Monthly Archives: December 2006

Dealing with cancer from a multicultural perspective

Julie Wargo, Michael D’Andrea and Judy Daniels December 9, 2006

Cancer is a nondiscriminatory disease. It impacts persons from all cultural, ethnic and racial groups and backgrounds. The American Cancer Society reports that, as the second leading cause of death in the United States, cancer is projected to affect more than 1.4 million Americans by the end of 2006. Of those individuals who are diagnosed with one or more forms of cancer, 564,830 will die as the result of their illness by the end of this year.

Counselors routinely come in contact with persons who either suffer from cancer themselves or are psychologically impacted by a family member or friend with cancer. Because this illness affects so many people in our nation, it is important for counselors to understand some of the central psychological and multicultural issues that are linked to the complex problem of cancer in our society.

From a multicultural perspective, counselors are encouraged to keep four particular points in mind when working with persons who either have cancer themselves or are adversely affected by someone close to them who does.

  • Become aware of your attitudes and biases regarding cancer
  • Recognize the disproportionate numbers of persons from different cultural-racial-ethnic groups who are diagnosed with cancer in the United States
  • Develop an understanding of the cultural-racial disparities that impede many persons from accessing the quality health care services designed to address cancer
  • Make a commitment to implement a broad range of helping services that are both culturally responsive and respectful when working with persons directly or indirectly affected by cancer

We hope the information presented here will help you become more aware of the counselor’s role in dealing with persons affected by cancer. We also hope to stimulate your thinking about the types of multicultural counseling competencies that you either already possess or need to develop to work more effectively, respectfully and ethically with culturally different persons who are affected by cancer.

Developing a greater awareness

The multicultural counseling competencies developed by the Association for Multicultural Counseling and Development in 1992 and formally endorsed by the American Counseling Association in 2003 fall within three main domains: multicultural counseling awareness, knowledge and skills. A number of these competencies are particularly relevant because they relate to counselors’ work with persons affected by the high incidence of cancer in our society.

Multicultural Counseling Competency #2: Culturally competent counselors are aware of how their own cultural background and experiences, attitudes, values and biases influence psychological processes. An expansive definition of the term “cultural background and experiences” includes individuals from diverse religious/spiritual and socioeconomic backgrounds as well as persons in vulnerable at-risk groups.

Mary and Allen Ivey, leading proponents of the multicultural counseling movement, have commented on the need for counselors to embrace a broad definition of culturally different groups. That definition is inclusive of the millions of persons whose unique physical, ethnic, racial, sexual, socioeconomic and residential characteristics and identities not only distinguish them from persons in other groups but often place them at high risk for future psychological problems.

Commenting further, the Iveys state that “Counselors and psychologists are frequently called upon to work with persons in various vulnerable at-risk cultural groups, including poor, homeless and unemployed people, adults and children in families undergoing divorce, pregnant teenagers, individuals with HIV or AIDS and persons with cancer.”

It is indeed important to embrace a broad definition of the terms “culture” and “cultural groups” that includes persons with cancer. It is also important for counselors to be aware of the attitudes and biases they may have developed as a result of not having any direct or indirect experience with cancer themselves. When left unexamined, such attitudes and biases may be subconsciously or unconsciously generalized to clients who are encountering psychological and emotional distress because of their own experience with cancer.

Multicultural Counseling Competency #3: Culturally competent counselors are able to recognize the limits of their competencies and expertise. This competency complements the previously mentioned points in a couple of ways. First, culturally competent counselors are aware that their attitudes and biases about cancer may be affected by their lack of experiences with persons who have cancer, their lack of personal experience as a cancer patient or the types of experiences they have had with a family member or friend who developed the disease. By reflecting on these issues, counselors can become aware of how their experience or inexperience with cancer may limit their effectiveness in professional practice. In doing so, counselors are better able to seek consultation and training to increase their level of competence and expertise when working with clients whose presenting problems are linked to cancer in some way.

Becoming knowledgeable

Culturally competent counselors also demonstrate a willingness to acquire new knowledge about this problem from a multicultural perspective. Multicultural Counseling Competency #12 captures this point: Culturally competent counselors possess specific knowledge and information about the particular group that they are working with. They are aware of the life experiences, cultural heritage and historical background of their culturally different clients.

The following section provides information about cancer from a multicultural perspective. Despite the fact that death rates for all cancer types have declined during the last several years and the incidence rates of various cancers have been stable since the mid-1990s, various cancer research groups have consistently reported cultural disparities in the incidence of cancer. In a recent report generated by the National SEER Cancer Statistics Review group, researchers reported that cultural-racial-ethnic group cancer incidence and death rates, from highest to lowest, were as follows: African-American, White, Hispanic, Asian/Pacific Islander and American Indian/Alaska Native. It is also noteworthy that there were consistently greater rates of cancer incidence for males in each subgroup.

The American Cancer Society further informs us that significant disparities in the incidence of cancer continue to exist among persons in specific racial-cultural-ethnic populations. African-Americans (males in particular) and people in low socioeconomic groups continue to have the highest rates of new cancer cases and cancer deaths. A more detailed report by the American Cancer Society indicates that African-American men show the highest incidence and death rates for all cancers, followed by White males, African-American females and White females, respectively.

Furthermore, the U.S. Department of Health and Human Services confirms that African-Americans in the United States are 19 percent more likely to die from all types of cancer than Whites. African-American men are 50 percent more likely to die from prostate cancer than their White counterparts. And although breast cancer is diagnosed 24.5 percent less frequently among African-American women than White women, women of African descent are 33 percent more likely to die from this disease.

Other minority groups are also afflicted with severe cancer rates nationwide. The Department of Health and Human Services published a report in 2005 stating that women of Latina descent are 2.2 times more likely to be diagnosed with cervical cancer than non-Hispanic White women. In addition, Asian/Pacific Islander women were found to be 2.4 times more likely to be diagnosed with stomach cancer than non-Hispanic White women. American Indian women are 1.9 times more likely to die from cervical cancer than White women. And Asian/Pacific Islander men and women are both found to have higher incidence and mortality rates for liver cancer than White persons in the United States.

Gaining up-to-date knowledge on the rates of cancer among various cultural-ethnic-racial groups may lead mental health professionals to think of the types of culturally sensitive approaches they can use to help persons cope with this disease’s unique challenges. In considering the types of specific interventions counselors can use, it is important to remember that individuals from disadvantaged cultural-racial groups who have received a cancer diagnosis often believe they have little control over the disease or the types of medical, psychological and social support services they can secure.

When faced with the prospect of cancer, people’s coping abilities are often undermined by feeling a lack of control over their medical problems or experiencing difficulties in accessing quality health care services for themselves, family members or friends. Knowledge of these issues can help counselors to better understand their clients’ thought processes and unique coping perspectives. With this knowledge in mind, culturally competent counselors will assess the degree of control that persons in diverse cultural-ethnic-racial groups experience in their lives and work to build on their current coping skills and strengths. When considering issues related to external and internal locus of control, it is also important to assess the role that religion and spirituality play in clients’ belief systems in terms of illness and healing.

Culturally competent counselors also understand the need to extend their professional impact in other ways. This includes advocating for the development and implementation of consistently high-quality health care services for all persons in the United States, especially those from culturally diverse groups, who are affected by cancer. In accepting an advocacy role, culturally competent counselors demonstrate their understanding of the need to move beyond simply providing direct counseling services. We need to implement other types of organizational, community, social and political change strategies that assist culturally different persons affected by cancer to experience a greater sense of control over the types of medical services that complement their cultural worldviews and values.

These efforts represent more comprehensive and respectful ways of promoting the health and well-being of culturally diverse clients who are affected by cancer. By implementing a more comprehensive approach to promoting the empowerment, health and well-being of these individuals, culturally competent counselors demonstrate their understanding of the multiple factors that affect persons impacted by this disease. In so doing, they exhibit a willingness to address the injustices that exist in the availability and delivery of quality health-care services that complement clients’ life experiences, historical backgrounds and cultural-racial-ethnic heritage.

Multicultural Counseling Competency #13: Culturally competent counselors understand how race, culture and ethnicity may affect help-seeking behaviors and the appropriateness or inappropriateness of various counseling approaches.

Race, culture and ethnicity play significant roles in the way a cancer patient views the appropriateness of help-seeking behaviors. Edward Sarafino of the College of New Jersey notes that many African-Americans and individuals with low annual family incomes are less likely than White persons and individuals in higher socioeconomic groups to access outpatient clinics for their health care needs. This is unfortunate because outpatient health care service providers can often detect and treat cancer during its early stages. Early detection and treatment often results in the amelioration of many forms of cancer that would otherwise result in more serious and even fatal outcomes.

Counselors need to be particularly sensitive to the differences that exist among people in diverse socioeconomic classes in terms of their utilization of health services. The underutilization of health care services among poor and working-class persons, specifically as it relates to early detection and treatment of cancer, is a major barrier in promoting the health and well-being of people in these cultural groups. In combination with socioeconomic status, other demographic factors such as age are closely related to how willing or successful a person will be in accessing needed mental health counseling services when experiencing cancer. It is useful for counselors to familiarize themselves with research findings that discuss why many poor and working-class individuals tend to perceive that they are less likely to develop cancer than are people from higher socioeconomic classes.

It is also important to be sensitive to the reasons many of these individuals may feel less welcome or less trusting of counselors, particularly if the professional is of another race, not fluent in the client’s native language or communicates in ways that reflect culture-bound biases in his/her helping approaches. Derald Wing Sue, a pioneer in the multicultural counseling movement, stresses that eye contact, vocal tone, hand gestures, body language and other verbal and nonverbal communication gestures are culture-bound. These culture-bound dimensions of communication style can either facilitate or hinder development of a positive relationship in counseling.

Culturally competent counselors implement intervention strategies that foster a trusting relationship and positive counseling outcomes with persons from diverse socioeconomic and racial-ethnic groups who are affected by cancer.

Acquiring a wider range of multicultural counseling skills

Considering that many persons in lower socioeconomic and non-White ethnic-racial groups view counseling as a White, middle-class profession, it is important for counselors to address these negative views and suspicions. Counselor education programs would do well to direct increased attention to these issues by implementing new training initiatives that foster a greater level of cultural sensitivity, knowledge and skills among students.

We believe it is particularly important for counselor education programs to provide training that enables students to develop and integrate an expanded skill set. This approach will assist future counselors in fostering mental, physical, spiritual and cultural wellness among persons in minority communities where cancer rates are known to be high. One of the fundamental ways counselor education programs can increase students’ multicultural counseling skill sets is to address the issue of linguistic differences. Many multicultural counseling situations involve clients who speak a language different from that of the counselor.

Multicultural Counseling Competency #29: Culturally competent counselors take responsibility for interacting in the language requested by the client. This may necessitate securing translation services when working with persons from linguistically diverse populations.

Linguistic differences and language barriers can pose an enormous challenge in counseling in general and when counseling individuals impacted by cancer in particular. Many cancer clients who are in need of mental health counseling services come from backgrounds in which English is the second language. It is obvious that positive counseling outcomes depend largely on the degree to which both the counselor and the client understand the verbal interactions that occur in the helping process. Yet the language bias that exists in the United States results in most counselors being limited in their multicultural communication abilities. Consequently, individuals who have limited ability communicating in English may suffer from the imposition of monolingualism in many counseling situations.

The dramatic increase in the number of persons of Latino/Latina descent living in the United States has resulted in counselors more frequently encountering clients whose primary or preferred language is Spanish. Commenting on this issue, Sue notes that the need for bilingual counselors and health care practitioners has never been greater. Thus, becoming competent in a second language is another important multicultural counseling skill that professional training programs are being challenged to address in our pluralistic society.

While this issue should be addressed as part of the counseling profession’s ongoing commitment to greater multicultural competence in professional training programs, counselors need to implement strategies to effectively confront the challenges associated with language differences now. Consequently, counselors are strongly encouraged to utilize the services of translators when they are not thoroughly fluent in the client’s preferred language.

Caution must be taken, however, to ensure accurate translation of the verbal interactions that occur between the counselor and client. Be constantly vigilant of this issue because the words to connote various issues in different cultural-ethnic groups often have different meanings. In addition, it is also important to point out the confusion that often emerges when counselors and clients use slang terms that make it difficult for professionals to accurately translate in multilingual counseling settings.

We hope the various issues presented in this month’s column will stimulate new thinking about the role counselors can play in addressing the needs of persons who are affected by cancer in our pluralistic society. We particularly hope our readers will consider both the strengths they currently possess as well as those areas they need to improve upon to work effectively and respectfully with persons from diverse cultural groups. By using the multicultural counseling competencies as described above, we can promote the dignity, development and well-being of persons from diverse groups and backgrounds who are struggling with cancer in our country.

New guidelines on dual relationships

Mary A. Hermann and Sharon Robinson-Kurpius

The recent revision of the ACA Code of Ethics significantly changes the ethical guidelines related to dual relationships. Careful review of the specific ethics code language addressing dual relationships is imperative in order to navigate this prevalent ethical issue. Though the 1995 code offered guidance on the topic of dual relationships, the 2005 ACA Code of Ethics provides more explicit guidelines about which dual relationships are ethically acceptable and which are strictly prohibited.

Dual relationships exist on a continuum ranging from potentially beneficial interactions to harmful interactions. One dual relationship that is always considered harmful is a sexual relationship with a client. The 2005 revision of the ACA Code of Ethics reiterates and expands the ban on sexual relationships with clients. Under the new code, counselors are ethically prohibited from engaging in sexual relationships not only with clients but also clients’ partners or family members (Standard A.5.a.).

Another substantive revision is the extension of the time ban on sexual relationships with former clients. In the 1995 code, the specified period of waiting was two years, with extensive justification after two years that such a relationship would not be harmful to the former client. The 2005 code extends this period to five years. Echoing the previous code, the 2005 code states in Standard A.5.b. that “Counselors, before engaging in sexual or romantic interactions or relationships with clients, their romantic partners or client family members after 5 years following the last professional contact, demonstrate forethought and document (in written form) whether the interactions or relationship can be viewed as exploitive in some way and/or whether there is still potential to harm the former client; in cases of potential exploitation and/or harm, the counselor avoids entering such an interaction or relationship.”

Though sexual relationships with clients are clearly prohibited, nonsexual relationships are ethically permissible under certain circumstances. Like a dual relationship that is sexual, a nonprofessional dual relationship has the potential to blur the boundaries between a counselor and a client, create a conflict of interest, enhance the potential for exploitation and abuse of power, and/or cause the counselor and client to have different expectations of therapy. The 1995 code instructed counselors to avoid nonsexual dual relationships when it was possible to do so. The Ethical Code Revision Task Force felt that this instruction was being interpreted as a prohibition on all dual relationships, including relationships that could be beneficial to the client (see “Ethics Update” in the March 2006 issue of Counseling Today). Thus, the 2005 code revisions clarify that certain nonsexual interactions with clients can be beneficial, and therefore, those relationships are not banned (Standard A.5.c.).

The 2005 code also provides examples of potentially beneficial interactions, including “attending a formal ceremony (e.g., a wedding/commitment ceremony or graduation); purchasing a service or product provided by a client (excepting unrestricted bartering); hospital visits to an ill family member; mutual membership in a professional association, organization or community” (Standard A.5.d.). When engaging in a potentially beneficial relationship with a client or former client, however, the counselor is expected to “document in case records, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit and anticipated consequences for the client or former client and other individuals significantly involved with the client or former client.” Standard A.5.d., “Potentially Beneficial Interactions,” further clarifies that “Such interactions should be initiated with appropriate client consent,” and if harm occurs because of the nonprofessional interactions, counselors are expected to “show evidence of an attempt to remedy such harm.”

In settings such as rural communities and schools, nonsexual dual relationships are often impossible to avoid. The 1995 code provided guidance on managing unavoidable dual relationships, stating that the counselor was expected to “take appropriate professional precautions such as informed consent, consultation, supervision and documentation to ensure that judgment is not impaired and no exploitation occurs.” Though this language is no longer explicitly stated, such precautions still seem warranted.

The 2005 ACA Code of Ethics also provides guidelines for supervisory relationships, stating that “Sexual or romantic interactions or relationships with current supervisees are prohibited” (Standard F.3.b.). Furthermore, the ethics code clearly states that “Counseling supervisors do not condone or subject supervisees to sexual harassment” (Standard F.3.c.). It should be noted that not only is sexual harassment unethical, it is also illegal.

Counseling supervisors are expected to “clearly define and maintain ethical professional, personal and social relationships with their supervisees” (Standard F.3.a., “Relationship Boundaries With Supervisees”). The standard goes on to say that “If supervisors must assume other professional roles (e.g., clinical and administrative supervisor, instructor) with supervisees, they work to minimize potential conflicts and explain to supervisees the expectations and responsibilities associated with each role.” The 2005 ACA Code of Ethics also cautions counseling supervisors to remain aware of “the power differential in their relationships with supervisees” (Standard F.3.e.). The code further clarifies that “Counseling supervisors avoid accepting close relatives, romantic partners or friends as supervisees” (Standard F.3.d.).

Standard F.3.a. also advises counseling supervisors not to engage in “any form of nonprofessional interaction that may compromise the supervisory relationship.” If a counseling supervisor believes a nonprofessional relationship with a supervisee has the potential to benefit the supervisee, Standard F.3.e. provides that supervisors take precautions similar to those taken by counselors who engage in potentially beneficial dual relationships with clients. It goes on to say that “Before engaging in nonprofessional relationships, supervisors discuss with supervisees and document the rationale for such interactions, potential benefits or drawbacks, and anticipated consequences for the supervisee.”

The 2005 ethics code addresses other dual relationships as well, including relationships between counselor educators and students and relationships between researchers and research participants. Standard F.10. sets guidelines for counselor educators and students that are similar to the ethical guidelines for supervisors and supervisees. Standard G.3. virtually mirrors these rules for researchers and their research participants.

The 2005 ACA Code of Ethics clarifies that nonsexual dual relationships are not prohibited; however, navigating dual relationships can be challenging. Counselors are ethically mandated to approach dual relationships with care and caution. Informed consent is a critical component of engaging in nonsexual dual relationships with clients, and this includes specifying the potential negative consequences of such a relationship. It is wise for counselors to consult when faced with a dual relationship to ensure that clients are not harmed. Though the standards related to dual relationships in the ACA Code of Ethics have undergone significant changes, the spirit of their intent can still be summarized in one sentence: Do what is in the best interest of the client.

Mary A. Hermann, a professor of counselor education at Virginia Commonwealth University, and Sharon Robinson-Kurpius, a professor of counseling and counseling psychology at Arizona State University, are members of the ACA Ethics Committee.

Letters to the editor:

Ethical use of technology in counseling

David Kaplan

Counseling Today is publishing a monthly column focusing on new aspects of the revised ACA Code of Ethics (the entire ethics code as well as previous “Ethics Update” columns are available on the American Counseling Association website at

ACA Chief Professional Officer David Kaplan conducted the following interview with ACA Ethics Revision Task Force members John Bloom and Christine Moll.

David Kaplan: Today we are talking about Standard A.12. of the revised ACA Code of Ethics: “Technology Applications.” When you compare the small section on computer technology in the 1995 code with the revamped and substantially expanded section on technology applications in the revised code, it seems like the comparison between an old Radio Shack Tandy TRS-80, complete with amber or green screen, and a current Dell XPS dual core processor.

John Bloom: The Ethics Revision Task Force got away from the 1995 emphasis on computer applications and expanded the section to include all technology, including the often overlooked application of telephone counseling, which actually predated computer counseling by decades.

Christine Moll: We have come a long way since those years. And we know that unknown technologies will emerge before the code needs to be revised again in 2015. As such, we tried to anticipate additional applications and issues that will occur within the next 10 years before the next code is written.

DK: That explains why the old code had less than one-half of a column devoted to technology, while the revised code has what is now the largest single section in the ACA Code of Ethics, measuring in at a whopping two and one-quarter columns.

JB: In 1995 we were dealing with this unknown entity called the Internet. We weren’t sure about its capabilities or shortfalls because at that time there was little or no research to document the effectiveness of computer-based counseling. As such, the previous standards were written almost out of fear and ignorance of the unknown and so emphasized what not to do. Now, 10 years later, we are starting to build a body of research which suggests technology-assisted counseling can be effective, and so we were able to build positive and proactive statements about how to proceed with technology. So one of the reasons that the section is greatly expanded is that counseling can now embrace technology rather than fear it.

DK: In 1999, under the leadership of President Donna Ford, ACA promulgated Ethical Standards for Internet Online Counseling. Is that document still in force?

JB: No. The current code of ethics incorporated and updated all previous ACA documents on ethics.

DK: As previously mentioned, the expanded section on technology takes up over two full columns in the revised Code of Ethics. Let me present a fantasy scenario to you: If you and the Code of Ethics were on a sinking ship and you only had enough time to save three of the many new statements in Standard A.12. about technology applications in counseling before the ship went under water, which three would you save and why?

CM: I would first save Standard A.12.e., “Laws and Statutes.” Technology-assisted counseling, whether conducted by telephone, Internet, e-mail or other application, often results in the crossing of jurisdictional lines. So laws which apply in Texas may not apply in New York. It is incumbent upon a counselor to know and be in compliance with all laws in both their state or jurisdiction and the state or jurisdiction of the client.

DK: Is there a specific example that comes to mind?

JB: The states of Washington and Colorado have idiosyncratic disclosure laws that counselors need to know about when they provide technology-assisted counseling to any resident of those two states. The cybercounselor should be aware that most legal authorities believe that counseling takes place where the client is. So if you accept a client from outside your own state, it would be wise to check with the licensing board in that state for the rules and regulations with which you must comply and to determine if you must be licensed in the state in which the client resides.

DK: To help our members do this, a complete list of counselor licensing board websites is currently available on the ACA website at

JB: My first priority for rescue from the sinking ship would be the section dealing with informed consent (A.12.g.). If we are conscientious about being ethical, we need to do a good job of clearly defining for clients the pros and cons and the limitations and successes of the use of technology. Also, counselors often fail to realize that when they provide services utilizing technology that they are not just talking about potential clientele from across the hall or across the city, but across the nation and across the world. It is easy to neglect language differences, cultural differences and time zone differences that come with having the world at your cyberdoorstep.

DK: In our sinking ship scenario, what third new ethical statement revolving around technology would you rescue?

JB: One I find that a lot of people haven’t thought about yet is A.12.d. (“Access”), which focuses on accessibility issues. Oftentimes when counselors have thoughts about accessibility, the focus is on the important need for lower income families to have access to computers and other technology. But there is another critical arena that needs to be considered: the need for clients, students or supervisees with a disability to utilize our technology-related services. For example, individuals who have a visual disability may not be able to distinguish colors on a screen or even see the screen at all.

DK: Does the issue of technology accessibility for those with a disability include compliance with the Americans with Disabilities Act?

CM & JB: (Simultaneously) Absolutely!

CM: ADA requires that counselors, counselor educators and supervisors provide reasonable accommodations so that a client, student or supervisee with a disability can see the computer screen, use the keyboard, utilize dropdown and other types of menus and, in general, be able to access any of our services. The federal government’s website for complete information on ADA requirements is

JB: A great resource for determining the accessibility of an ACA member’s website or other website is Web Exact. The web address is

DK: The new technology subsection on World Wide Web sites (A.12.h.) has many important ethical imperatives, including the need to verify the identity of a cyberclient. Why is that important?

CM: For the purposes of confidentiality, it is important to know that the person you are communicating with at any given time is the same person with whom you obtained informed consent and with whom you established a counseling relationship. In other words, you need to know that the individual at the other end of the cybercounseling is your actual client and not a parent, partner, friend or hacker.

DK: A second reason for establishing client identity right from the start revolves around the issues of suicide and homicide. What if a client gives you an alias and then at some point tells you that they are going to kill themselves or someone else? If all you have is an alias and false contact information, the ambulance, police or other responsible party cannot respond to protect a life.

JB: A final reason for establishing client identity is that minors may seek counseling without their parents’ knowledge and therefore may pose as adults. It may be both an ethical and legal violation to provide services to a minor without parental permission, and the responsibility lies with the counselor to ensure that the client is old enough to give informed consent.

DK: How can you verify the identity of clients when you cannot see them?

JB: The counselor and client can create and exchange a confidential password at the beginning of a session.

CM: You can also set up a webcam with the client. Most computer stores can get you set up fairly inexpensively.

DK: The technology section in the ethics code talks about the need to use encrypted websites and e-mail communications whenever possible.

JB: We don’t want to break confidentiality by having a hacker break into our cybercounseling and communications with clients. Encryption is not as difficult as it sounds and is cost-effective.

DK: Do you have any resources or websites for counselors to learn how to encrypt?

JB: There is an excellent article titled “How Encryption Works” at

DK: Another new technology-related ethical imperative is that counselors must now strive to provide website translation capabilities for clients who have a different primary language. Are there any web resources to assist counselors in these efforts?

JB: I would encourage counselors to check out

DK: At this point our readers may be feeling that we have added more technology-related ethical imperatives than they can handle. How would you respond to a professional counselor who says, “This is overwhelming. I have a degree in counseling, not information technology. I can’t do all of this stuff.”

CM: The purpose of the new technology statements in the revised Code of Ethics was to inform, not to overwhelm.  Standard A.12. is meant to be educational, visionary and inspirational. It therefore outlines areas that professional counselors need to learn about if they choose to utilize technology in their direct services, teaching or supervision.

JB: There are many resources available to help educate counselors and counselor educators about incorporating technology into their practice, teaching and supervision. The newly revised ACA Ethical Standards Casebook by Barbara Herlihy and Gerald Corey (available at or 800.347.6647 ext. 222) gives helpful examples covering each of the points in Standard A.12. NBCC (National Board for Certified Counselors) provides a training program that leads to the credential of distance credentialed counselor ( Employee assistance programs are fast becoming experts in Internet counseling and can be excellent resources.

DK: ACA has a number of resources available in addition to the ACA Ethical Standards Casebook. The second edition of Cybercounseling & Cyberlearning: Strategies & Resources (available at or 800.347.6647 ext. 222) and the online continuing education course “Cybercounseling: Going the Distance for Your Clients” (from, click on “Resources” and then “Professional Development” for a list of courses) are both excellent guides for online counseling and distance learning. And of course, Larry Freeman, the ACA manager for Ethics and Professional Standards, provides personal attention to your specific needs and questions at or 800.347.6647 ext. 314.

Next month: Obligations for protecting the confidentiality of the deceased

Letters to the editor:

Understanding passive aggression

Loriann Hoff Oberlin

Ben complained that he was passed over for promotions. His boss said, “You don’t seem to be able to handle the responsibility.” But Ben complained more, and the boss finally gave him a small project to work on as a chance to show his abilities.

This project, unbeknownst to Ben as the test case, sat on his desk collecting dust. When the boss complained that he didn’t have it on time, Ben replied, “You didn’t tell me when it was due. And besides, I had to finish my other work, too.”

Inside, Ben was pleased he got back at the boss by making him unprepared for a meeting. But guess who still didn’t get a promotion? Well, of course, Ben, who attributed this to his boss’s incompetence rather than his own.

With lack of action, Ben created a problem, felt like a victim and got back at his boss. Rejection, resentment and revenge all stemmed from doing nothing.

— Excerpted from Overcoming Passive-Aggression by Rep. Tim Murphy and Loriann Hoff Oberlin (2005)

In many offices, schools, homes or other settings across the country, people who don’t fulfill ordinary expectations or obligations in their given roles annoy us to no end. Very often, they have a handy alibi, the proverbial excuse, which causes many of us to offer them “free passes.” We tend to accept, smooth over or excuse their behavior as they shirk responsibility for their actions and often for their covert anger. Only over time do we catch on to the pattern of indirect, incongruent, subtly manipulative behavior. We fall into this unproductive pattern — often called passive aggression — because we may misunderstand the core needs, irrational fears or things avoided, and at the same time fail to recognize how we (and others) enable people to hide anger.

If you come into regular contact with someone who fits this profile, particularly if you are trying to work with or help this individual, the first indication that something has gone amiss is that you feel stalled, blocked or even controlled. You feel the other person’s frustration vicariously. Unlike exploders, whom we recognize easily, anger concealers disguise their true feelings because they have so often been programmed to keep frustration and anger at a distance or project it onto someone else. When they were growing up, they may not have been allowed to say “I’m mad” or they may have been chastised for asserting themselves, even with “I statements.” Most likely, they were blamed and learned to do likewise.

With no constructive outlet for unsettling emotions, feelings go underground, emerging only when the build-up becomes too intense. Still, the angry person cannot embrace anger but discharges it through:

  • Sarcasm, criticism and blame
  • Chronic irritability and entitlement
  • Negative nonverbals (sighs, angry looks)
  • Self-destructive or addictive behavior (eating disorders, substance abuse)
  • Ambivalent, oppositional stances (mixed messages, defiance, “getting back”)

To a certain extent, we have all acted in a passive-aggressive way at one time or another. However, the persistent pattern of inactivity and shying away from active problem solving leads to larger problems in relationships, academic success, career progression or personal happiness. When passive aggression moves from being a temporary state to a permanent or semipermanent trait, it’s time to really understand how the behavior became rooted and how to help eliminate it.

Touching upon one’s childhood memories of anger leads to the pivotal awareness needed to turn around passive aggression. The people our clients grew up with were their first relationship lab — installers of their buttons. How was anger managed or mismanaged? What was the result when family members showed anger? Did it solve problems or make matters worse? Were there healthy outlets for expressing anger?

In many families where anger secretly lurks, children never grow beyond sugar-coating negative emotions. Thus, they remain vulnerable to reactivity in adult relationships because they lack an assertive skill set to help them cope against stressors. They protect themselves from anger by using any number of defense mechanisms, most notably blaming, denial and projection.

As “negativistic” was added to the literature, Theodore Millon and Roger D. Davis wrote in Disorders of Personality: DSM-IV and Beyond (1996) that many passive aggressors felt they had been “replaced” by a younger sibling and robbed of their due, thus acknowledging strong feelings of jealousy and resentment. But these individuals couldn’t risk being direct with mom or dad and possibly losing favor, so their new sibling became an easier anger target. Throughout life, these individuals may seek approval, yearn for independence yet feel dependent, avoid responsibility and feel powerless, fearing they’ll never get it right. In short, they remain rather childlike — one of the types of passive aggression my co-author Rep. Tim Murphy (R-Pa.) and I identified in Overcoming Passive-Aggression.

Other types we identified may look more controlling or manipulative, with a core need to have the upper hand, push people’s buttons and still manage to keep responsibility at bay. They also fear and avoid cooperation, competition or risks and confrontation. They may be the first to claim, “I’m not angry,” yet their behavior sends the powerful and incongruent message that they indeed are very angry.

Two other anger-concealing types include the depressed/walking wounded and the self-absorbed. Both struggle with self-esteem. Each type drives others away in a distinct way: one by whining and seeing life as half-empty and the other by becoming a legend to themselves, ingratiating, acting like the superstar and displaying little to no empathy for others.

Passive aggressors quickly see others as authority figures to resist. So respond carefully, and teach clients who experience passive aggression to do likewise. If you take away an angry person’s freedom of choice, you might cement the unproductive behavior even more. Anger concealers are masters of the double-bind and placing others in no-win situations. And they are much more skilled at all of this than the average person. If anyone accepts and holds their anger for them, concealers will be happy (even relieved) because they have escaped frustration, even while getting it churning in someone else. With anger concealers:

  • Listen without argument
  • Reflect what they say while avoiding interpretation
  • Offer empathy informed by the core needs
  • Model assertiveness with “I statements” and show respect

Don’t talk to the person’s anger; instead talk to the resolution of any problem at hand. More specifically, with controlling or manipulative anger, show that you are trying to get on their side. Channel the vain person’s strengths for everyone’s benefit (trying to ignore ingratiating, annoying behavior), and reinforce responsible steps that the depressed and/or childlike type may take. Remember, theses individuals vacillate between the polarities of independence and dependence as well as activity and passivity, as Millon and Davis explained. Shift from problem-focused to solution-focused thinking.

The term passive-aggressive has grown into everyday use since its earliest inception during World War II. Many well-regarded clinicians and researchers such as Scott Wetzler, Leslie Morey and Lorna Smith Benjamin believe it was a mistake to relegate passive-aggressive personality disorder to the DSM-IV-TR appendix. Remain informed about the diagnostic criteria and traits because you may see this behavior often in clinical practice, schools, offices, homes and relationships. Recognizing passive aggression and understanding how not to enable it are key pieces that help all of us lead more direct, congruent and happier lives.

ACA Career Center resources

Amy Reece Connelly

This month’s column is a bit of a potpourri: a wrap-up of the series on web resources and some announcements about new resources and upcoming programs.

Online applications

For the last two months, this column has examined some of the online tools available for job searches, including strategies for identifying appropriate counseling jobs. After you have found positions in which you’re interested, here are some reminders for your application:

  • Follow the directions outlined in the advertisement for applying for the job. Think of this as your first real test with this employer.
  • Proofread submitted materials carefully. Spelling, punctuation and grammar always count — even if you’re submitting an application online. Double-check to make certain your e-mail address and phone number are correct.
  • Make your materials scannable. The easier it is for an employer to find the information he or she is looking for on your resume, the more likely it is that you’ll be screened into the pile of finalists.
  • Use key words. Many organizations now use scanning technology to review applications. If specific terms and words are used in the advertisement to which you are responding, make certain that those words show up in your cover letter and resume. Some people have effectively employed a “key word” category in the body of their resumes, listing every term (theory, technique, etc.) imaginable. This can be particularly helpful to candidates who post their resumes on a job board, because they can be picked up in key word searches by employers using the site.
  • Cut and paste your resume for online applications. Make certain to use the correct formatting codes when you create your resume, or you could have a real mess on your hands when you paste.
  • Follow up. Check the status of your application. Showing interest in the position can yield interest in you on the part of the employer.

ACA partners with

The American Counseling Association is pleased to announce a new partnership with to bring you the ACA Job Center, an enhancement to our Career Center page.

The ACA Job Center has been designed to help counselors find nationally advertised, (mostly) nonacademic positions more easily. ACA staff members Martha McIntosh and Don Kenneally have spent numerous hours designing the site and refining search parameters that appropriately capture professional counseling positions for several practice areas. We will continue to tweak the system as we receive feedback from users, so don’t hesitate to send us your suggestions. This is your job search tool, and we want to make it work for you.

To access the ACA Job Center, go to our website at and click on “Career Center.” Look for the ACA Job Center logo on the left-hand column of the page.

‘ACA Preferred’ still a top resource

When you’re checking out the new ACA Job Center, don’t forget to check the “ACA Preferred” listings. These are positions that are advertised in Counseling Today; they’re available online at the top, left-hand corner of the Career Center page as “Opportunities.” These listings are still one of the top resources for academic positions in counseling and counselor education.

Just remember, as we have discussed over the last several months, while the Internet is an excellent tool in your job search, it should never be used to the exclusion of other resources, particularly networking and direct contact.

Looking ahead to the convention

Believe it or not, the 2007 ACA Convention in Detroit is less than six months away. As in the past, the Career Center will be available as an onsite resource in the Exhibit Hall. This is a value-added program available to all registered attendees of the convention.

Of particular interest to both job candidates and employers is the interview program. If you think you might participate as either an employer or a candidate, e-mail and indicate your name, institution (if you are an employer), position and contact information. It costs nothing to register and helps us with our advance planning.

Searching for supervision success

On a related note, this year’s convention will feature a special series targeting graduate students and new professionals. One of the programs will address supervision. If you have fulfilled your supervision requirement in a unique way, we want to hear about your approach! Please e-mail

Amy Reece Connelly is ACA’s manager of Career Services. Contact her via e-mail at Telephone consultation is available to ACA members on request. Letters to the editor: