Monthly Archives: December 2012

The anniversary is over, but the celebration continues

Richard Yep December 1, 2012

Richard YepAs we close out our yearlong celebration of ACA’s 60th anniversary, I want to share some meaningful moments that took place along the way. I was fortunate to meet up with Robert Shaffer, ACA’s very first president. Well into his 90s, Bob was easily able to recall the years that led up to ACA’s founding, who played roles in the association’s creation and what challenges he faced as our president in 1952-1953.

Then there was a decision by Brooke Collison (ACA president in 1987-1988) to return to the classroom, but this time as a visiting professor in Kenya. He and his lovely wife Joan chose to reach out and share their knowledge, compassion and caring with students and communities halfway around the world. Brooke has been blogging for ACA about his experience at

Interacting with these two individuals reminds us that life not only goes on after you serve as ACA president but that it looks significantly better as well! You should know that many of ACA’s past presidents have gone on to serve the profession with distinction and their communities with great compassion. ACA is better because of our 60 past presidents.

One milestone of note during this anniversary year is that our membership increased each and every month. We now stand at more than 52,000 members and continue progressing toward our all-time high membership total (around 58,000 individuals back in 1991). I thank all of you for our growth.

During this 60th anniversary year, we also grew to eight professional counselors on staff. These fellow ACA members have made the commitment to work full time on behalf of the profession, and I am so pleased that they did. I believe their service in the areas of professional development, career consultation, research and public policy advocacy enhances what we do for members.

Although I don’t know what we will look like in another 60 years, I can tell you that 2013 will feature institutional growth, enhanced advocacy and services that are the result of your input. One example is that next month, we will launch a significantly improved ACA website. Our goal is to deliver the content you want in an easy-to-use and responsive format. Let me know what you think.

Have you registered for the ACA 2013 Conference & Expo in Cincinnati from March 20-24? The Super Saver discount deadline is Dec. 15! This event includes more than 400 education sessions and will again feature our pre-conference learning institutes (which require separate registration) and more than 100 exhibit booths. Our keynote speakers will be actress and advocate Ashley Judd and counselor luminaries Allen Ivey and Mary Bradford Ivey. This is one professional conference you absolutely want to attend.

As the year ends, I call your attention to those in need. At the professional level, I encourage you to consider a year-end donation to the ACA Foundation. Chaired this year by Courtland Lee, the ACA Foundation has been instrumental in assisting graduate students, providing help to “our own” in the form of the Counselors Care Fund and supporting ACA through the years. I know the ACA Foundation would appreciate your consideration, so please visit and give generously.

I also want to express my thanks for the 60 years of work that ACA members have done for their clients and students. You and those who came before you are what make this profession so special. The entire ACA staff wishes a 2013 full of peace, hope and prosperity for you and for those whom you serve.

As always, I look forward to your comments, questions and thoughts. Feel free to contact me at 800.347.6647 ext. 231 or via email at You can also follow me on Twitter: @RichYep.

Be well.

Laura Gallo: Doing what is best for students in a complex role

Jessica Eagle

This is the third in a series of school counselor advocacy stories that will run online as a counterpart to the school advocacy stories running in Counseling Today’s Counselor, Educator, Advocate column. To read the first post in this series, click here. To read the second post in this series, click here

Laura Gallo, a school counselor at Linn-Mar High School in Marion, Iowa recognizes firsthand the complexities in her profession. She has worked in challenging situations, such as with students who have abusive parents but refuse to leave their homes in order to care for their younger siblings. She has seen resiliency and self-advocacy in students who take on school leadership positions after experiencing bullying because of their sexual orientation. She has worked with students with learning disabilities who are so driven to succeed, they go above and beyond the regular workload requirements with very few accommodations, proving their immense capabilities.

As a professional school counselor Gallo has listened, encouraged, focused on strengths and created opportunities. She points out that school counseling advocacy work stems from having a visible presence in the school. She reaches out to students and is available when a student needs help. In many situations, she relies on her resourcefulness when needing to find students access to computers outside of the school or quiet environments for homework completion outside of a chaotic home. Gallo says this about being a student advocate.

“The many roles a school counselor plays can be overwhelming and sometimes confusing,” she says, “but keeping our role as an advocate at the forefront, helps us keep our focus. “Doing what is best for kids is always the top priority.”

A new view of evidence-based practice

Stanley B. Baker

(Photo:Wikimedia Commons)

Promotion of the evidence-based practice concept is widespread across the mental and behavioral health professions. Intrinsic motives include placing the well-being of our clients/patients/students at the forefront, desiring to discover and use the best practices available, and wanting to be respected as highly proficient professionals. Extrinsic motives include being eligible for insurance reimbursements, avoiding ethical and legal challenges, and saving one’s job from funding cuts or other negative employment decisions. Unfortunately, too few counselors either conduct research or read research findings. Although they may value research intellectually, many lack confidence in their ability to use research findings.

The responsibility for engaging in evidence-based practice falls primarily on counseling practitioners. Evidence-based practice requires application of practices for which the evidence was the product of rigorous scientific empirical studies — that is, outcome research. Outcome research is the domain and responsibility of trained researchers, who are usually employed in university settings. Therefore, counselor educators are included among those responsible for producing the evidence.

The corresponding responsibility for counselors is to be willing and able to locate and use evidence-based interventions. Consequently, the two concurrent challenges are 1) having counselor educators (outcome researchers) produce sufficient volumes of evidence and 2) training counselor practitioners to find, interpret and use the evidence. Ironically, the circumstances create a codependency.

Counselors are dependent on counselor educators to conduct the research and teach them how to find and use the evidence with confidence. Counselor educators are dependent on counselors to respond to training efforts enthusiastically, search for the evidence constantly, use the evidence appropriately and help the counselor educators to conduct the needed outcome studies. These challenges limit the range of interventions available to counseling practitioners.

Accountability and action research

Counseling practitioners who evaluate their local interventions can use the findings to improve their practices and to be accountable to their stakeholders. This accountability process involves action research as opposed to outcome research.

Action research focuses on generating local rather than generalized knowledge (as is the case with outcome research). There are numerous approaches to and definitions of action research, but the common theme seems to be that it is not outcome research. That is, the demand for attention to rigorous research design controls and inferential data analyses is often not a requirement in action research. Action research seems to cover all data collection activities that lead to findings that are useful for evaluating local programs. Goals for action research include acquiring useful local knowledge for program improvement, involving local stakeholders in the process, being open to the viability of a variety of data sources and anticipating that constructive actions/
decisions will follow the data.

Although action research typically is less rigorous and sophisticated than outcome research, the brunt of the responsibility for conducting the accountability process is also on counseling practitioners. Historically, counselors have been perceived as resistant to evaluation and accountability and needing to be coaxed or assisted in the process by counselor educators and local supervisors. This resistance was usually attributed to a number of supposed impediments, including a perceived lack of the requisite sophistication, insufficient time to do it, uncertainty about the value of the kinds of data being collected, the perceived cost of the process, uncertainty (and possibly fear) about how stakeholders would use the findings and a dislike of being evaluated.

Counselor educators share the accountability challenges with counseling practitioners. Counselor educators can and should address all the causes of resistance when training entry-level counselors. The evaluation/accountability competencies covered in the standards of the Council for Accreditation of Counseling and Related Educational Programs fall within the action research domain. Therefore, the ability to conduct action research to achieve accountability goals is not beyond the sophistication of entry-level counselors. Teaching the necessary skills and influencing appropriate attitudes about action research and accountability are important responsibilities held by counselor educators.

Linking evidence-based practice with accountability and action research

Evidence-based practice and accountability appear to depend on different research paradigms and focus on different viewpoints. While evidence-based practice is a product of outcome research findings, accountability activities employ action research methods. Evidence-based practice is synonymous with aptitude testing, having a focus on how previously collected data can be applied to future performances. On the other hand, accountability is akin to achievement testing. The focus is on past performance to seek evidence of how well interventions have worked. Therefore, evidence-based practice and accountability appear to be two different concepts, each of which is very important for the counseling profession but apparently difficult for counseling practitioners to do well.

My thesis is that the two concepts can be combined in a manner that might make it easier for counseling practitioners to be accountable and engage in evidence-based practice. The keystone of this idea is to view evidence-based practice more broadly than is currently the case.

As mentioned earlier, evidence-based practice is the product of rigorous, sophisticated outcome research studies. My view is that evidence-based practice can also be the product of local action research studies that are a part of the counseling practitioner’s evaluation/accountability function. If counseling practitioners are able to collect volumes of evidence that their local interventions work, then those data could also qualify as evidence to support their local evidence-based practice.

The typical format for outcome research is to conduct tightly controlled studies with random sampling from targeted populations, control groups and inferential statistical analyses. Often, these studies are not replicated, and the findings are generalized to a population similar to the one used in the sample. These samples and populations may or may not be similar to those in many local settings.

On the other hand, although local action research may be less rigorous, the samples and populations are indeed of interest to local counseling practitioners. And if the interventions are repeated and evaluated many times, evidence accumulates. Therefore, the action research paradigm provides volumes of relevant local data, as opposed to the findings of a single rigorous outcome study that may not always have applicable samples and populations.

To be clear, I do not intend to replace or diminish the value of outcome research. It is important to understand, however, that rigorous outcome research has its limitations as a source of evidence-based practice in the counseling profession. My goal is to add local action research data to the evidence-based practice information that counseling practitioners are already able to locate in outcome research publications.

Two examples

Two of the most common interventions are individual counseling and psychoeducational group interventions. How the action research framework can be used for evidence-based practice is described briefly for each practice.

Individual counseling: My recommendation for individual counseling is to apply the AB single-subject design to counseling interventions and to encourage and assist clients in engaging in self-monitoring between counseling sessions. Counseling goals would determine what behaviors are to be changed (for example, reducing the number of negative thoughts per day) and what attitudes are to be influenced (for example, rating one’s negative or positive affect about his or her job on a scale of 1 to 10). The clients would record the self-monitoring data. The data could be presented graphically, starting with a baseline and then continuing throughout the counseling process. The axes of the graph would be number of data-gathering points (horizontal axis) and points on the behavior or attitude scale (vertical axis). The evidence would be visible in the graphic representations of the self-monitoring process.

This process is clearly within the sophistication domain of entry-level counselors and could be used in a number of individual counseling interventions. The data could be accumulated over time to provide both accountability data and evidence of the
effectiveness of one’s practice.

Psychoeducational group interventions: I would recommend a pre-experimental pretest/posttest design for psychoeducational group interventions. Control groups are unnecessary in action research because multiple groups are presented with the same proactively planned interventions. Similar to the instruments that schoolteachers develop to test their students, practitioners can design instruments to assess knowledge and attitudes. Simulations can be established to assess acquisition of targeted behaviors. Pretest data can be collected before the intervention begins, and posttest data can be collected at the end of the intervention program.

Correlated t tests can be used to compare the pretest and posttest scores to determine if desired changes occurred. Although the correlated t tests require application of statistical knowledge, that knowledge is within the competency range of entry-level counselors.

Answering the challenge

In his 2009 critique of the state of published research in counseling journals and of the attitudes of counselor educators toward research, David Kaplan, chief professional officer of the American Counseling Association and a past president of ACA, called on the profession to be primarily engaged in evaluating the effects of our counseling interventions. I do not know if he was promoting outcome or action research, but both paradigms are applicable to answering his call.

Publication in the counseling journals requires outcome research studies conducted primarily by counselor educators. To meet Kaplan’s challenge, however, a larger volume of counseling practice evaluations likely need to be addressed via the action research paradigm — and done so by counseling practitioners.

It therefore behooves our profession to inform practitioners that action research is a road both to accountability and to evidence-based practice, and to encourage them to travel that road. It may currently be the road less traveled, but it does not have to remain so.



Stanley B. Baker is a professor of counselor education in the Department of Curriculum, Instruction and Counselor Education at North Carolina State University. Contact him at

Letters to the editor:

Counseling adopted clients: A Q & A with Kara Holt

Heather Rudow


In conjunction with National Adoption Month, which promotes the awareness of the need for adoptive families for children in foster care, Counseling Today spoke with Kara Holt about how to counsel adopted clients. Holt, an assistant professor in the University of Wyoming counseling program, is a member of the American Counseling Association, the Association for Child and Adolescent Counseling, the Association for Counselor Education and Supervision, the Association for Humanistic Counseling and the Association for Creativity in Counseling. She believes it is important for the adopted individual to understand his or her own unique story and for counselors not to pass any judgment until they have listened to and understood the client’s story.

Is there is more or less stigma for adopted children now? Why?

I do not think it is more or less as much as it is that the stigmas have changed. I think that adoption has become more commonplace in our society and that we do not often try to hide the fact that someone is adopted as frequently. However, I think that children who are adopted are often stigmatized [by mental health professionals] and given automatic diagnoses such as reactive attachment disorder without really getting to know the child.

 What are some do’s and don’ts for families with adopted children?

I think some of the do’s are to help the children understand their own unique story and learn how to integrate this into a coherent narrative of their life and sense of belonging.  It’s so important to celebrate the unique way that people create families. I think one of the don’ts, although very challenging, is to try to not take personally the struggles and resistance that some adopted children demonstrate.

What are some do’s and don’ts for counseling adopted clients?

I think it is essential to conceptualize the client within the framework of attachment dynamics, trauma and the effects that both of these have on brain development. It is essential to remain patient and remember the therapeutic power of safe and consistent relationships that involve a systemic approach. Remembering the difference between chronological age and emotional age is also key. Counseling should be geared toward the emotional and developmental age of the client, which is often younger than the chronological age. I would say it is important to not automatically label adopted children with a diagnosis without truly getting to know them and their experience and not to isolate treatment to only be between you and the client. I would also be cautious and remember that a behavioral change does not always equate to an emotional shift. This often takes time, and counseling can ebb and flow. It is also important to normalize [the client’s] experience and struggles. Often, adopted parents are reluctant to reach out for additional support and help.

Should parents be involved in counseling sessions with adopted children?

Absolutely, any time that this is an option.

What issues can the subject of adoption raise in clients? How about within clients’ families? What can counselors do to help?

This can often raise question surrounding belonging, abandonment and way to initiate and maintain healthy and supportive relationships. Families also experience anxiety about how to talk to their children about adoption and what language to use. Questions often arise about the open adoption, the status of the birth family or connecting with the birth family, and social situations. Counselors can help parents with activities that are developmentally appropriate to help them talk to children. Counselors can also help facilitate relationship-building therapies between parent and child and help serve as an advocate for the family. Counselors can also help parents understand the child’s behaviors and emotions within the context of the adoption experience that often includes some kind of attachment struggles even when the child was adopted at birth. Many times, parents do not expect struggles with an infant [adoption].


For more information, read Counseling Today’s March cover story, “Fitting together as a family,” which features an interview with Holt.

Alcohol screening and brief counseling interventions for trauma unit patients

Nathaniel N. Ivers & Laura J. Veach

Laura Veach offers counseling services to patients in a hospital trauma unit.

As I (Laura) prepare to see another patient, I read the quick details indicating he has an alcohol-related injury. His blood work showed an alcohol level of .16, two times the legal limit of intoxication. He fell off a ladder and has a mild concussion with a nasty cut above his swollen and bruised right eye. He probably won’t be here in the hospital trauma center long. He is in the “day” hospital and represents one of the 1,000 people we have seen for alcohol screening and brief counseling interventions in the past five years at Wake Forest Baptist Medical Center.

So, I walk toward him — toward hope that maybe, just maybe, this will become a memorable, teachable moment for him. And maybe, just maybe, this amazing set of professional counseling skills that I have acquired and honed over 30 years will be there for him in just the right way, at just the right time, to help him as he explores changing his risky drinking patterns. He is not diagnosed as an alcoholic, but he does infrequently overdo drinking and is assessed as a risky drinker.

My route takes me past the waiting area for the intensive care unit (ICU). At least 30 people are here, speaking in hushed tones. I know intuitively why they left their cozy family homes so early on a Saturday morning to assemble here in these sterile concrete hallways where there is nowhere to suffer silently under the harsh lighting. I am struck by the sheer force and heaviness of their worry and pain.

So many young faces are in this waiting area. They are here not for one of their own but for two: two teenagers, ravaged, lying in beds, surrounded by prayers and forever changed, the focal points of all the heroic efforts our highly specialized trauma surgeons and medical team can provide.

The trauma surgeon’s medical notes, written upon her initial exam of the teenage driver, rattle back and forth in my mind, like gravel pinging loudly in a tin can. They are reverberating words that cannot be erased or forgotten: “Skull fracture, severe.” The prognosis is dire.

I can imagine the pure, carefree, wide-open joy this 19-year-old felt the previous night as he entered that twisting curve, the wind in his face, and popped the top as he rode that powerful rocket into the night. Knowing he had such power at his fingertips, heightened oh so sweetly by those liquid kisses from that last ice-cold blue can.

Such total freedom — then.

Now, he and his rider, an 18-year-old friend, lie in tubes and plastic in the ICU. Their connection to this day is tenuous at best. Will this be a teachable time for any of the caring neighbors, the classmates, the church members, the community leaders, the parents? So little is spoken about the drinking.

Both the driver and his passenger had alcohol levels far exceeding the .08 legal limit to operate a vehicle, and both were under the legal drinking age. What do we make of this? Do we keep our silent vigil?

We have learned through extensive research that approximately half of the patients admitted to hospital trauma centers have alcohol-related injuries. Now, as I go to see the man in the day hospital to provide alcohol screening and a brief counseling intervention, what will he see? How willing will he be to see the connection between his injury and his risky drinking? Will he be open to exploring change?

There is an enormous weight attached to my work here at this hospital, teaching many counseling student interns and doing what many say shouldn’t be done by counselors. Naysayers question whether anyone will really make changes to their drinking habits after just one counseling session. Yet quietly, and frequently, we see trauma unit patients making these healthier changes. Our own research, as well as the research of others, confirms that many of these individuals sustain those changes.

So, I walk on. I walk on this Saturday morning, just like many other days, toward this injured person and toward hope that maybe, just maybe, this will be another memorable, teachable moment.

The purpose of this article is to introduce counselors to a community context — the hospital trauma unit — in which counselors historically have not been represented. We believe, however, that counselors, because of their unique set of skills, can provide an invaluable service in these units. The individuals depicted in this account are based on composites rather than on any actual cases.

Negative effects of alcohol

According to statistics from the National Institute on Alcohol Abuse and Alcoholism (NIAAA), approximately 65 percent of U.S. adults drink alcohol. An estimated 9 percent of U.S. adults drink in an addictive or abusive pattern, while an additional 19 percent drink in risky patterns, often involving binge drinking; 72 percent of U.S. adults either do not drink alcohol or do not exceed the NIAAA risk limits when drinking.

NIAAA has indicated that males younger than 65 who drink more than four standard drinks in one day and 14 or more standard drinks in one week are more susceptible to alcohol-related harm, such as violence, accidents and alcohol dependence. (A standard drink equates to one 12-ounce beer or one 5-ounce glass of wine.) For females, NIAAA has indicated that more than three standard drinks in one day or more than seven standard drinks in one week constitutes “risky drinking” behavior that may lead to alcohol-related harm. NIAAA also has a resource for those exploring changes to their drinking habits, called Rethinking Drinking, which outlines a number of negative effects from alcohol.

According to NIAAA, alcohol is a contributing factor in 60 percent of deaths resulting from burns, drowning or violence; 50 percent of severe physical traumas and rapes; and at least 40 percent of fatal car crashes, suicides and deadly concussions from falls. In addition, heavy drinkers often have a greater risk of physical deterioration such as cirrhotic liver failures, heart attacks, vascular strokes, insomnia, depressive disorders, gastric bleeding, numerous cancers and sexually transmitted diseases. Additional alcohol-related complications thwart effective management of diabetes, hypertension and anxiety. Drinking by pregnant women can cause serious brain damage and other complications to the unborn infant.

In summary, negative effects from alcohol use are seen throughout the spectrum but particularly among the 28 percent of individuals who drink excessively or addictively. Our alcohol screenings and counseling interventions are focused on these individuals.

The teachable moment

A Level I accredited hospital trauma center provides the best in trauma care and is required to provide alcohol screening and brief intervention to patients when clinically indicated, such as when patients enter the unit inebriated. (Note: Given the context of this article and the language used by hospital staff, we will most often be referring to “patients” rather than to “clients.”) In many hospitals, nurses and other staff complete these screenings and interventions. Our particular hospital is one of a very few in the nation engaging counselors to provide this service. We thought that counselors would be effective in this role because of their training in active listening, rapport building and empathy, their attention to multicultural considerations and their skills pertaining to alcohol and substance abuse.

The motive behind providing this service in trauma units is simple. Faced with a crisis (in this case, the realization of being seriously injured and in a hospital as a result of alcohol use), patients may be more amenable to the idea of making healthy changes regarding their consumption of alcohol. Counselors can help patients explore their alcohol use and connect the dots between their alcohol use and their health risks. Without the screening and brief interventions, however, many patients may not consider the connection between their alcohol consumption and the injury that brought them to the hospital.

Our Teachable Moment research study was funded by the Robert Wood Johnson Foundation. The research team, led by physician Mary Claire O’Brien, also included co-investigators Beth Reboussin, Laura Veach and Preston Miller. The primary goal of the project was to analyze the effects of two brief counseling interventions on patients’ alcohol consumption: a quantity/frequency intervention and a qualitative intervention. An auxiliary goal was to determine the potential role counselors could play in providing brief alcohol screenings and interventions to patients in hospital trauma units.

The quantity/frequency intervention consists of counselors focusing on how much alcohol patients consume (quantity) and how often they consume it (frequency) in a typical day and week. A key element of this intervention is providing education about risky drinking behavior based on research conducted by NIAAA.

The qualitative intervention consists of counselors eliciting information about instances when patients have “drunk too much” or have “overdone” their drinking. Patients are also asked what they believe might have contributed to these instances of overdoing it or drinking too much.

With both interventions, counselors provide patients with screening results, explore patient perspectives regarding their drinking behaviors, help patients to formulate goals for changing their alcohol behaviors (when desired) and emphasize the patient’s options in making changes, if any. Screenings and brief interventions, which generally last between 20 and 40 minutes, are done in the patient’s hospital room, usually at the patient’s bedside. Patients with more serious or advanced problems associated with alcohol, such as alcohol dependence, are encouraged to seek additional help and are given referrals to licensed counselors who specialize in alcohol dependence.

Cultural considerations

Multicultural considerations are key in our hospital trauma center, which serves a vast geographical area and a diverse patient population. For example, one patient might be airlifted from rural Appalachia with severe stab wounds; another patient might be a gang member severely injured in a car wreck who is transferred from an urban hospital; yet another patient may be a college sophomore from a local private university who was admitted through the Emergency Department after a serious fall. Each will have sustained life-threatening, alcohol-related injuries, and each will be offered alcohol screening and brief counseling interventions, with emphasis placed on cultural considerations to enhance each patient encounter. Cultural considerations are particularly emphasized when our patients speak a language other than English. In our region of North Carolina, this commonly involves Spanish-speaking patients.

We have had the opportunity to serve a diverse group of English- and Spanish-speaking trauma center patients. These opportunities have provided us with some insights into cultural factors that potentially influence alcohol screenings and brief interventions. Particularly, we have recognized that patients’ worldviews, or the way they make sense of the world, play an important role in how we assess and intervene with these individuals. Specific elements of worldview we have found helpful to consider include internal versus external locus of control, rugged individualism versus collectivism, high- versus low-context communication styles and personalismo.

Locus of control refers to an individual’s sense of control over and responsibility for circumstances in her or his life. Individuals with a strong internal locus of control believe they are the masters of their destiny and that their choices determine their circumstances. In the 1994 film Renaissance Man, Danny DeVito’s character expressed his internal locus of control orientation when he stated, “The choices we make dictate the life we lead.”

Conversely, an external locus of control — sometimes referred to as fatalism or fatalismo — refers to a person’s belief that life events or circumstances are attributable to external forces such as destiny, luck or God and are, therefore, beyond one’s control. Individuals with a high external locus of control may not respond well to interventions that emphasize a future orientation and goal setting as a priority.

Both the quantity/frequency and qualitative interventions described earlier are goal- and future-oriented in that patients are prompted to set goals for improving their drinking behaviors. This focus works well with patients who espouse an internal locus of control, but patients with an external locus of control may struggle with this approach.

To further illustrate this point, I (Nathaniel) will share an instance from a few years ago when I was providing individual counseling services to a middle-aged Latino male. During one session, I was attempting to help this client create a therapeutic goal that was both measurable and realistic. Nonverbally, he demonstrated a lot of hesitation to formulating a goal. I was puzzled by this reaction, so I mentioned to him the nonverbals I was noticing and asked for clarification. He said he was uncomfortable setting goals because it made him feel like he was “playing God,” which, to him, was inappropriate and unreasonable.

To be sensitive to his perspective, I decided that, rather than couching our work together in terms of goals, I would present it in terms of his values, which happened to be religion and family. Thus, instead of asking him to set goals, I asked what he believed his family or God would want for him and how he thought he could accomplish it. That approach seemed to work for him.

In a similar vein, the values of individualism and collectivism influence our work with trauma unit patients. Rugged individualism places value on the individual; one’s sense of meaning and worth comes from one’s individual accomplishments. A common phrase used in the United States that illustrates the value placed on individual responsibility is “He needs to pull himself up by his bootstraps.” Thus, in individualistic cultures, the smallest unit of society is the individual.

Collectivism, on the other hand, places value and responsibility on the collective, or group. In many cultures, the group is synonymous with the family. One’s value and worth comes from honoring one’s group or family. Familismo, a strong bond within a family, is common in Latino cultures. In a collective society, the smallest unit is the group, because individual values cannot be extricated from those of the group.

Most counseling theories and interventions have been developed by and for people who espouse an individualistic worldview. Thus, when working with trauma unit patients who valued collectivism, we had to modify our approach slightly. Rather than discuss individual goals in isolation, we would help patients tailor their goals to fit those of their family or group. We also asked all patients if they had people on whom they could count to support them in their goals.

I (Nathaniel) speak Spanish and provided alcohol screenings and brief interventions to Spanish-speaking patients. However, fluency in Spanish was not enough to be effective with these patients. It also was important to take into account high- versus low-context communication styles. In Beyond Culture, Edward T. Hall postulated that White Americans engage more frequently in lower-context communication than do ethnic minorities in the United States. In other words, White Americans often focus on what is being stated verbally and less on nonverbals and context. High-context communicators, on the other hand, place less emphasis on words and more on the context of the conversation, the paralanguage and the nonverbals being used.

Latino immigrants, who made up the majority of the patients I served, often communicate from a high-context perspective. Thus, it was very important for me to assess the nonverbals, the tacit messages and the nuances these patients used in addition to the actual words being spoken. For example, it is considered rude in many Latino cultures to say no to a request or to refuse something outright. Because we were running a study as well as providing a service, we had to describe the study in detail and ask patients if they would consent to participate. In a few instances, patients verbally consented but, when presented with the informed consent form, decided they “weren’t feeling well” or “would prefer to look over it and get back to me later.” In one case, a patient chose not to participate after giving verbal consent because he was not comfortable placing his signature on a white piece of paper (the informed consent form). Having lived in a Spanish-speaking country and having experienced high-context communication firsthand, I recognized that these comments, especially when coupled with the paralanguage and nonverbals, were polite ways for the patients to express they were not interested in participating in the study.

Personalismo, the valuing and cultivation of an interpersonal relationship, also influenced our work with Latino patients. Personalismo often is developed through mutual sharing. Thus, a good way for counselors to foster personalismo is to open up and share aspects of their lives with clients. This is important because, regardless of the context, one’s alcohol use is usually not a subject that people feel readily comfortable discussing. To help patients feel more comfortable discussing private, intimate and guilt-laden topics, we found it helpful to take a few minutes to connect with them by asking patients about themselves. With our Latino patients, that oftentimes meant sharing things about ourselves with which we felt comfortable, such as where we were from, where we learned Spanish, hobbies we might have in common with the patient and so on. Those few minutes were very helpful in breaking the ice and creating a sense of connectedness and trust that encouraged patients to discuss their drinking habits.


In providing this service to more than 1,000 individuals in an intense medical setting, it has become clear that offering alcohol screening and brief counseling interventions has substantial benefit to the recipients and to their loved ones. There is also benefit to the health care system in the form of reduced medical costs and reduced rehospitalizations for alcohol-related injuries. Then there is the benefit to society. Studies spanning several different trauma centers show a 50 percent reduction in subsequent DWIs when alcohol screening and brief interventions are provided.

The majority of those receiving our bedside alcohol screenings and brief counseling interventions have never spoken with a counselor previously, yet they overwhelmingly rate these sessions as positive and beneficial. Further, in our six-month follow-up phone calls, former patients report substantial improvement in their quality of life (this result corresponds to other screening and brief intervention studies). The majority of individuals also report a substantial reduction in drinking, showing trends of drinking below at-risk levels or abstaining.

We continue to increase our counseling services in a medical setting, placing emphasis on cultural competence, while also providing research, exemplary professional counseling and counselor education training opportunities.

“Knowledge Share” articles are based on sessions presented at American Counseling Association Conferences.

Nathaniel N. Ivers is a licensed professional counselor, national certified counselor, human services board certified practitioner and assistant professor in the Department of Counseling at Wake Forest University. Contact him at

Laura J. Veach is a licensed professional counselor, licensed clinical addiction specialist, certified clinical supervisor and associate professor in the Department of Counseling at the University of North Carolina at Charlotte and in the Department of Surgery at the Wake Forest School of Medicine.

Letters to the editor: