in the trenches of a normal workday by deterring suicides, stabilizing and improving tenuous relationships, healing deep and traumatic emotional wounds and advocating for the respectful treatment of all individuals in an ever-changing and diverse world. Through the use of effective interventions, successes are regularly achieved, but rarely is it allowable to celebrate these successes with a drumroll. In the confidential confines of schools, mental health agencies and communities throughout our country and beyond, counseling efforts too often go unnoticed.

The counseling profession has come a long way since its beginnings. We are now a proud profession characterized by a code of ethics, accreditation guidelines, competency standards, licensure, certification and a commitment to excellence. Although the term counseling can be difficult to define, our mission, which is well articulated by the American Counseling Association, is generally accepted to be “The application of mental health, psychological or human development principles through cognitive, affective, behavioral or systemic intervention strategies that address wellness, personal growth or career development, as well as pathology.”(In March 2010 at the ACA Annual Conference in Pittsburgh, delegates to the 20/20: A Vision for the Future of Counseling initiative reached a consensus definition of counseling: “Counseling is a professional relationship that empowers diverse individuals, families and groups to accomplish mental health, wellness, education and career goals.” Twenty-nine major counseling organizations have since endorsed the definition.)

Nearly every counselor wants to ensure that this mission — retaining our unique identity as leaders in prevention, advocacy and empowerment — is not just rhetoric but reality. However, the challenge is that the National Institute of Mental Health reports that one in four adults — approximately 60 million Americans — experiences a mental health disorder in a given year. Crises in our homes, schools and communities, as well as global hardships, seemingly produce so much individual and collective suffering that counselors struggle to intervene effectively. Could the level of individual and collective suffering in our homes, schools and communities leave counselors struggling to retain our identity as leaders in prevention, advocacy, wellness and empowerment? Most of us are so overwhelmed that primary prevention and empowerment becomes de-emphasized as we focus on the most serious of mental health problems.

Prevention and the promotion of wellness have always presented enticing reasons for counselors to enter the profession. Even before positive psychology was in vogue, counselors advocated for increased efforts to promote physical, intellectual, social, psychological, emotional and environmental well-being. As each new edition of the Diagnostic and Statistical Manual of Mental Disorders grows thicker, vast numbers of individuals still need help ensuring healthy relationships, selecting meaningful careers and making healthy choices throughout the life span as they seek a sense of sustained joy and deep meaning in life.

The good news is that an emphasis on strengths-based interventions, self-efficacy, social support, self-help groups and incorporating community mental health models can minimize environmental pressures and promote the prevention of psychological difficulties.

Unfortunately, numerous funding sources appear to be in serious jeopardy due to economics, reimbursements and politics. Despite the impressive efforts of professional counselors during the past 30 years, there is clear evidence that overall mental health in our country is deteriorating.

How would our society be different if there were an emphasis on the following?

  • Social and emotional learning for our children, including character education
  • Diversity training that focuses on respect for individuals living in a culturally diverse society
  • Healthy relationship skills and effective sex education for our youth
  • Career development for those who lack awareness of their interests, values and aptitudes
  • Wellness promotion to combat unhealthy choices and the epidemic increase in obesity
  • The incorporation of drug and alcohol prevention efforts in all of our schools
  • Service projects for those who wish to advocate for individuals living in unhealthy environments
  • Premarital counseling for those seeking enriched, lifelong marriages
  • Parent education for those yearning to promote the healthy growth and development of their children

On a personal note, my (Mark’s) interest in prevention was cultivated early on by wonderful professors and supervisors, as well as through lessons learned from my clients. For instance, in the case of couples counseling, it soon became evident that most couples did not seek counseling until divorce was imminent. Generally, they would present a long list of grievances about their spouse, suggesting problem saturation. I would then begin the almost overwhelming task of helping them focus on learning from past mistakes, while simultaneously trying to foster some hope for the future of their marriage.

Although couples often felt quite defeated and desperate at the beginning of counseling, I found that I could often be helpful to them through sheer perseverance and by always focusing on their best interests. After one particularly challenging session, however, it occurred to me that I might be able to develop a more proactive method that would have the effect of creating a strong marital foundation in order to prevent the marital breakdown I was witnessing on a daily basis. I began envisioning a positive learning experience for couples that would give them information and tools to strengthen their marriage on an ongoing basis. That was 18 years ago, and in that time, 1,600 couples have participated in the Marital Preparation Program (pursuingthegoodlife.com).

Couples often seem hungry for information and skills to improve their relationships. Evaluations indicate that more than 90 percent of participants not only find the program to be meaningful, but that it also exceeds their expectations. The vast majority of couples participating in the Marital Preparation Program acknowledge actually enjoying the process. I believe this is an example of the strong, untapped demand for preventative efforts by individuals in our society and beyond.

Prevention and counseling should never be seen as mutually exclusive. That is, whenever a session includes a psychoeducational component with the objectives of helping a client improve coping strategies, change cognitive distortions, examine behavioral choices, explore career options or identify pathways to a more satisfying life, a component of prevention can be identified. Perhaps our ultimate goal is to continue reframing the counseling process as a wellness endeavor that can be utilized to some degree in each counselor-client interaction in hopes of providing a positive impact throughout the client’s life span.

This article serves as a respectful yet serious reminder to all professional counselors working in a variety of contexts to revisit with a renewed vigor our mission to focus on prevention. If we fail to do so, we are doomed to live with the consequences of remedial interventions that very often are too late to help relieve the significant emotional pain and suffering of many individuals.

The counseling profession has an opportunity to continue growing and to become a primary provider in the mental health arena. As a result, we will be successful in facilitating the health and well-being of individuals and creating more caring, respectful and altruistic communities that are responsive to reducing serious mental health problems through creative and effective efforts.

Mark J. Britzman is a tenured professor in the Department of Counseling and Human Resource Development at South Dakota State University. He is also a national trainer for the Josephson Institute of Ethics and the CHARACTER COUNTS! Initiative, a Glasser scholar, a clinical mental health counselor and a licensed psychologist. Contact him at Mark.Britzman@sdstate.edu.

Sela E. Nagelhout is a former registered nurse with several years of experience in critical care settings. She is a certified Within Our Reach instructor and is in private practice at Pursuing the Good Life Professional Counseling and Consultation Services.

Letters to the editor: ct@counseling.org


 

Life on overload

Lynne Shallcross

So, this is life. Long, busy workdays and weekends with little rest. A weak economy and constant worry over the prospect of losing a job or even a home. Nonstop technology that never allows us to unplug. Ever-growing pressure on kids (and therefore on parents) to be involved in every activity under the sun. Two wars, one of which is the longest the nation has ever endured. A variety of natural disasters, from hurricanes to tornadoes to floods, that turn people’s lives upside down in a matter of seconds. Now toss in the typical trials and tribulations of everyday life, and it should come as no surprise that many clients who walk through the counselor’s door today are simply stressed out. If such a thing as “the simple life” ever really existed, it is confined to history.

Dawn Ferrara, a private practitioner in Mandeville, La., has worked with many clients to address the stress and anxiety in their lives. One client she remembers in particular was a stay-at-home mom who reported a growing inability to get her daily tasks done. “She was feeling so overwhelmed that she started avoiding things, creating more distress as they piled up,” says Ferrara, a member of the American Counseling Association. “She was also complaining of poor sleep, fatigue and headaches. She had been to the doctor already, and nothing physical was found to be causing her symptoms. So, we began by looking at her world, how she saw herself in that world and the things she identified as stressors.”

The client expressed a belief that it was her role to carry the lion’s share of responsibilities at home. She also held another belief — that it was neither possible nor OK to take care of herself. “What was most striking about this lady was that when I asked her, ‘When was the last time you took some time for yourself and what did you do?’ she looked at me like I was speaking a foreign language and burst into tears,” Ferrara says. “It had been so long since she had taken some meaningful time that she couldn’t even recall [it]. So, we challenged some of those beliefs and began to implement some behavioral strategies.”

First, Ferrara and the client worked on prioritizing and defining which tasks were legitimately necessary and which ones the woman shouldered simply because she thought she “should.” They also examined whom the woman could delegate some responsibilities to and determined certain tasks that weren’t really hers to carry. “[That] was a hard one for her,” Ferrara says.

Next, they identified the client’s support system, mapping out how she could ask for help and for which tasks. In reality, her spouse and kids were willing to take responsibility for certain areas and were happy to be asked for help, Ferrara says. Ferrara and her client also looked at lifestyle management, including eating well, getting good sleep, getting fresh air and sunshine, and making a schedule for the day and limiting what was on it.

“Carving out personal time to relax and recharge was the cornerstone of her treatment,” Ferrara says. “She had ignored the need to relax for so long that in some ways, she had to relearn how to do it. She was mentally on ‘go’ all the time. We started with 15 minutes of being still and present, not in bed, every morning after the kids were on the bus and before she started her day. She chose to sit on her back porch with her morning coffee and listen to the sounds of the morning. At first she struggled with being able to quiet her mind, so we focused on some basic mindfulness techniques. Over time, she came to enjoy this time and began taking a walk. This became a daily ritual for her and, eventually, she was able to add some other activities such as taking a yoga class or a girl’s night with her friends.”

Although this client’s worries didn’t stem from trauma related to a natural disaster, Ferrara says she has noticed an overall increase in anxiety issues ever since Hurricane Katrina struck the Gulf Coast in 2005. Ferrara, whose office is directly across Lake Pontchartrain from New Orleans, now puts more focus on stress and anxiety topics in her practice. “People down here live in a state of heightened alert, especially as hurricane season approaches and the talk about being prepared escalates,” she says, noting that each hurricane season lasts six months — a long time to remain on pins and needles.

Ferrara also encounters a lot of worry over the economy and job security. People feel anxious about their continued ability to provide for their families, hold on to their homes and make sure that everything gets done at work in hopes of protecting their jobs. Nadine Rosen, a counselor practitioner in Charlotte, N.C., is witnessing that same level of employment stress among her clients. Charlotte-based Bank of America recently announced a plan for future layoffs in the range of 30,000 jobs. Many of Rosen’s clients work for the bank and are naturally anxious about the news. In constantly wondering whether their jobs are at risk, they are also dealing with performance anxiety, hoping they can impress their bosses enough to save their spot in the company.

Kathleen M. Horrigan, who works in private practice in Severna Park and Towson, Md., says she sees more stress among clients than she ever has before in her 20 years of being a lay and professional counselor. The economy and a difficult job market are surely factors, she says, as are relationship issues, whether between romantic partners, parents and children, or clients and in-laws.

The continuing wars add another element of stress, says Horrigan, a member of ACA. Not only are service members feeling this added pressure, but so are their families and significant others, who are often left waiting to hear from the soldier, possibly not even knowing where their loved one is, all the while having to juggle the household responsibilities on their own. “It’s a high level of stress [for them],” Horrigan says.

Georgene Dwyer, a counselor in private practice in Tulsa, Okla., isn’t necessarily sure that she’s seeing more individual cases of stress than in years past, but she has noticed that less stigma is attached to anxiety than there used to be and that clients are more willing to come forward and talk about it.

Ferrara agrees, saying more people today are willing to seek help to deal with stress and anxiety. “It’s a good thing because I don’t think there’s any shame in asking for help. The shame is in not asking for help,” she says. “There are so many good counselors out there.”

“A perfect storm”

Stephnie Thomas, an anxiety disorders specialist at the Anxiety and Stress Disorders Institute of Maryland, says stressors are a normal part of life, but when people ruminate on those stressors without problem-solving, anxiety can enter the picture. “Most people think if I worry enough about something, I’m going to solve the problem,” says Thomas, a member of ACA. “But actually, that doesn’t always happen. Worrying very rarely solves it.”

As described by Ferrara, stress is what is going on in our world that creates discomfort for us, whether conflicts at work, relationship problems or any number of other things. Anxiety is the resulting worry. “What happens is we start worrying about one thing and stressors pile on, and that worry generalizes to everything,” Ferrara says. “I have clients who tell me they can’t turn it off.”

Unchecked chronic stress can lead to anxiety, with symptoms that might include insomnia, appetite change, distractibility, a feeling of being overwhelmed, avoidance of activities and even absenteeism from work, says Rosen, a member of ACA. Everyone’s tolerance level for stress is different, she says, and that level is often determined by a person’s coping skills, natural temperament, support systems and physical well-being, as well as by the health of his or her relationships.

Current life stressors aren’t the only elements that can figure into a person’s anxiety level, Horrigan says. Anxiety can also be the result of genetics or of past stressors that occurred in a person’s environment over a long period of time — for instance, she says, being exposed to abuse, being abandoned by a parent or growing up in a household where anxiety was the norm. “Then, enough stress in their adult life can lead to anxiety. The biological, the psychological and the environmental all come together at one point. It can be a perfect storm,” Horrigan says.

Ferrara points out that stress can also serve as a positive influence at times, such as propelling people to meet deadlines and get things done. But when stress builds to the point of affecting a person’s ability to function the way he or she wants to, it becomes a problem. “And when it starts to impact health, that’s absolutely a big red flag,” Ferrara says.

For Ferrara, the biggest indicator that clients have “crossed the line” into the realm of anxiety is when they tell her they can’t sleep, even if they have been good sleepers historically. Another warning sign is experiencing body aches, including headaches, stomachaches or other pains, for no apparent reason. Anxiety can also decrease productivity, leading people to feel as though they’re working nonstop and still not accomplishing anything, Ferrara says.

Other symptoms of anxiety include angry outbursts and feelings of being pulled in every direction, Horrigan says. Like Ferrara, she also reports seeing clients with physical ailments that can be traced to anxiety. Oftentimes, she says, these clients have gone to the doctor, received a clean bill of health and yet are still experiencing chest pain, jaw pain, stomach issues, high blood pressure or migraines. But in order to rule out any medical problems, Horrigan asks clients to schedule an appointment to see their doctor if they come to her with physical symptoms of anxiety. If a client’s daily functioning is impaired — for instance, if the client can’t get out of bed or is dealing with panic attacks — Horrigan also asks him or her to see a psychiatrist for an evaluation.

Thomas has also experienced this situation in reverse, receiving clients through referrals from a physician. “[Clients will] often say, ‘I’m not quite sure why I’m here. And then we talk, and a lot of the stress will come out,” she says. Seeing a physician is often the first stop for individuals experiencing anxiety, Thomas says, especially for those whose cultures stigmatize counseling.

Taking the first steps

These counselors say the first order of business with clients seemingly struggling with anxiety is a careful assessment to determine the exact nature of the issue. Anxiety often goes hand in hand with other disorders such as depression or attention-deficit/hyperactivity disorder (ADHD), Ferrara says. Rosen agrees, adding that clients who have a history of trauma, undiagnosed ADHD or untreated depression might have a tougher time coping with everyday stressors.

A good clinical assessment will ascertain which symptoms the client is experiencing, how intense those symptoms are, when those symptoms occur and what context they occur in, Ferrara says. Counselors should also ask about the client’s family history, substance abuse history and functionality at home and work, she says. Horrigan adds that having a client complete a genogram can offer insight into the individual’s family history and tip a counselor off to any potential genetic predisposition to anxiety.

After finishing a thorough initial assessment, Dwyer immediately teaches breathing and relaxation techniques to her clients. She works with them on noticing the physiological changes that take place when they slow down their breathing and on visualizing a calm, safe, peaceful place where they can take themselves when feeling anxious.

Similarly, one of the first things Ferrara discusses with clients is how they’re feeling and acting physically because in stressful times, she says, people often neglect their health. She works with them on deep breathing and taking time during their day to disconnect. Also important, Ferrara says, is what she calls “sleep hygiene.” Do clients have a set time to go to bed? Is the room in which they sleep quiet, cool and comforting? Are animals or kids in the bed as well? Sticking to a schedule, both for going to bed and for waking up, is helpful, Ferrara says. “If people can get good restorative sleep, they’re more likely to function well the next day,” she says.

Horrigan follows a two-pronged approach with clients who present with stress and may have underlying anxiety. First, to reduce some of their physical symptoms, she teaches them relaxation techniques such as abdominal breathing, progressive muscle relaxation, guided imagery and meditation. She also encourages clients to practice yoga, listen to calm music, eat well and stick to a routine sleep schedule. “I also have clients look at their daily demands … and prioritize what are the most important things in their lives and what can they alleviate to be able to give more self-care,” Horrigan says.

The second prong is aimed at addressing the underlying issues that might have led the client to experience sustained stress and anxiety. “During this phase of treatment, I work at a slower, more careful pace, collecting information from the client’s history and background, including a complete family history genogram,” Horrigan says. “I have found that in the process of collecting this information, it not only reveals to me a clearer picture of the client’s psychodynamic makeup, but also allows the client more opportunity to see firsthand the development of their own family patterns. This affords the possibility for the client to make the connection [and see] how and why they may be experiencing the stress and anxiety in their lives now from their past.”

Many clients’ symptoms of anxiety stem from genetics, growing up in an abusive home, being abandoned as a child by one or both parents, or experiencing trauma as a child and then repeating this lifestyle as a dysfunctional parent or family system, which can trigger the client emotionally, Horrigan says. “By teaching a client to identify those situations or things that trigger their anxiety, a client can avoid certain situations or prepare themselves for … feelings that may come as a result of a situation,” she says. “This might mean that they reduce their exposure to a situation or learn coping skills to deal with the feelings that come as a result of a given situation.”

Horrigan also works with clients to find the common threads that tend to ramp up the anxiety in their lives. For one of Horrigan’s clients, this was searching for available parking at work. The client would ride around and around in the morning looking for an open spot, often arrive late to work as a result and then have trouble remembering where the car was parked at the end of the day. Horrigan and the client came up with a solution: carpooling, which greatly reduced the client’s stress level.

Everyone experiences some amount of stress, and because the resulting worry can either be exacerbated or mitigated by the way a person handles it, Thomas works with clients to distinguish between productive and unproductive worry. She describes productive worry as something an individual can take action on in the present moment. For example, if you oversleep, worrying about getting to work on time can help hasten your morning routine and get you out the door a little faster.

“Unproductive worry is when you have a thought about something anxiety-provoking, and then another thought and another thought,” Thomas says. “And then you’re back at your original thought and you haven’t made any progress.” Thomas encourages her clients to take their worries one by one, determining if any action can be taken immediately. If not, that worry gets put aside.

“You can’t stop the thoughts from coming, but what you can do is start tuning them out,” Thomas says. She compares this with driving on the highway and merging into another lane while the music is on. Although you remain aware of the music, you’re not focused on it because you’re paying attention to driving. The same approach can be taken with worrisome thoughts, Thomas says. “The thoughts won’t disappear, but treat them like the background noise instead of focusing on them.”

Counselors can also assist clients in prioritizing responsibilities, growing to accept that they can’t be everything to everyone and learning how to take more time for themselves, Horrigan says. She advises helping clients to recognize both the important things and the unimportant things that pull them in different directions. “Sometimes,” she says, “that means saying no to good things to have a healthy life.”

Another relevant topic Horrigan addresses with anxious clients is control. In doing so, she shares a motto: “We can only control one person 100 percent of the time.”

“When a client believes that they can somehow control another person, they begin to have expectations of them,” Horrigan says. “When these expectations are unmet, this can lead to disappointment, which can lead to stress, which can produce feelings of anxiety. Helping and preparing clients to realize that they can only control themselves assists them to depend on themselves and not to have expectations of or worry about others whom they have no control over.”

Issues with control can stem from growing up in a dysfunctional family system, Horrigan says. In some cases, clients might have felt the need to assume too much responsibility for other family members. Or, on the flip side, clients might have experienced a family member exercising unhealthy control over them through the use of guilt or manipulation. When counselors help clients realize that they cannot control others and, furthermore, that they don’t need to take responsibility for others, their thinking changes, which also opens the door to behavioral changes, Horrigan says. Releasing that responsibility helps clients to prevent automatic thoughts concerning how things were handled when they were growing up. It also aids them in avoiding repeated patterns of behavior, reframing their self-defeating thinking and speaking positive statements to themselves, all of which can reduce anxiety, she says.

Staying in the moment

Recently, Rosen was working with a client in her late 20s who was dealing with symptoms of anxiety after losing her real estate business due to the struggling economy. This client prided herself on her accomplishments and her self-esteem was tied to her achievements, Rosen says, and she subsequently went through bankruptcy after her business was shuttered.

Rosen encouraged the client to acknowledge and mourn her losses, explore her erroneous beliefs connected to perfectionism, separate her value and worth from her career accomplishments, build her positive coping skills and utilize her support system. They also worked together on two other techniques: mindfulness and radical acceptance.

“Radical acceptance is more about accepting where you are at a given moment and allowing yourself to have the experience without judging it or having to do something about it,” Rosen explains. “So, for example, if I am anxious, rather than avoiding the feeling or trying to do something to get rid of it in a negative way because I am so distressed by it, I would acknowledge it and allow myself to experience it without labeling it as ‘bad’ or [telling myself] that I shouldn’t feel that way. When we allow ourselves our emotional experiences, they tend to dissipate quicker than if we act out on [them] in a negative way.”

Mindfulness requires us to be engaged and present in the here and now, Rosen says. “It is amazing how distracted we can become, often worrying about the future, as in the case of anxiety, or ruminating and dwelling on the past, as in the case of depression,” she says. “When we are mindful, we are present-focused and, therefore, neither in the future nor the past, which can be very beneficial in dealing with stress, anxiety, depression, etc.”

To teach her clients mindfulness, Thomas asks her clients to list their thoughts on a whiteboard and then discuss whether each thought is related to the past, the present or the future. “Every time you go off to a future ‘what if’ or a past event, come back to the center,” Thomas tells clients. “When people can be more centered, they’re less stressed.”

Rosen also uses mindfulness-based cognitive therapy, a multidimensional approach that combines mindfulness and radical acceptance with cognitive therapy. She says the approach incorporates the cognitive experience by teaching clients to notice when they are engaging in negative thought patterns and cognitive distortions that could be contributing to their anxiety.

Compartmentalization is another suggestion Rosen offers to anxious clients. For example, if a client is dealing with anxiety related to work, Rosen might suggest the client imagine putting those worries in a box at work and leaving them there overnight or visualize hanging them on a tree outside the house each day when arriving home from work.

Rosen has also found it helpful to clients to teach them anxiety-reduction techniques such as progressive muscle relaxation and guided imagery. Also important, she says, is getting clients to examine how they contribute to their own anxiety. Depending on what the client identifies, the counselor can then work with the person to improve time management skills, keep perfectionism in check, prioritize more effectively or establish stronger boundaries and learn to say no.

Ferrara relies heavily on cognitive behavior strategies with anxious clients because they allow clients to become more aware of what they’re thinking and feeling, how that affects their level of anxiety and what they can do to alleviate it. Many clients come to counseling seeking tools to help them get relief from their symptoms, she says, and cognitive behavior strategies can provide them with such tools.

Thomas also finds cognitive behavior techniques constructive because they prompt clients to closely examine how their thoughts help or hinder them in living life to the fullest and then to problem-solve where possible. Rogerian techniques are also useful, Thomas adds, requiring the counselor to be an active listener from a position of empathy and respect. “When clients feel they are being heard and listened to, they are more likely to implement the cognitive or behavioral strategies that are collaboratively agreed upon as ways to cope with stress,” she says.

Dwyer, a member of ACA, finds journaling an easy and beneficial exercise. She asks clients to take out a notebook and simply start writing about their stress and anxiety, instructing them not to worry about making corrections. “Then,” Dwyer tells her clients, “realize that the paper can hold that [stress and anxiety] for you so you don’t have to hold it. And anytime you want to go back and look, it’s right there.”

Be well

Stress is an unavoidable part of everyday life, and these counselors say that wellness is one of the key tools in improving the ability of clients to handle their stress and anxiety. “Wellness is the cornerstone of managing stress,” Ferrara says. “The things we do to rejuvenate [ourselves] help in how we deal with stress long term.”

Ferrara is always surprised by how many clients today acknowledge not taking a true vacation. Although they might stay away from the office for a week, she says, they often spend that time working from home, cleaning the house, checking email or pursuing other tasks that leave them feeling depleted. “They don’t ever unplug,” she says.

Making sure to be peaceful and quiet each day is crucial in the struggle to control stress and anxiety, Ferrara says. That’s why she recommends that her clients find someplace to be quiet and still for a few minutes each day, where there’s no email to check, no phone ringing and no kids running around. Ferrara also recommends yoga as a stress buster. She points out that this activity doesn’t require that clients sign up for classes because there are yoga programs on TV as well as inexpensive DVDs that can lead clients through routines. Ferrara owns a few such DVDs and loans them to her clients. She also notes that other forms of exercise are beneficial in reducing anxiety.

Horrigan encourages clients to create a list of fun activities and then to make a plan for actually partaking in some of them. “Some clients report that after a walk or a warm bath, a ride in the country or watching a funny movie, they have felt less stress and experience less anxious feelings,” she says. “For clients who enjoy a massage, I encourage them to consider making a monthly standing appointment so that they have this on their schedule and in their budget.”

“On a different level,” she continues, “we talk about ways in which others — work, friends and family members — may make demands on a client’s time and how this may raise the client’s anxiety due to taking care of everyone else and not having time to properly care for themselves. So we work in sessions discussing ways to build healthy boundaries, especially for the client who grew up in a home where there were not clear boundaries in place. As clients begin to develop more strengths and positive beliefs in themselves, the anxiety symptoms are often reduced.”

Rosen agrees that wellness and self-care are essential to managing stress. “I always recommend that clients make sure they are eating well and getting the proper nutrition, taking care that they get enough rest and sleep, engaging in regular exercise, planning fun leisure activities, spending time with family and friends and leaving time for relaxing and being mindful of their own needs.”

Wellness is a way of living that promotes physical, emotional and spiritual well-being and balance, Ferrara says. “I approach stress management from a wellness perspective and look for action-oriented interventions that promote positive change,” she says. “Consistently engaging in those activities that promote optimal health and well-being can also act as a buffer against the impacts of life’s stressors. Clients struggling with the negative impact of stress can learn to use lifestyle strategies that bring balance and healthy coping back into their lives. I try to provide them with practical tools and lifestyle strategies that they can use to return to healthy functioning and that promote future well-being. The wellness model really allows us to help the client with reducing the current stress load, while strengthening the ability to better manage future stressors as they come.”

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

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