Tag Archives: Professional Issues

Professional Issues

What gets in the way? Examining the breakdown between research and practice in counseling

By Samantha McMorrow March 22, 2017

It is frequently noted that counselor practitioners in the field do not contribute nearly enough to research and publications, despite calls for them to do so. It is believed that research should inform counseling practice and practice should inform counseling research, yet there appears to be a breakdown between the two.

The counseling literature has presented several common hypotheses regarding why counselors in practice typically choose not to participate in research and publication efforts. These reasons include a lack of time, a lack of reinforcement, a lack of interest and a lack of experience in research.

Lack of time certainly seems like a valid hypothesis. It is undoubtedly a factor with considerable influence, especially for those counselors who are working in agencies where they must secure a large number of billable hours each week. Still, it is not necessarily the prohibitive factor.

Arguments can definitely be made that there is also a lack of reinforcement or a lack of interest for counselor practitioners to conduct research or to publish. For instance, employers at agencies and schools do not have their systems set up to reinforce this work in the way that universities do. However, this in itself is not inhibitive either.

Inexperience in the area of conducting research also seems like a reasonable factor that could impede practitioners’ contributions to research and publications. However, as a practitioner myself, I contend that a looming factor exists that has not been brought to the forefront. Namely, it is just not very easy to be out in the field and have access to channels to conduct publishable research. There are systems in place that are meant to protect our subjects (and rightfully so), but these systems do not lend themselves well to counselors in the field conducting research.

Furthermore, the path for practitioners to follow to get started in research is not always clear. A counselor in the field has access to clients but not necessarily access to university faculty, and without that, the counselor is stopped before he or she even gets started. The counselor could certainly conduct action research in efforts to inform his or her own practice. However, peer-reviewed, scholarly publications will not accept traditional research for publication without Institutional Review Board (IRB) approval, which comes from universities. Furthermore, universities will not grant IRB approval to research proposals without having a principal investigator (PI), and this PI must be a full-time faculty member of the university.

This is the first and most difficult hurdle to get over in practitioners conducting research. The counselor must find a full-time faculty member at a university that is willing to be the PI on the counselor’s research, which is no small commitment. Then the counselor must hope that the faculty member remains at that particular university throughout the course of the counselor conducting and writing up the research. Otherwise the counselor goes back to the beginning again to locate a new PI and submit an amendment to the IRB board to get approval for this change. The whole process can be confusing and intimidating for counselors in the field to navigate.

Subsequently, the process of getting IRB approval once the counselor practitioner has formed a partnership with a PI is detailed and somewhat lengthy, but not overly complex. Both researchers in this partnership will need to complete certain trainings to ensure that they understand issues surrounding protecting their subjects. They will also complete documents displaying the informed consent process that will be used in their research and submit the detailed and complete plan for the research, which may require cultivating further relationships with other departments if advanced statistical analysis is part of the research plan. This relationship can be the lifeline that keeps practitioners involved in the research effort once the analysis of the data becomes advanced and possibly intimidating for the average counselor in practice.

Furthermore, the university should have comprehensive instructions for how the counselor will submit the research proposal for IRB approval. This will be done once the counselor has a PI and a complete plan for how the research will be conducted. In addition, if counselors plan to conduct their research at their agencies or in their school districts, they will need to secure additional approvals from those specific sites.

This is the less understood and more complicated side of research for many practitioners, but it can be sorted through. Cultivating relationships with faculty members in counseling and other needed departments at universities can ease this process.

In a 2005 article, “Collaborative Action Research and School Counselors,” Lonnie Rowell looked at these collaborative relationships, noting that research-oriented facilities were being developed to bridge this gap between university faculty and practicing counselors. In addition, they serve as a model to link counselors-in-training with counselor practitioners for action-based research.

But despite attempts to build stronger connections between researchers and clinicians, another important factor often impedes counselors from engaging in research. A 2010 study by Darcy Haag Granello published in the Journal of Counseling & Development looked at cognitive complexity among practicing counselors over the course of their careers. The study found that counselors do grow and develop over their careers, especially with 10 or more years of experience. However, seasoned counselors may “forget” that they did not always know a particular technique or approach or did not possess their current conceptual understanding of issues or relationships when starting out in practice. This lack of reflection on their own growth could lead them to erroneously believe that they have nothing to research or write about that other counselors do not already know.

Taking some of our own advice as counselors in this situation could prove to be the solution. If counselors are mindful about their practices and really reflect on what they are doing, how they are doing it and why they are doing it, plenty of ideas will follow. Alyson Pompeo and Dana Heller Levitt proposed in their 2014 article, “A Path of Counselor Self-Awareness,” that practicing counselors have an ethical responsibility to self-reflect on their practices. Being a curious observer of your own work as a counselor can lead not only to professional growth but also inspiration regarding needed research and possible publications.

The literature has identified several factors to explain the existing disconnect between counselor practitioners and research efforts. If we are to truly use research to guide practice and use practice to inform research, then a bridge needs to be built that will bring counselor practitioners into the world of research. If we acknowledge the need for developing connections between university faculty and counselor practitioners, plus the need for increased self-reflection in the field, perhaps the gap that must be bridged will end up being not quite so large.

 

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Samantha McMorrow is a practicing school counselor with K-12 endorsement and a licensed professional counselor. She is also a national certified counselor and is certified as a chemical dependency counselor in Alaska. McMorrow currently serves as an adjunct instructor for the University of Alaska Fairbanks in its Counseling Department. Contact her at sgmcmorrow@alaska.edu.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The healing language of appropriate touch

By Gregory K. Moffatt March 7, 2017

I learned a lesson about the power of touch totally by accident. I didn’t learn this lesson in graduate school, from a book or journal article, or from any professional training. Instead, it happened in the front yard with my son.

He was 8 years old at the time and already displaying the burgeoning need for the independence of adolescence. We were wrestling in the grass, and I intended to tease him by holding him like a baby, thus challenging his independence. I expected him to immediately resist my grasp, but when I looked into his face and talked to him like a baby, he became surprisingly still. He stared straight into my eyes as one might expect an infant to do. I talked to him about when he was little and how I used to snuggle him in our rocking chair in the middle of the night.

“I can stop if you want,” I told him.

“No, that’s OK,” he answered calmly. Almost mesmerized, he stayed in my arms until I was too tired to hold him any longer.

This incident fascinated me so much that, in the tradition of theorists such as Jean Piaget, I used my child as a miniresearch subject, adding this type of snuggling to my son’s bedtime ritual. Several times over the next couple of weeks, just before sleep, I would snuggle him close, caress his hair or rub his back and talk to him about when he was a baby and what it was like bringing him home from the hospital. Each time I got the same response I had witnessed in the yard. It appeared that my son gained peace by letting me touch him tenderly as he lay in bed at the end of the day. If I didn’t snuggle him, he requested it.

After awhile, I decided to see if there was a use for this type of energy in therapy.

Why we touch

If you take a moment to observe people in the public square, you will be astonished at how often they touch — couples holding hands, a friendly back slap between friends, a couple sitting side by side on a park bench leaning into one another, a friend who touches another’s upper arm while listening intently.

Why do we do this? After all, most of the ways we touch are unnecessary for conveying the basic message. We could easily restrict ourselves only to words. Touch augments our conversations, adding garnish and accent to what we want to communicate, but it is also something much deeper.

Without touch, relationships are less than satisfying. Ask any married military couple when one partner is deployed, people who have loved ones in prison or couples whose relationships are dying. The absence of touch leaves us yearning and empty, even if we still hear statements such as “I love you.”

Conversely, watch the reunions of military families, loved ones outside of prison on the day of release or the power of gentle touches between couples who are trying to repair their broken marriages. These touches communicate that “You are safe” and “You are not alone.” These messages are at the very core of healthy human attachments.

There is great precision in touch, and social rules for touch are highly refined. We can touch only certain people in certain ways. At times touch must be invited, but there are other instances when it is expected; to ask for it would be uncomfortable. In my college classroom, it may be acceptable for me to briefly put my hand on a student’s shoulder as I lean over the desk and provide assistance on a test question, but I can’t leave it there very long. And if I move my hand in any direction at all from that shoulder, the touch immediately becomes awkward at the very least, but more likely unwelcome and inappropriate.

Appropriate touch depends on who is touching whom, the genders and ages of each person involved and the relationship between these individuals. Who we touch, what body part touches what body part, how long and with how much pressure — these are the unwritten rules of touch that, under normal conditions, we develop over time in our home cultures. Similar to the way that we manage personal space, we manage touch using unwritten rules that most of us know, yet we would have a very hard time articulating them.

The importance of touch  

We don’t have to look far to discover the importance of touch from the research. Studies going back to the 1800s demonstrated that babies who were not cuddled beyond their basic needs were more likely to die of fetal failure to thrive. They just didn’t grow.

Attachment theory is built on the importance of touch and has demonstrated that extensive face-to-face and skin-to-skin contact between caregiver and child is important for the bonding process. This is the foundation on which all relationships are built throughout life. Infant massage and the soothing effects of therapy animals are just two more recent areas of touch that are well-documented.

Interestingly, many mammals rely heavily on touch to communicate many things. For example, when an elephant mother delivers a calf, every adult female in the herd touches it. They bump up against it with their legs or trunk or in some other way make contact. This communicates acceptance into the herd. If they do not do this, the mother and calf are shunned. For the first several months of the calf’s life, it stays within touching range of its mother. Dogs, cats, lions, otters and chimps all touch with great frequency.

Early in the past century, John B. Watson advised parents to touch their children “as little as possible.” He couldn’t have been more wrong. Humans are social creatures. We have an innate need to interact with others, and touch is essential to our existence. The difference between good touch and bad touch is timing, place of touch, context and purpose. Touch that communicates giving is healthy. Hugging a crying child who has hurt his or her knee is a giving touch. Physical and sexual abuse are selfish, taking touches.

I saw the important role of touch in assessing relationships in the days when I did marriage therapy. Couples in my practice often didn’t touch at all. They sat on opposite ends of the couch or in different chairs. I could often spot the most troubled marriages by the way the couples touched or the way they completely avoided touching. Couples who were deeply committed to salvaging their marriages would touch one another gently, with compassion and healthy emotion, even in the midst of their hurts, resentments and anger. I remained on the lookout for things such as a pat on the arm, an empathetic hug or a natural snuggle against each other on the sofa.

John Gottman has noted that in healthy marriages, touching is one of the vital signs of positive interaction. According to Gottman, people in very troubled marriages may touch, but they grip, cling or touch with force or desperation. At home they withhold touch or touch too hard (abusively), both of which are deeply damaging.

The physiology of touch 

Touch affects us in the right side of our brains. We don’t think it through logically. In both positive and negative ways, we respond to touch instinctively.

In infancy, even before the cerebral hemispheres are fully developed enough to manage language, the brain stem, through the vagus nerve, connects the brain, the heart and the visceral organs of the abdomen. Interesting research known as polyvagal theory proposes that it is this 10th cranial nerve that gives us our “gut feeling” in some situations.

Touch stimulates this nerve, which is wired to the amygdala, the central switchboard of our emotions. When touch is “good,” it can stop the release of the hormones that cause stress. Good touch promotes the development of attachment. Bad touch does the opposite. In either direction, these routes are classically conditioned and become our default emotional responses; they can be changed only with counterconditioning. Consequently, right-brained emotional regulation may be part of the source of many dysfunctions. These dysfunctions serve as facsimiles for the things we really want.

Children touch freely and naturally. It isn’t until they are socially conditioned to do otherwise that they change. Unfortunately, that is when children join the ranks of even relatively healthy adults who desire to be touched but don’t know the most effective way to ask for it. In short, we don’t know how to say, “Hold me.”

Could it be that simple?

The ethics of touch in therapy

We don’t have to look far to find a reason to avoid touch in therapy. Some people don’t like to be touched; touch can be self-serving for the therapist; touch can be misinterpreted and blur boundaries; touch is especially risky with some client populations such as sexually abused children.

But I believe there is a place for touch in therapy. About 10 years ago while I was attending an ethics seminar for child therapists, someone brought up the issue of touching one’s clients. “I never EVER touch any client,” one therapist adamantly averred. Nods and mumbling agreements from others followed.

After several similar comments, I couldn’t keep quiet any longer. I said, “If you choose never to touch your clients, you probably will be relatively safe from accusations of impropriety, but you may also cheat your clients of one of the most powerful tools you have at your disposal.”

I expected scowls and sneers from the 200 or so professionals in the room, but, strangely, my comment seemed to change the direction of the conversation. One after another, people noted how they had carefully used appropriate touch to bring healing and comfort to their clients. In the end, the general conclusion was that touch is a tool, like any therapeutic tool. To ignore it completely may be unnecessarily limiting to one’s practice. A proper touch in an appropriate way at the appropriate time can be comforting and healing.

The ACA Code of Ethics does not prohibit or, for that matter, even directly address touch. With the obvious exception of Standard A.5.a., which prohibits sexual or romantic relationships with clients, one must think through the various ethical implications of the ACA Code of Ethics regarding touch. Avoiding harm to the client (termed nonmaleficence and addressed in Standard A.4.a.) is probably as close as one can come to the issue at hand.

The question we must pose as counselors is whether touch would be helpful or harmful to the client in any given situation. A recent paper from the Association for Play Therapy proposes that touch should be used cautiously, but the key ethical issues are to avoid exploitation, to touch only in ways that are consistent with the therapeutic goals and needs of the client, and to take developmental considerations into account. The paper suggests that the likely interpretation of the touch by the child is also critical. This conceptual approach to touch is consistent with ethical codes from nearly all professional associations.

Therapeutic applications

I decided to work with children early in my career because, while I was an intern, I saw many people still carrying the pain of childhood abuse with them into their 50s and 60s. If bad touch can be so powerful that its effects can be felt for a lifetime, then maybe good touch can be so powerful that it can help heal these hurts.

At the time of the experiment with my son, I thought I was on to something new. Little did I know that this idea wasn’t novel. Donald Winnicott proposed this idea almost 70 years ago when he taught us that touch could be useful in psychotherapy. It is interesting that Winnicott’s research demonstrated that parents don’t actually have to be “great” parents. They simply have to be “just good enough,” to use his words, to meet the child’s needs. In other words, even marginal parents by social standards can be just good enough if they coo, snuggle and lovingly touch their children.

With a parent’s help, I’ve used touch as I did with my son with some of my clients. For example, one of my 5-year-old clients was exceedingly impulsive and hyperactive. I described what I wanted the mother to do and asked her if she would be interested in sitting in with her son during therapy and trying this behavior with him in session.

“He won’t let me hold him,” she said. “He is just too hyper.” But she agreed to try.

After asking his permission (I always respect a person’s right to not be touched — adult or child), we proceeded, and the results were fantastic. As I expected, his response was exactly like my son’s. He relaxed in his mother’s arms for almost 15 minutes without exhibiting a single hyperactive symptom. For this reason, I have given “touching homework” to parents for years. I am amazed at the number of issues that can be addressed with this simple behavior.

Another of my clients was a 15-year-old girl. She was defiant at home and at school, obstinate and bordered on incorrigible. The relationship between this teenager and her mother was tense to say the least. I suggested to the mother that her daughter really needed a physical connection with her. “Try just holding her and see what happens,” I suggested. Like the mother of the 5-year-old I just described, this mother told me that her daughter wouldn’t allow herself to be held, but she agreed to try.

The next week, the mother called to tell me about her experience. “My daughter came home from school and came in the kitchen. I asked her about her day and got the normal disinterested grunt from her. I said, ‘Come hug your mother.’ My daughter said she didn’t want to, but I said, ‘I’m not asking. Mother needs a hug.’”

She continued: “I stood there holding her for a minute or so, initially expecting her to pull away, but she didn’t. I felt her relax, and weakly she put her arms around me too. We stood there for 20 minutes. Neither of us said anything. You never told me how long to do it, so I just kept standing there!”

The mother finally told her daughter that she could go if she wanted, but — as my son did with me — the daughter declined and continued standing there soaking up the human-to-human contact. Her real need was for contact — especially from her mother — but she didn’t know how to ask for it. This teenager had substituted promiscuity, chemicals and other facsimiles because she didn’t know how to say “touch me” in a healthy way. After this interaction, her dysfunctional behaviors began to abate.

I believe that counselors can also garner great benefits by carefully using therapist-client touch. For instance, I have used hand massage with children who have been physically abused. Their body memory has taught them that touch is a painful thing. At first, some of them have trouble interpreting touch. Others, sadly, but consistent with the research, feel very little at all. This is their bodies’ subconscious defense against repeated painful touch.

My goal is to use hand massage as counterconditioning to retrain the body memory of these children to recognize good touch, pleasant connection with another human being and how touch can be a giving behavior rather than a taking behavior.

During these sessions, the child stands in front of me while a parent watches from a nearby chair. I gently massage the child’s hands with lotion as I talk about his or her value as a human being and what a great gift it is to feel another person in a nonthreatening way. The first time or two that I do this, these children often stare at me and remain motionless, having absolutely no idea how to process a touch that feels so pleasant. Over time, they begin to long for it and, as parents practice this technique at home, the children need me less and less.

Conclusion

The number of reported cases of abuse today is far beyond what it was 20 years ago, in part because people know what to look for. People who routinely work with children are trained to look for signs of abuse in children and also in behaviors that they observe between adults and children. Even laypeople have become acutely aware of various forms of abuse.

For the most part, this has been a very good change. However, it has been accompanied by an increased possibility of being sued for abuse or, even worse, charged with a crime and jailed because of abuse allegations. This has led many professionals who work with children (teachers, counselors, psychologists and others) to completely back away and, like some of my colleagues in the seminar, never to touch children in any way. This is a tragic shift. Children long to be touched — as do most of the rest of us.

A friend recently told me that he and his wife had gone to couples therapy. At the conclusion, the therapist asked if she could hug them both. It offended my friend greatly, and he told me he would never go back to counseling. I suspect this therapist either significantly misread cues or, more likely, was seeking to fulfill her own needs. As we all learn very early in our training, it isn’t about us.

But as is the case with any tool in therapy, appropriate touch can be a powerful tool for healing. Just as we have learned over the decades about the use of personal space, we can find differences in the meaning of touch based on who is touching whom, in what way, with what frequency and in what context. So, I propose that counselors consider using touch as one of the many tools in their therapeutic toolboxes.

By the way, my son is an adult now. Recently he came home for a visit. One of his boyhood friends was with him when he came through the backdoor. Even though his friend was watching, my son hugged me long and hard. It was a deep and meaningful hug and, just as when he was little, I was surprised that he held on so long. But I didn’t mind at all.

 

 

For some good reading in this area, I recommend Touch: The Science of Hand, Heart and Mind by David J. Linden, and Touch in Psychotherapy: Theory, Research and Practice, edited by Edward W. L. Smith, Pauline Rose Clance and Suzanne Imes.

 

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Gregory K. Moffatt is a licensed professional counselor, a certified professional counselor supervisor and a professor of counseling and human services at Point University in Georgia. He has been in private clinical practice for nearly 30 years. For the past 18 years, he has specialized with children ages 3-10, and he has worked with infants and babies, providing developmental analyses and consultation with parents and organizations that deal with children. Contact him at greg.moffatt@point.edu.

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having your article accepted for publication, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The journey to counselor educator: Deciding to get your doctoral degree

By Makeba Boykins February 21, 2017

The moment you decide to pursue a doctoral degree is one of the defining moments of your career. You have decided that you want to go further, push yourself and obtain the skills needed for training new counselors. You begin to research schools and their doctoral programs. A glimmer forms of what you would like to write your dissertation on. You apply to your favorite schools, plus some that you don’t like as much to increase the chances of your dream becoming a reality.

But when the interviews start, reality kicks in. For some people, that reality is the amount of work it takes to become a counselor educator. For others, it’s the reality that their favorite school might be just out of reach for a variety of factors.

And if you are a minority student, a different kind of reality starts to settle in. One that tells you your dream might be far more complicated to reach than it is for other students.

Growing up as a black woman in the United States, I was aware of the implicit bias that can affect who gets opportunities and who doesn’t. My father was born in 1928 in the South, so the history of being black in America is forever cemented in me in ways that are hard to describe.

This knowledge becomes personal when you enter the workforce and experience implicit and explicit bias firsthand. Even while obtaining my master’s degree in community counseling, I could see how this bias played into higher education. Once I completed my master’s and went into the field, I worked in social services, attempting to make a dent in the systems and make life better for those who may not be able to do so on their own. When I decided to get my Ph.D., I felt accomplished. I felt ready to go on an academic journey.

 

Roadblocks

Upon starting the application process, I quickly realized how exclusive the “doctor” club is. Most schools accept six to 10 students for Ph.D. programs, and you are competing with students from around the world. What you want to do research on becomes extremely important because some universities want you to participate in or further research that aligns with the research interests of professors who are already in the program.

What I realized very quickly was that even if a professor has interest in multicultural issues or even race, it is rare to want to tackle implicit bias head-on. Diversity and social justice, even in the counseling profession, can be dirty words.

Some research has shown that students generally give poorer evaluations to professors who teach diversity. If those professors are minorities, their evaluations are often even lower. Depending on the university, those student evaluations can be the difference between getting tenure and not getting tenure, so these things matter.

You can imagine that several programs would proceed with caution if a student of color applied and stated that he or she wanted to do research on bias. There is a fine line between telling students that they must change their research ideas (which often change anyway over the course of study) or setting them up for a hard road that may lead to limited academic success. This was the first lesson I learned in my journey.

The first school to which I was accepted did so on the condition that I change my research topic. I had somehow been naive enough to think that in the world of academia, pushing the boundaries was encouraged. Entire bodies of research exist on implicit bias and how it affects almost every facet of society. Given the popularity of the online Implicit Association Test and the ever-growing body of research on the topic, I assumed that research on bias was no longer that controversial.

But when the program chair discussed concerns about my topic with me, I got a rude wake-up call. It shook me and made me question whether pursuing my Ph.D. was really the right course of action. I pushed on and eventually found a school that I am proud to call my academic home.

Upon starting classes, I realized this road could be a constant battle unless I had strategies for success. I hope that some of the skills I learned and implemented can be beneficial to other students, particularly minority students who are pursuing their doctoral degrees.

 

Strategies for success

Being accepted to a school that was interested in my research topic and supportive of my inclination toward social justice was the first hurdle. So, when applying and interviewing for schools, remember that you are reviewing those schools as much as they are reviewing you. It is important for any student, but particularly a student of color, to find an academic home that is supportive of your goals. Do not settle for the first school that accepts you. Review your options carefully, and make a choice that you will be happy with for the next several years to come.

The second step was becoming knowledgeable about the difficulties that African American students face. Per a 2011 research study by Malik Henfield, Delila Owens and Sheila Witherspoon in Counselor Education and Supervision, many African American doctoral students in counselor education programs feel that they face discrimination and a high level of stress. Many cite feelings of isolation, lack of support from faculty and treatment by other students as reasons for not continuing their programs. The article cited additional research done in 1996 that showed that as many as 49 percent of African American doctoral students felt at least partially, if not totally, negatively about their doctoral experience.

I was shocked to learn about these statistics and this research, but arming yourself with this knowledge will allow you to be prepared for the road ahead. So much of completing any graduate degree involves the subjective experience we have in our programs. Counselors, specifically, can forget to check in with themselves emotionally because we are used to caring for everyone else. So do your research and allow yourself to be sad about the extra set of hurdles ahead, but allow those hurdles to motivate you to achieve your goals.

Once you have been accepted to a doctoral program for counselor education, seek out professors and campus organizations that are supportive of and foster your passions. When I began school, I joined the campus diversity department, I stood strong in my passion for social justice and multicultural competency. Basically, I began the ongoing process of carving out my own space — one that is filled with support and is uniquely my own. Universities, particularly predominantly white institutions, might not have a ready-made space for you. If you begin creating your professional and collegiate identity early, it will allow you to start to set your own metric for success.

Set small, achievable goals that remind you that you are making progress. Setting your own standard for success is crucial, particularly for minority students, because feelings of isolation and a lack of support can make it hard to recognize how far you have come. This is where your family and friends can come in because they don’t have to understand what you are writing about to celebrate that you have finished a huge paper. They can constantly give you encouragement, and although their emotional support may not equal an A in the classroom or create a more inclusive environment in your school, it can mean the difference between feeling completely isolated on your journey and feeling supported.

My next step was having frank conversations with family and friends. I had already done this prior to applying to my doctoral program, but after becoming more knowledgeable about all the hurdles that minority students can face even after acceptance, it was important to talk again. I let my partner, my family and my friends know that I might need additional support because I wouldn’t necessarily be able to get it consistently at school. I feel completely supported by my school and faculty, but I wanted to ensure that I possessed multiple levels of support.

As mentioned previously, counselors can be hard pressed to practice self-care. Do not wallow in feelings of guilt when you need help or support, and don’t feel bad about telling your support network early on that you might need them to help lift you up.

Directly correlated with creating your support network is learning to be patient and gentle with yourself. Obtaining any degree is difficult, and the higher you go, the harder it is. You must deal with life’s challenges, and if you are a minority, you may face extra hurdles.

For most people, it will be a year from the time you start submitting applications to the time you actually enter school. During that year, begin practicing your self-care techniques, and then take them with you into the program. If possible, attend campus and association events to begin connecting yourself to your colleagues. Research divisions of the American Counseling Association that you might be interested in joining; these divisions can provide opportunities to expand and affirm your interests.

Also remember that pursuing your doctorate is as much about your learning as it is your grade. Talk with your adviser and take the course load that makes the most financial and emotional sense for you.

Finally, stand strong and proud in your interests and in who you are as an individual. Getting your doctorate should be about more than calling yourself a doctor. You should pursue a doctorate to do scholarly work that matters to you and to be a part of training future counselors.

What drew me to this path and program was a desire to learn more and further the discussions on implicit bias and mental health. Shying away from that path would have been detrimental to my ability to complete my studies and feel fully engaged in my profession. Although it is possible that I will change my topic down the road, it is important for me to pursue what interested me. My end goal is always “scholar” and “educator” first, not “doctor.” So unless your goals or interests change, don’t back away from your passions.

 

Conclusion

The challenges that students face when applying for and entering a doctoral counseling program can be great. Those stressors can be compounded when issues of diversity and inclusion arise. Arm yourself with all the tools and supports available to you to make your journey as smooth and successful as possible. Always be kind to yourself and, remember, we are our ancestors’ wildest dreams.

 

 

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Makeba Boykins has been working in the field for more than a decade. She obtained her master’s degree in community counseling from Argosy University Chicago and is currently pursuing her Ph.D. in counselor education from the Chicago School of Professional Psychology. Contact her at mboykins@ego.thechicagoschool.edu.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

APA accepting feedback for DSM revision

By Bethany Bray February 6, 2017

The American Psychiatric Association has created an online portal for the public to submit suggested changes to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Launched this winter, the portal allows clinicians, scholars and members of the public to submit suggested additions, deletions or modifications to the DSM.

Often called the “psychiatric bible,” the DSM-5 is a go-to resource for many practitioners when it comes to the classification and diagnosis of mental disorders. APA released this most recent version of the DSM in May 2013, after more than a decade of planning, research and review.

The online portal creates a way to keep the DSM updated in a more timely manner and make changes incrementally, as new information and research is available, according to the APA website.

This new medium offers an important and much-needed chance to have counselors voices considered in what has traditionally been an arena dominated by psychiatrists, says Stephanie Dailey, who was involved with the American Counseling Association’s DSM-5 Task Force and co-author of the ACA-published book DSM-5 Learning Companion for Counselors.

However, Dailey, a licensed professional counselor and associate professor and director of counseling training programs at Argosy University, Washington, D.C., expresses some skepticism about which submissions might actually be considered for changes to the DSM. She contributed some thoughts, via email, to Counseling Today:

 

“The Diagnostic and Statistical Manual of Mental Disorders (DSM) has long been criticized, amongst other things, for poor utility; inadequate psychometric evidence for diagnostic categories and specifiers; comorbidity issues; overutilization of ‘catch all’ diagnoses (e.g., not otherwise specific [NOS] and generalized anxiety disorder [GAD]); and underutilization of emergent genetic, neuroscientific and behavioral research.

While APA’s DSM-5 Task Force attempted to rectify many of these issues, there are still considerable challenges in regard to validity, reliability and clinical utility within the DSM-5. Clarification of diagnostic descriptions, criteria, subtypes and specifiers is needed and there is a significant dearth of information regarding sociocultural, gender and familial patterns for diagnostic classifications. There is also a lack of rigorous psychometric validation for suggested dimensional and cross-cutting assessments (introduced in the DSM-5) and no consensus was made during the last revision to the DSM in terms of modifications needed for the personality disorders category. Thus, this diagnostic category has remained unchanged and clinicians (and clients) are facing the same challenges as they did 20 years ago when the DSM-IV was released.

In terms of the new portal, it is important for individuals to understand the revision process of previous iterations of the DSM to really appreciate the magnitude of an ‘open’ call for revisions. The revision process of the DSM-IV to DSM-5 was a 14-year process, beginning in 1999, which originated with a research agenda primarily developed by the American Psychiatric Association

Image via Flickr http://bit.ly/2lfWuka

(APA), the National Institute of Mental Health (NIMH) and the World Health Organization (WHO). In 2007, APA officially commissioned a DSM-5 Task Force which formed 13 work groups on specific disorders and/or diagnostic categories. While the scope was broad, the intent of the workgroups was to improve clinical utility, address comorbidity, eradicate the use of not otherwise specified (NOS), do away with functional impairments as necessary components of diagnostic criteria and use current research to further validate diagnostic classes and specifiers. Having released the draft proposed changes, three rounds of public comment and field trials were conducted between 2010 and 2012. During this time, numerous professional organizations, including ACA, voiced significant concerns (See ACA’s 2011 letter to APA: bit.ly/2kxJBVY).

Despite attempts to become involved, at no time has any professional counselor ever served on APA’s DSM Task Force. In regards to the new portal, our time to have a foothold in changes to current diagnostic classifications is now.

In looking at the portal which lists specific kinds of revisions sought, one can easily see that APA is looking to remedy the long-term critiques of the manual, specifically validity, reliability, utility and the need to capture emerging research.

However, what proposals (and by whom) that are selected for inclusion remains to be seen. While the portal allows anyone to submit a proposal, there is a long history of bias in the type of research which is deemed appropriate for consideration by APA. While there is no dispute in terms of the need for rigorous research designs and large scale studies to validate criterion, these studies are not likely going to be conducted by anyone outside of APA, NIMH, WHO and other large scale ‘think tanks.’

The problem, particularly for counselors, is both philosophical and practical. First, the psychiatric profession as a whole is trained in the medical model, while counselors tend to operate on a more humanistic, holistic perspective. Next, while Paul Appelbaum, chair of the DSM Steering Committee, stated that acceptance thresholds will be high, reports from Appelbaum and others have ensured scrutiny for submissions which don’t provide ‘clear evidence.’ This is not only vague, but likely slanted towards the psychiatric community.

No one is disputing the need for the best available scientific evidence or the ability of the counseling profession to produce substantive outcome research for the mental health community. The American Counseling Association has members who have significant, scientific-based expertise in areas relevant to the DSM and strong research agendas which can support evidence-based changes. However, our seat at the table in these discussions has been scant.

Thus, counselors are strongly urged to contribute to the revision process by submitting proposals and working towards serving as unique contributors to the next edition. This is particularly relevant to counselors whose focus is on marginalized populations and underserved groups. Outcome-based research is needed, specifically that which has been repeatedly shown to improve treatment outcomes.

This is the time for counselors to become involved and make our experience known, and more importantly, our clients’ voices heard.”

 

 

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Find out more

 

Visit APA’s DSM portal at https://psychiatry.org/psychiatrists/practice/dsm/submit-proposals

 

See Counseling Today’s Q+A with Dailey: “Behind the Book: DSM-5 Learning Companion for Counselors

 

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

‘I’m not broken, just stuck’

By Timothy A. Sisemore December 27, 2016

Yet another model of counseling? I would have asked the same question before my introduction some years ago to acceptance and commitment therapy (ACT, and pronounced as the word, act). It is a model that stands on the shoulders of long-endorsed approaches to counseling, yet it takes these ideas into new and, I believe, more fruitful directions. So, if you’ll share with me a few minutes of your time, I’d love to introduce this intriguing model for clinical work. Maybe, like me, you’ll find this worth a closer look.

ACT actually evolved from behaviorism, although it is far from the old stereotypes of behavioral therapy. It draws largely on insights from a branch of behavioral research into language called relational frame theory (RFT). This fascinating approach concerns how our “languaging” about things can cause and perpetuate emotional distress. RFT is a bit difficult to understand, but ACT is like operating a car: You can drive it without understanding all that is going on “under the hood.” (By the way, my use of metaphors is deliberate. Part of RFT shows how metaphors are very beneficial in helping us understand and change how we see things.) One can be a competent ACT therapist without being an expert in RFT.

ACT also draws from cognitive behavior therapy (CBT) but pursues goals that are quite distinct. Although thoughts and language play a role in ACT, ACT does not share CBT’s focus on disputing the thoughts rationally. Rather, the goal is to form a different relationship with one’s thoughts. I’ll share more on that a bit later.

In keeping with its heritage, ACT is built on empirical research and boasts a bevy of studies showing its effectiveness across a wide spectrum of problems. More than 120 randomized trials have shown it to be as effective, if not more effective, than traditional therapies. Counselors can utilize ACT with confidence that it can help. One encouraging note is that studies show that counselors starting out in ACT generally feel less confident than they do with CBT but see better results.

Central points

One of the attractions of ACT is that it is transdiagnostic. That is, it works across diagnoses and does not make much of traditional diagnostic categories. In the counseling world, the idea of diagnosis is being increasingly questioned, particularly because of the overlap of symptoms and the lack of discrete categories. Earlier efforts to find empirical support for counseling models focused on identifying specific therapies for each diagnosis. That is a challenge given that comorbidity is more the rule than the exception in diagnosis.

The search is now on for the core processes that account for emotional suffering rather than just naming more and more diagnostic categories. ACT enters this debate by suggesting a core concept that produces suffering across many diagnoses: psychological inflexibility.

ACT argues that some pain, including emotional pain, is natural and inevitable in life. ACT authors somewhat mischievously refer to counseling that tries to help clients never to feel any anxiety or sadness as pursuing “dead person’s goals.” These clients become intent on avoiding all suffering and discomfort, and in so doing become “stuck” in their thinking, feeling and behavior. They thus spend their days trying to avoid discomfort that is inevitable in life. This paradoxically results in more suffering and a tightening of the pattern’s grip — much like trying to escape from a Chinese finger trap. The more effort that is spent on trying to avoid pain, the more pain it causes. This “control” agenda is in reality hopeless. Only a dead person experiences no unpleasant emotions, so a different approach is needed.

An example might illustrate further. Juanita is depressed and feels ignored in all social situations. To avoid the resultant pain, she begins staying home and watching television by herself. Although this allows her to avoid the anxiety of being in social situations, Juanita is stuck because she lacks the social relationships that she needs. Her anxiety of being “out there” is replaced with the more intense loneliness and depression of avoiding people.

In contrast, psychological flexibility involves a person’s skill in adapting cognitive processes and behavior to the specific context that he or she is facing and to contact the positive consequences of present actions as part of pursuing a valued path (adapted from Steven C. Hayes, Kirk D. Strosahl and Kelly G. Wilson, 2012). It requires flexible attention to the present moment and acceptance of some suffering, combined with a commitment to pursue values and the behavioral activation processes to do so.

For Juanita, psychological flexibility would mean examining her thought process, accepting the apprehension that comes with stepping into social situations and moving toward, rather than away from, those situations. She would learn skills for defusing her thoughts from those social situations, accepting the inevitable anxiety and stepping into occasions so that she can build the relationships she values.

The six skills of psychological flexibility

ACT focuses on six core processes that yield the goal of psychological flexibility. These processes are often diagrammed in a hexagon pattern, cleverly called the “hexaflex,” to show how each impacts the others (see figure below). We’ll look at each point on the diagram in the pairs they naturally come in, but only after a brief note on another important concept: namely, that ACT is not a preplanned, fixed approach. Rather, the counselor takes cues from what the counselee brings into session to determine which aspect might need work on a given day. (ACT texts also provide helpful assessment strategies.)

 

Open response style

This style is marked by looking at things as they are and not reflexively making unhelpful associations. The skills that constitute this style are defusion and experiential acceptance.

The first component, defusion, is one of the most difficult constructs in ACT and the most dependent on RFT. Skipping the technical explanations for our purposes, ACT sees comprehension of how we become fused to certain understandings of things and how we react to those understandings as being vital to change. People with obsessive-compulsive disorder might fuse the idea that anything they think must be true with a thought that they might kill someone. As a result, the mere thought that they might hurt someone else is tantamount to actually having evil intent in their core being and makes them a murderer. Obviously, this causes distress.

CBT might address this through a logical disputation of the irrational thought. In contrast, ACT teaches an awareness of this process and defuses the thought from the interpretation. One can look at one’s thoughts rather than from them.

A simple first intervention might be to have the counselee replace “I must be a murderer at heart” with “I had the thought that I might hurt someone.” In so doing, the person moves “from” the thought and seeing it as a statement of fact to seeing it merely as a passing idea in the mind. The popular “leaves on a stream” mindfulness exercise is helpful here too, with the person viewing thoughts as leaves to be observed and then released. The counselee thus learns to defuse rather than to debate. A phrase I often offer to counselees at this point is “You don’t have to believe everything you think” or, even simpler, “Thoughts aren’t facts.” The same approach also can be used with emotions.

The second component of the open response style is acceptance. In general, this term refers to an openness to accept things such as unpleasant thoughts or feelings. But in ACT, a more precise term would be willingness — the individual is willing to accept some thoughts and feelings in pursuit of a greater good.

A familiar illustration of this idea is the fitness mantra of “no pain, no gain.” Counselees often chuckle when I suggest that I want to lose weight without sweating or working out. They are aware that getting in better shape requires some discomfort. This allows me to ask a question: Why wouldn’t the same be true of mental health?

Numerous ACT metaphors illustrate this idea, but one of the simplest is the ball in the pool. Imagine that you have a beach ball in the pool with you. It annoys you, and you want it out of sight. You hold it underwater so that you don’t see it. That solves the problem in a way, but you also lose the mobility to do most of the fun things you normally do in a pool. Controlling the ball is so “expensive” that it costs you the pleasures of swimming. But if you are willing to accept the annoyance of the ball, you can reengage with the delights of life in the pool. An internet search of “ACT metaphor videos” will yield some short, clever resources that are very helpful in communicating these points to clients.

Now consider this as it relates to Juanita. You work with her to realize that her control agenda of avoiding all pain won’t work, so she is open to ACT. She is fused to the thought that whenever she goes to a social setting, she is shunned. Rather than argue with her about the objective truth of the thought, you guide her to realize that this is simply a thought. She need not hold on to it so tightly.  It is much like the beach ball metaphor. If Juanita can accept this thought in the background, she is freer to move toward people and relationships.

Centered response style

In the center of the hexaflex (conveniently enough) are the two skills that constitute this vital part of psychological flexibility. The two skills that keep one centered in responding to one’s immediate context are contact with the present moment (being present) and self-as-context.

Present moment awareness, the third element of the hexaflex, likely strikes you as being related to mindfulness, and you are correct. However, mindfulness serves a different purpose in ACT than in other therapies. Whereas mindfulness often is considered a way to decrease stress and induce calm, it plays a different role in ACT. In fact, relaxation may even run counter to ACT’s goal. ACT counselors use mindfulness as a skill to help clients keep in contact with the present moment, even if there is discomfort in it. Much of our thinking gets us lost in the past or anxious about the future, but the only time we can act is in the present. We use many strategies to avoid the present, such as constantly doing something, shifting topics, living in the future through worrying and thinking about everyone else’s business except our own.

This shifting of attention away from the here and now serves to avoid discomfort and unwanted emotions even as it perpetuates problems. We need a moment-by-moment awareness of our internal states and external contexts to respond appropriately in the present. Simple examples of activities for this in ACT include having the counselee relax, close his or her eyes and keep one thought in mind, raising his or her hand whenever the thought slips away. Alternatively, one of my favorites is helping the person become centered, then placing an ice cube in his or her hand (a paper towel is also needed for the inevitable dripping). I then guide the counselee to observe the changing feelings from holding the ice cube — wetness, coolness, maybe a slight burning sensation and so on. This exercise keeps the counselee aware of the present situation and teaches him or her to accept the sensations that accompany it rather than using avoidance strategies.

Perhaps the most conceptually challenging dimension of psychological flexibility is self-as-context, the fourth element of the hexaflex. ACT distinguishes several aspects of self. Self as concept is the way we say, “I am …” So I can say, “I am a counselor” or “I am an art enthusiast” and so forth. This can be destructive, however, when it includes statements such as “I am a loser.” We can become fused to such notions of the concept of the self.

The self is more than this. It is also the place from which we observe life. Consider yourself in a counseling session. If you are like me, you are largely caught up in the flow of what is happening, but a part of you is simultaneously monitoring progress — observing it rather than participating in it. I catch myself noticing that I’m talking too much, or that my mind is drifting when the counselee talks, or even that the counselee is making poor eye contact or struggling to maintain a stream of thought. So, I simultaneously participate in the interaction and observe it.

Once we are aware of this as counselors, we can help our clients develop this vital skill. As we have seen, often clients are fused to their thoughts, and defusion may require the ability to step back and take perspective. People are also often fused to their interpretations of their thoughts (such as Juanita’s fusion to the sense that if people don’t line up to talk to her, it means they are ignoring her).

You can learn to listen to how much interpretation people bring to their stories and descriptions. I illustrate this with the example of two broadcasters at a basketball game. One broadcaster, typically designated the play-by-play commentator, describes the action so that listeners have a sense of objective presence at the game. The other broadcaster is a color commentator charged with analyzing and interpreting events. Many of our counseling clients are all color commentator and very little play-by-play. Much of mindfulness in ACT involves learning to be the observer rather than the participant or analyst.

A popular metaphor for this is the chessboard (it may be beneficial to have one in your office as you share this with clients). Explain how the black and white chess pieces can represent thoughts in the counselee’s mind. They are battling with each other in different ways and causing distress, much like the little angel and demon that appear on the shoulders of old cartoon characters when they are contemplating an action. Clients identify with this struggle and feel caught up in it. Invite the counselee to consider if there is another participant in this debate/game of chess. The answer is the chessboard itself. Every move affects the chessboard, but the thoughts are not the chessboard. This is the self-as-context.

Returning to Juanita, consider what the centered response style would look like for her. As her counselor, you would guide her to greater skill in observing her thoughts (and, yes, this overlaps with defusion). You might begin with exercises to help her monitor her thoughts and feelings in the counseling office to develop better contact with the present moment (this is also helpful should a client wander “out of the office” into other topics, times or places). Then ask Juanita to imagine going to a party. Have her track her thoughts as a play-by-play commentator without attempting to escape or interpret the feelings, developing a better sense of self as the person experiencing the anxiety rather than being hopelessly wrapped up in the anxiety.

Engaged response style  

We have considered the “acceptance” part of ACT, but what of the “commitment” piece? This is the aspect of the psychologically flexible person that pursues valued directions through commitment.

One of the costs of avoidance is the loss of pursuing valued things in life. For Juanita, this is obvious. She avoids anxiety, but in the process she does nothing to move toward the relationships that she values. To borrow from our fitness metaphor again, the “gain” of working out is the reason one accepts the associated “pain.” One values fitness and health and understands those things cannot be achieved without doing difficult things to promote and maintain them.

The fifth element of the hexaflex is defining valued directions. Clients often are lost in escape and avoidance activities that cost them opportunities to have the things they value. Thus, a child who is afraid at night misses the opportunity for sleepovers with friends, even though he or she would value the fun of being at the friend’s house or, more precisely, the richness of a deeper relationship with the friend.

Values are life directions that are global, desired and chosen. They are “bigger” than goals. To illustrate, one may enter a counseling program with the goal of becoming a counselor, but the value behind it is investing one’s life in helping others. ACT offers a number of suggestions for helping clients clarify their values and how their inflexibility is keeping them from pursuing those values.

For example, you might ask clients to complete a “heroes worksheet” of people who inspire them or people they would like to emulate. Discuss what about the person speaks to the client. Another helpful technique is to have counselees imagine their 80th birthday party, attended by all the people they love most. Three of the people stand and state words of affirmation about what the counselee has meant to them. Who would those people be? What adjectives, descriptions or accomplishments would they speak about?

Values can lead to frustration if not pursued, so the sixth point of the hexaflex is committed action. The counselor helps the client translate values into committed action steps to take. Traditional behavioral activation or motivational interviewing strategies come into play here, with a focus on enduring any suffering the values might entail.

Think back to the Olympic Games that took place this past summer. So many of the stories of the successful athletes included conquering hardships, persevering through challenging contexts and overcoming various obstacles. We are well aware that sacrifice is necessary to achieve things in any area. ACT deliberately helps counselees make action plans based on their values and build patterns of action over time. Strategies might include encouraging clients to share their values with others and preparing them to stick to their plans in the midst of the barriers they will encounter along the way.

Values and committed action provide a natural home to the personal resources of counselees who value spirituality or religion in their lives. Properly understood, spiritual values are some of the more profound aspects of many people’s lives and a focal point to their getting out of bed in the morning. Furthermore, faith and spirituality can be helpful in moving reticent clients to action (Jason A. Nieuwsma, Robyn D. Walser and Steven C. Hayes, 2016).

Juanita just knows that she is anxious around people. She may not be aware that this is the flipside of desiring to have close relationships. As her counselor, you walk with her to help her recognize that intimacy is one of her core values and being around potential friends or lovers is a necessary step. She now realizes how her avoidance works against what she really wants, and she grasps that she wants intimacy more than freedom from anxiety. She develops a plan with you for attending a social event at work. Together, you and Juanita develop strategies to increase her motivation, including visualizing a friendship that comes out of the party. You troubleshoot how she will feel along the way and how to use the other skills as she willingly walks through the anxiety that awaits her. Together, you plan a celebration of her success at the next session.

Conclusion

The ACT model is a learning process. Clinicians will grow to use the six skills of psychological flexibility not only in counseling, but also in their personal lives. The growth I have personally experienced in learning ACT is one of my favorite things about it. My present moment awareness tells me how superficial this survey of ACT is, but I hope that this brief article activates your values of learning and trying new things, and that you will read up on ACT (a few resources are listed below), attend a workshop and test some of the techniques discussed here.

 

 

Additional suggested readings:

  • Get Out of Your Mind & Into Your Life: The New Acceptance & Commitment Therapy by Steven C. Hayes with Spencer Smith, 2005
  • Acceptance and Commitment Therapy: The Process and Practice of Mindful Change, second edition, by Steven C. Hayes, Kirk D. Strosahl and Kelly G. Wilson, 2012
  • Learning ACT: An Acceptance and Commitment Therapy Skills-Training Manual for Therapists by Jason B. Luoma, Steven C. Hayes and Robyn D. Walser, 2007
  • Mindfulness and Acceptance in Multicultural Competency: A Contextual Approach to Sociocultural Diversity in Theory and Practice by Akihiko Masuda, 2014
  • ACT for Clergy and Pastoral Counselors: Using Acceptance and Commitment Therapy to Bridge Psychological and Spiritual Care by Jason A. Nieuwsma, Robyn D. Walser and Steven C. Hayes, 2016

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Timothy A. Sisemore is director of research and professor of counseling at Richmont Graduate University. Contact him at tsisemore@richmont.edu.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.