Monthly Archives: August 2008

Back to the future of counseling

Brian S. Canfield August 1, 2008

One of the things I enjoy most in my role as American Counseling Association president is the opportunity it provides to listen to and learn from counselors around the country. I can confirm that counselors, reflective of our larger society, are a diverse group of people who hold a variety of opinions on various social and professional issues. Counselors cover the full political spectrum from liberal to conservative. And with rare exception, I have found my colleagues around the country to be both thoughtful and independent in their thinking.

Any notion that there is a consensus or particular social or political bias among counselors as a group is a convenient or inconvenient fiction, depending on one’s own personal perspective and agenda. I know this to be true from conversations I have had with hundreds of professional counselors nationwide, most of whom have been very open in sharing their opinions with the ACA president.

What I have found is that professional counselors do share a desire to help others. As counselors, we want to play a positive role in the lives of our clients. This is the essence of the counseling profession. Philosophically, we draw from the work of many innovative and brilliant minds, both past and present. Some names, such as Parsons, Rogers and Carkhuff, are widely know; others, less so. We continue to be enriched by our growing body of knowledge and practice.

Despite all we have accomplished in our brief time as a profession, we must occasionally remind ourselves that the profession and practice of “counseling” cannot be all things to all people. It is not a panacea for the human condition. Counseling does not offer a path to salvation or enlightenment, which is the domain of religion. Counseling is a poor substitute for political and social activism, which is essentially the realm of politics. Should we as counselors attempt to emulate and replicate the endeavors of psychiatry and psychology, emphasizing a pathological view of human behavior — a concept that has dominated Western thought in the “behavioral sciences” for well over a century — we will do so poorly and fall short of our potential.

As we have grown and struggled to define ourselves, several themes have emerged. These include the value of respecting the rights and dignity of all people, narratives about issues of social justice and a heightened understanding of cultural diversity issues. Newer areas of interest and passion are beginning to emerge as well. Issues such as “health and wellness” and “creativity” are gaining increasing interest among counselors who wish to see these concepts earn greater prominence in our professional consciousness. I’m confident that many members of our profession will continue to explore these and many other important topics and areas of counseling practice.

Although pursuit and exploration of these issues are worthy in their own right, they only have relevance to the profession of counseling to the extent that they expand our ability to work more effectively with our clients. As counselors, we make a difference one client at a time. The essence of professional counseling is this helping relationship; it’s why we exist. It is our professional “calling card” and our pre-eminent “signature product.”

As a profession, we have an opportunity to make a unique contribution to society. If we deliver, we will further evolve into an established and valued profession. If we fail, we will become increasingly irrelevant and our helping role will be assumed by others who offer society a better promise.

The future of the counseling profession and the American Counseling Association is inextricably linked. Without ACA, many groups will remain that offer services and utilize the term “counselor” in their title, but there will be no “profession of counseling.” However, tens of thousands of professional counselors recognize the critical importance of membership and involvement in one’s professional association. As such, we must actively recruit our colleagues who are not currently members into ACA and its divisions and branches. This is the only way to ensure a positive future for our profession and guarantee our capacity and role to help others.

Washington Update

Scott Barstow, Christopher Campbell and Peter Atlee

On Feb. 4, President George W. Bush released his final budget proposal — a record $3.1 trillion spending plan — for Fiscal Year 2009, spelling out his fiscal priorities and recommendations for Congress to consider in developing its own budget this year. Bush’s proposal would provide the biggest increase in military spending since World War II to fight the wars in Iraq and Afghanistan, while squeezing billions of dollars out of federal health care programs and freezing or cutting most domestic agencies to below FY 2008 levels. As part of the proposal, the Bush budget calls for making permanent — at a cost of $635 billion over five years — the 2001 and 2003 tax cuts weighted toward the most well-off Americans.

The budget proposal would freeze Department of Education (ED) spending at $59.2 billion in FY 2009. While some programs within ED’s budget would receive increases — notably, Title 1, Reading First, a new voucher program called Pell Grants for Kids, IDEA and Pell Grants — these would be paid for with $3.3 billion in cuts to other programs. Some of the spending cuts include a substantial decrease for Career and Technical Education ($1.3 billion), a large reduction to Safe and Drug-Free Schools ($150.5 million) and the elimination of the Elementary and Secondary School Counseling Program ($48.6 million), Mental Health Integration Grants in Schools ($4.9 million) and Federal Supplemental Educational Grants ($757.5 million). In total, 47 ED programs would be eliminated outright. Education officials stated the cuts and eliminations were in programs deemed “ineffective” or that had “accomplished the goals they were created for.”

The president’s budget also calls for deep funding cuts for many health care programs. Discretionary spending for the Department of Health and Human Services would be cut by nearly $2 billion, which will affect behavioral health programs. Funding for the Substance Abuse and Mental Health Services Administration would be set at slightly more than $3 billion for FY 2009, a 14 percent cut from last year’s funding levels.

The major entitlement programs, Medicare and Medicaid, would be cut by $178.2 billion over five years. While most of this $178.2 billion would be used to pay for increased defense spending and tax cuts, part would be used to increase funding for the State Children’s Health Insurance Program (SCHIP) by $19 billion during the next five years. The SCHIP increase is a step in the right direction, but members of Congress want to increase SCHIP spending by $35 billion over the same time period and have reacted negatively to the proposal to cut one part of the social safety net to patch up another.

On Medicare, the president’s proposal consists almost entirely of cuts, except for subsidies for managed care companies; the proposed budget would keep in place the billions of dollars of government overpayments to private sector Medicare Advantage plans.

Congressional Democrats quickly attacked the president’s budget, and the proposal also elicited concerns among some Republicans. Congress will now begin putting together the budget that it will use in configuring government spending for the next fiscal year. The outcome of deliberations concerning congressional budget targets and the budgetary rules Congress chooses to live by will predetermine the fate of this summer’s appropriations battles. The American Counseling Association is working within several coalitions to push Congress to adopt a more responsible budget framework.

Regulatory issues add to Medicaid/SCHIP fight

In December 2007, Congress passed legislation to provide enough funding to maintain current enrollment in the SCHIP program through March 2009. The bill also placed a six-month moratorium on Medicaid regulations issued by the Bush administration this past year, halting implementation of regulations that would have significantly restricted school-based services, rehabilitation coverage and targeted case management service options under Medicaid, among others. As one example, the administration wants to prohibit states from covering individuals over 250 percent of the federal poverty level (FPL) unless they have first covered 95 percent of those below 200 percent of FPL — a goal most experts have deemed impossible to attain.

The regulatory issues add fuel to already heated disagreements over Medicaid and SCHIP policy, but some analysts are hopeful that with states looking down the barrel of onerous restrictions, increased pressure on members of Congress may help break the logjam. The Medicaid/SCHIP regulatory issues will make this spring an even busier season for health care policymakers.

Superbill gets super response

Robert J. Walsh and Norman C. Dasenbrook

We were surprised and gratified by readers’ response to the information about using a superbill in our August 2007 column and have received almost 100 requests to date for examples of our superbill.

With the superbill option, the counselor can collect the fee at the time of the session. The client then sends the superbill directly to his/her managed care or insurance company to be reimbursed. Many insurance companies accept the superbill for reimbursement, but some may not.

Q: I have a question about a certain managed care company. I recently got on their panel, but they keep referring EAP clients to me. I don’t really understand the difference between an EAP client and a regular counseling client, other than the fact that I don’t get paid nearly as much to see the EAP clients. Is this sort of a scam, or is there something I don’t understand about this system? How can I get paid the full counseling fee for seeing these clients?

A: First, let’s start by defining terms. EAP stands for employee assistance program. Most major employers offer EAPs as a benefit to employees and their families. EAP is essentially a counseling assessment and referral service paid for by the employer. Employees can confidentially access counseling services (or be referred by the employer) for mental health, marriage/family, substance abuse, elder care, legal or financial issues at no cost to the employee.

In the past few years, managed care companies began offering EAP services bundled in with the insurance package. Most of these bundled packages offer a few “no cost” sessions for the insured, meaning they do not have a copay or fees applied to their deductible. The insured can see any counselor, not just the EAP counselor, and be covered by the managed care company to use the EAP benefit. Typically, EAP session reimbursements are at a slightly lower fee than the regular insurance contract rate. However, after the EAP sessions, and if clinically appropriate, the counselor can continue treating the client and access the regular insurance benefit.

We don’t recommend signing up with a couple of managed care companies due to their horrible EAP rates (their regular fees are not much better) and the extensive paperwork involved. Contracts for getting on managed care panels can include participation in both the EAP and regular insurance program. Read the contract before you sign it. You can choose not to participate in the EAP and still be a provider. If you decide not to accept EAP clients, look at your contract and see how to terminate participation. Don’t, however, just refuse to accept EAP clients, because you have a signed agreement, and they could come back and hold you to the letter of the law.

Q: I am a therapist in private practice. What is the appropriate time frame for sending a termination letter to a client who has dropped out of therapy but has not officially notified the therapist that they do not wish to continue?

A: We don’t know of any standard procedure that addresses what to do should a client “drop out” of therapy. The 2005 ACA Code of Ethics addresses termination and referral issues in Standard A.11. However, there is no exact reference either to method of contact or time frame should a client discontinue therapy without notifying the counselor.

Still, while there are no hard and fast rules, there are other considerations. In the Health Insurance Portability and Accountability Act documentation (or in the informed consent document), clients should have indicated how they wish to be contacted. If they did not give you permission to contact them at home, then no letter can be sent.

If clients have granted you permission to contact them at home, then a phone call or letter advising them of the missed or canceled appointment and inquiring if they wish to reschedule would be appropriate. If, in your clinical judgment, the client needs ongoing counseling or you think a referral to another professional is appropriate, then you can send a certified letter outlining your concerns (again, if HIPAA compliant).

We will be presenting our workshop “Starting, Maintaining and Expanding a Successful Private Practice” on Dec. 1 in Illinois. The Illinois Mental Health Counselors Association is sponsoring the workshop. For more information, contact IMHCA at 800.493.4424 or visit www.imhca.org/.

Robert J. Walsh and Norman C. Dasenbrook are coauthors of The Complete Guide to Private Practice for Licensed Mental Health Professionals (www.counseling-privatepractice.com). ACA members can e-mail their questions to walshgasp@aol.com and access a series of “Private Practice Pointers” on the ACA website at www.counseling.org.

Letters to the editor:
ct@counseling.org

Military intelligence

Angela Kennedy

It’s not uncommon for children to act out or for teens to test boundaries when a parent is away from home. The stress caused by the absence of a parent is only amplified for children of military personnel and is further exacerbated when that parent is deployed on a military mission, especially to a hostile zone.

What role can school counselors play in addressing the needs of these children? How can school counselors help students cope not only with a parent’s temporary absence but also the fear that their parent could be injured or killed in a war?

“In this unstable and transient era that we are living in, we have to, as school counselors, be much more intentional about teaching and facilitating resiliency issues, especially to the children of military members. We have to be preparing kids to be resilient,” says LaVerne Jordan, a counselor educator at Denver Seminary and a member of the American Counseling Association Task Force on Promoting Resiliency of Children in Military Families. Beyond the threat that their parents may deploy to a combat zone, she adds that children of military personnel often have some very specific issues related to relocating so frequently and never truly putting down roots.

One ACA member who understands these issues firsthand is Jackie Harriman. The self-proclaimed “Air Force brat” served in the National Guard and was deployed to Saudi Arabia. In her civilian life, she was a school counselor and a former youth coordinator for the Colorado National Guard. Today she is married to an Army soldier and continues to be employed by the federal government.

As an elementary school counselor in Colorado, Harriman worked with a high concentration of children who had parents deployed to Bosnia. Herself familiar with the emotional cycle of deployment, she helped students and families to feel supported and stay on track. Although the conflict in Bosnia took place more than a decade ago, Harriman believes the group counseling session techniques she used are timeless and can be implemented with today’s school-age military dependents.

Emotional cycle of deployment

Family members of mobilized military personnel experience a gamut of emotions. By being aware of this cycle and the emotional ramifications of each stage, school counselors and educators can lessen the impact of separation on these students and identify issues before they reach a crisis point.

Children have different reactions to a parent’s deployment depending on their age and the coping skills of the family before the military assignment, Harriman says, but certain behaviors are indicative of separation anxiety or family stress, including:

  • Absenteeism
  • Isolation/withdrawing from family or friends
  • Depression
  • Acting out
  • Poor grades

The emotional cycle of deployment consists of four basic stages, each with its own issues to be faced by deploying military members and their families.

Pre-deployment

The military member is notified of the assignment at this stage. From this point, it could be months or the matter of a few short days before military personnel must leave their families. Harriman notes that, at this stage, children and teens may:

  • Express anger toward the parent who is leaving
  • Protest and push boundaries
  • Become clingy
  • Withdraw or disengage from the deploying parent because, knowing the parent is leaving, spending time with him/her is too difficult

Deployment

This stage takes place during the first few weeks of the parent’s absence, as the family adjusts to new routines. Children can find this stage especially difficult, Harriman says, because things seem disorganized and the stress level is high. “The family is adjusting and the kids are sensing that turmoil,” she says.

This is the time for counselors and educators to take note of dropping grades or incomplete homework assignments, Harriman says, as they may be a tip-off to larger problems. “A lot of kids will take the lead of the at-home parent and will look to them for signs,” she says, adding that if the at-home parent is depressed, then the children also may become depressed.

In the case of teenagers, she says, they may feel obligated to take on more responsibility to care for their parent and to step into a more adult role within the family. This blurred line of authority can cause problems between the parent and the teen.

Sustainment

Fortunately, after the first month, many families find their routine again. At this point, Harriman says, the family typically starts to stabilize.

Reunion

The final stage of the cycle can actually be the most difficult, both for the family and the returning service member, Harriman points out. “Sometimes the parent who was deployed returns and feels unneeded within the household. They have to ease their way into the role they once had, and kids sense that stress, so there may be some testing or playing one parent against the other,” she says.

As the positions of authority are being readjusted, the children may need time to “warm up” to the returning parent, she says. In a worst case scenario, the family may have to deal with a loved one returning home with post-traumatic stress disorder or a physical disability. Those cases offer their own challenges, Harriman says.

Communication is key

To assist these children and teens, school counselors and educators must first be informed of the deployment, which is often not brought to light until after the student is in crisis.

“One of the problems we see is that parents often don’t tell the schools about the deployment,” Harriman says. “Communication between the parents and the school is really important. Schools want to help as long as they know what’s going on. That’s an area that needs improvement.” She suggests that teachers and counselors ask students if they have parents in the military and then contact those parents directly to establish open lines of communication about current or future deployments. Teachers and counselors can then monitor those children more closely and be better prepared for early interventions if red flags arise.

Additionally, having this information provides school counselors the opportunity to make one-on-one contact with these students or to establish group sessions specifically for military students, which is what Harriman did for her elementary students. Once a week during school hours, she met with all the students of deployed military personnel. The group sessions allowed her to more closely monitor their emotions, while providing the students with activities that helped them track the time until their parents returned.

“I taught them coping skills, relaxation techniques and talked to them about responsibility and viewing the family as a team,” she says. “I would ask them, ‘What have you done this week to help your mom or dad?’ I tried to get them to think that we are all in this together.” The students were also encouraged to talk about the country where their parent was deployed, often bringing in items for show-and-tell.

Harriman would ask students about their initial reaction to hearing the news of their parent’s deployment. “What was really interesting was for all the kids to see that their feelings were normal and other kids felt those emotions too,” she says, adding that many of the students felt angry at first. “Then they felt guilty about feeling angry, but by talking about those emotions, it allowed them to relate to each other and also helped them find other, more positive ways to cope with their emotions instead of internalizing or acting out.”

Every week, Harriman presented a different activity for the students to work on and share with their families. They wrote letters and collected items for a memory book so they would have plenty to talk about when their deployed parent called or returned home. Keeping a journal or scrapbook helps students with the time line for a parent’s return and also fills in the gaps of what the deployed parent missed, Harriman says. Older students may want to keep a video journal or blog for a parent who is deployed abroad.

The group also helped Harriman connect with the at-home parents so she could ensure they were getting the support they needed. She points out that school counselors should learn about military family support programs in the area so counselors can refer the families for additional care. Most military installations have family support centers, mental health clinicians and school liaison officers to help military parents and students through times of transition.

Other considerations

Harriman says school counselors have some differences to consider depending on if the child’s military parent is active duty or in the Reserves. Oftentimes, she points out, active duty military families will not have extended family members nearby, while members of the Reserves or National Guard are much more likely to be stationed in their hometown. Regardless, school counselors can encourage military families to identify friends or family members in the area who can help out and take some of the stress off the single parent.

Another consideration is that those in the Reserves and National Guard are “suddenly military” when deployed. Leaving their civilian jobs, even temporarily, can cause great financial stress on their families. Additionally, the family may be a long distance from the nearest military base and unable to easily access government-provided assistance.

Says Harriman, “Part of the culture (of military families) is ‘I’m strong and I can pull myself up by my bootstraps and do this on my own’ — until they hit a crisis and then need real help. We need to offer preventative measures to these families to help them deal with things before issues arise.”

Harriman established relationships by calling each parent weekly and explaining what the students had done in the group meeting. “Over time and continuing to do that, I started to become a regular voice to the parents, and they felt comfortable reaching out to me for things,” she says. “School counselors are really busy people, but a five-minute phone call to the parents of those children can really make a difference.”

Harriman suggests school counselors be proactive about reaching out to military families first, perhaps by hosting a potluck lunch at the school or an evening meet-and-greet. Counselors may also want to invite representatives from military family support organizations to PTA meetings to talk about the effects of the emotional cycle of deployment on families and children.

Harriman says it’s also beneficial for counselors to try to stay in contact with the deployed military member. School counselors can ask the parent or caregiver at home to leave stamped, self-addressed envelopes with the school so newsletters, artwork or positive progress reports about the student can be mailed to the deployed parent.

Because of the itinerant nature of military life, mandatory classes and graduation requirements are sometimes another issue for these students. Many times, Harriman says schools are very rigid in their requirements, but some flexibility may be in the best interest of the military child.

Furthermore, she says, school staff and administration should remain neutral as far as expressing personal views on military involvement and politics. “When you are not connected to the war, you have opinions about it. I don’t want to attack the civilian population, but I think there are a lot of people in the civilian world who don’t understand what these families are going through,” Harriman says. “This isn’t the same as a business trip. This is a trip where people are getting shot at. There are totally different stressors. The war itself is so volatile and it’s like the elephant in the room that no one wants to talk about, but these families are living it day after day. It’s not about special treatment for these kids but just leveling the playing field.”

Deployment activities for students

The North Carolina Public School System, in conjunction with the State Board of Education and the Department of Public Instruction, has developed a website dedicated to supporting military children. At www.ncpublicschools.org/militarysupport, educators can find several suggestions for classroom or group counseling activities. Here are just a few:

  • Put together a “Proud to Be a Military Kid” bulletin board and encourage students to display pictures of military family members.
  • Arrange a field trip to a nearby military base or training facility.
  • Make a memory book or calendar reflecting positive thoughts and actions while a loved one is deployed.
  • Write cards or letters to the deployed family member.
  • Have a deployed family member pen pal program. Ask parents to send postcards, maps, stamps, coins, menus or information and articles that describe the foreign duty station, port and so forth, and then use them for lessons.
  • Turn a shoebox into a deployment time capsule. At the beginning of the deployment, fill the box with items such as a piece of string as long as the child’s height, a tracing of the child’s hand or foot and a list of the child’s favorites (song, candy bar, TV show, toy, etc.). Open them when the deployed parent returns to measure changes that have occurred.
  • Ask more experienced military students to assist those students who have little or no experience with deployments.

— Angela Kennedy

Additional resources

  • The National Military Family Association offers two free PDF downloads, “Support to Civilian Schools Educating Military Children” and “Working With Military Children — A Primer for School Personnel,” both available at www.nmfa.org.
  • Military Teen on the Move, www.defenselink.mil/mtom, is a support and helpful tip website for teens and tweens dealing with moving … again.
  • The Department of Defense Military Student website, www.militarystudent.dod.mil, offers an abundance of information, tools and resources to help parents, leaders and educators meet the unique needs of military children. “The Educator’s Guide to the Military Child During Deployment” can also be downloaded for free from the website.
  • Sesame Workshop, the nonprofit educational organization behind Sesame Street, has partnered with the New York Office of Mental Health and
  • Military Child Education Coalition to develop “Talk, Listen, Connect,” an outreach initiative to help young children of members of the U.S. Armed Services, National Guard and Reserves cope with the feelings, challenges and concerns they experience during various phases of deployment. Call Military One Source (www.militaryonesource.com) at 800.342.9647 for a free DVD to use with students ages 3-5.

— Angela Kennedy