Monthly Archives: January 2014

U.S. shows some improvements in behavioral health

By Bethany Bray January 31, 2014

substanceabuseA recent government survey indicates more Americans are getting the help they need in crucial areas – such as heroin addiction – and our nation’s behavioral health is improving in some aspects, including the abuse of prescription pain medications.

The Substance Abuse and Mental Health Services Administration recently released the results of its 2013 National Behavioral Health Barometer, a survey of Americans’ behavioral health problems, from suicidal thoughts and underage drinking to rates of serious mental illness and substance abuse.

Positive strides have been made in some areas in recent years, SAMHSA reports. For example:

  • The rate of prescription pain reliever abuse has fallen for both children ages 12-17 and adults ages 18-25 between 2007 and 2011 (from 9.2 percent to 8.7 percent and from 12 percent to 9.8 percent, respectively).
  • The number of people getting buprenorphine treatment for a heroin addiction has jumped 400 percent from 2006 to 2010.
  • The number of people getting outpatient behavioral health treatment through Medicare has increased by more than 30 percent from 2006 to 2010.

Data was compiled from numerous federal surveys. In addition to nationwide statistics and trends, the report’s information is broken down for each U.S. state as well as by gender, age group and race/ethnicity where possible.

“[The report] provides both a snapshot of the current status of behavioral health nationally and by state, and trend data on some of these key behavioral health issues over time,” SAMHSA said in a press release. “The findings will be enormously helpful to decision-makers at all levels who are seeking to reduce the impact of substance abuse and mental illness on America’s communities.”


To view or download copies of the report, visit


“The Barometer is a dynamic new tool providing important insight into the ‘real world’ implications of behavioral health issues in communities across our nation,” says SAMHSA Administrator Pamela S. Hyde. “Unlike many behavioral health reports, its focus is not only on what is going wrong in terms of behavioral health, but what is improving and how communities might build on that progress.”



Reaching out to vulnerable populations

By Cirecie West-Olatunji January 30, 2014


Cirecie West-Olatunji, ACA President

Advocacy must mean more to professional counselors than legislative action on Capitol Hill and calling child protective services when we suspect that our clients have been abused. That doesn’t mean these forms of advocacy are not valued or not needed, but we must incorporate other forms of advocacy into our professional skill sets.

I don’t believe the progenitors of our profession conceptualized us as working primarily in our offices while ignoring the social ills that plague our clients on a daily basis. Vulnerable populations are often the most marginalized in communities. They are the poor, the elderly, the young, the disabled and those who are sexual, ethnic or religious minorities. But engaging in clinical outreach means more than assuming the cape of a do-gooder and swooping down into a community to rescue clients from their problems.

What, then, is the nature of our outreach as professional counselors? How do we visualize ourselves as mental health professionals, and how does that change how we work? As counselors, we are called to a) incorporate an understanding of the relationship between our clients’ presenting problems and the sociopolitical realities that they face and b) take action to reach out to the most vulnerable of our client populations. This means we do not have to wait until our clients come to us. Rather, we must incorporate proactive interventions in communities.

For professional counselors, context (or environment) is everything. Our conceptualization of a client’s problem relies not only on our ability to understand what is articulated, but also our ability to imagine what is not stated so we can provide a three-dimensional view of the client’s reality. To do this effectively, we must understand what it means to be vulnerable within the client’s system. This is a difficult task for most of us because we often come from privileged backgrounds wherein our lived experiences create barriers to our understanding of others.

Reaching out to vulnerable populations allows us to strip off the cloak of professionalism and assume the role of learner in the client’s world. Stepping away from our offices and entering into communities affords us opportunities to be humbled by our clients’ courage, strength and sheer willingness to live through life’s challenges. From this vantage point, we are able to learn more about our clients and their situated realities.

Outreach to the vulnerable permits us to learn more about ourselves, thus allowing us to grow as human beings and as professionals. From this more accurate conceptualization of clients’ problems, we are able to provide more appropriate and expedient interventions that are grounded in clients’ own worldviews and values.

Taking action within the context of our clinical roles and responsibilities transforms our work so that it is more humanizing, allowing us to become more strongly connected to our clients and the world. Reaching out to vulnerable client populations allows us to become vulnerable. In our vulnerability lies the opportunity to truly experience the space between the past and the present, between oppression and liberation, between being stuck and embracing change. Thus, outreach has the potential to serve as a catalyst for transformation that is trans-subjective. That is to say, transformation occurs both for the client and the counselor.

This year as ACA president, I have focused on outreach as a key aspect of our identity. At the upcoming annual conference in Honolulu, several sessions will highlight the work of ACA members who understand the importance of outreach to our professional growth and development. I encourage each of us to step up and step out of our comfort zones to transform our clients, ourselves and the world.



Follow Cirecie on Twitter: @Dr_CWO

This is not your annual conference plug

By Richard Yep


Richard Yep, ACA Executive Director

Two things to share with you this month. The first is that your ACA staff is in the final phase of planning as we prepare to host somewhere in the neighborhood of 4,000 professional counselors, counselor educators and graduate students who will gather for the annual ACA Conference & Expo next month.

This year’s conference will provide more than 400 continuing education sessions and inform attendees about the latest in research. It will offer plentiful networking opportunities with colleagues from around the world and bring to light new products and resources from more than 100 booths in the expo hall. It will provide access to the highly regarded ACA Career Center and feature two very compelling keynote speakers in Morgan Spurlock and Cloé Madanes.

Without question, this is one of the events of the year for the counseling profession. Regardless of whether you plan on attending this event, however, it should not be seen as the pinnacle, the zenith, the capstone or the “last really big audacious conference of the year.”

No, the ACA 2014 Conference & Expo is not meant to be an end point. Rather, it is a place on your continuum of professional development as a counselor, counselor educator or graduate student. At the 2014 conference, we will be releasing some groundbreaking information relative to the newly revised ACA Code of Ethics, a risk management report for counselors in practice and results from our first-ever counselor salary study.

My hope, of course, is that many ACA members and those who identify as professional counselors and counselor educators will find a way to join us for the ACA 2014 Conference in Honolulu. The added bonus of holding the event in one of the world’s most beautiful places is the chance for you to simply “chill out” and reenergize for the important work ahead.

But if you cannot join us, please know that ACA is still committed to providing you with many professional development opportunities and services throughout the year. With our newly improved website and resources that will be released throughout the year, we really are trying to be your professional partner wherever and whenever you need us.

If you think attending the ACA 2014 Conference & Expo is a possibility, you will find a very comprehensive description of the event on our website. Visit us at for the latest information.


And now, a personal reflection. I grew up in the suburbs of the San Francisco Bay area. Beginning in the 1960s, I trudged out to Candlestick Park with my dad to watch our beloved San Francisco Giants. (Some say that Willie Mays would have surpassed Babe Ruth’s home run record had he not had to play in that windy stadium. I would add the word cold to windy.) When the San Francisco 49ers abandoned Kezar Stadium, they also headed to Candlestick, which meant I had even more reason to go to that concrete monstrosity. In time, I even took my own son to Candlestick.

Well, the Giants finally found a way to build a state-of-the art baseball stadium in what is now a thriving part of San Francisco. Next season, the 49ers will head down to Santa Clara, where they will move into their new home. However, as I sat at what was to be the last regular season professional football game at Candlestick Park at the end of December, I felt a wave of nostalgia come over me. I began to think that the cold temperatures, the biting wind and the austere facility weren’t so bad. My sense is that these thoughts were driven more by memories of what had been and what I had shared, first as a son and then as a father, than by reality.

From a practical point of view, the new baseball and football stadiums really do (or will) enhance most aspects of the “fan experience.” Just as in the work you do with clients and students, I guess this is about working through the transitions and challenges that life places before us. And let’s face it — I will still have the memories of Candlestick Park without having to suffer the wind and the cold.


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:

Embedding in the culture of an organization

By Burt Bertram January 28, 2014

Staff-SmallFor many years when asked to describe my perfect job, I would say, “I’d like to be a corporate priest.” What I meant was that I could imagine a mental health professional being woven into the cultural fabric of an organization in a way that would allow her or him to become a familiar face to the people in the organization. Over time, the mental health professional would gain credibility for being both trustworthy and competent. Then, as events unfolded in the lives of the organization’s members — including when the emotional complications of life became too much — they would have a safe and confidential harbor to pull into, with a mental health professional who understood their world and possessed the skills to help.

In recent years, the U.S. military has begun to embed mental health professionals into its operational units, much as it does with medics. Of course, school and college counselors already operate from this embedded perspective on behalf of students, but not for faculty or staff. Certainly employee assistance counselors and psychologists provide services to employees, but generally these professionals are not visible in the everyday lives of the employees. Therefore, the comfort level that develops from familiarity is not possible.

Frankly, I didn’t know the concept of a corporate priest actually existed until I met Herdley O. Paolini. Herdley is the director of Physician Support Services (see below), a comprehensive counseling, coaching and leadership development program that provides services to more than 2,200 physicians and their families affiliated with the Florida Hospital system. Florida Hospital is a hospital organization with eight campuses and more than 2,400 beds for patients in Orlando, Fla. As detailed in “Antidotes to burnout: Fostering physician resiliency, well-being & holistic development,” an article posted on the web resource Medscape in April 2013, Physician Support Services “provides whole-person care through specialized professional resources aimed at maximizing the personal and professional well-being of Florida Hospital physicians and their families.”

Why embed in a culture?

Sometimes it is difficult for members of the general public to generate much empathy for the emotional and mental health needs of physicians. After all, the cultural mythology of physicians is that they sit at the top of the health care food chain and direct the efforts of many people while being handsomely compensated for their efforts. How difficult can that be? Is there really something about being a physician that presents special challenges and stressors?

The answer is a resounding yes … and increasingly so. Physician burnout, a phenomenon that directly affects quality of care, patient safety, treatment outcomes, patient satisfaction, nurse turnover, hospital staff morale and financial performance, is present at alarmingly high rates. A study published in the Oct. 8, 2012, edition of the Archives of Internal Medicine (now JAMA Internal Medicine) explored burnout rates by medical specialty and compared physicians with workers in other fields. The study revealed that job stress resulted in almost one of every two physicians experiencing burnout symptoms. The study’s conclusion was a compelling call to action: “Burnout is more common among physicians than among other U.S. workers. Physicians in specialties at the front line of care access seem to be at greatest risk.”

If doctors are at such risk, can’t they just go into the marketplace and obtain therapy? They can, and certainly they do. What is difficult, however, is finding mental health professionals who 1) understand the realities of the all-consuming work-life stressors that define the daily life of a physician and 2) appreciate the power of the physician ethos, which is best described as a belief system intentionally honed to create a sense of deep self-reliance, if not denial of their own humanity.

Physicians-in-training very quickly learn to not feel what they are feeling. As medical students and continuing through residency and fellowship, physicians are taught to tough it out and endure. Depression, illness and trauma are for patients … not for doctors. As a result, physicians are notoriously reluctant patients — and even more so when mental health is the issue.

Embedded in a physician culture

Exposure to trauma, both profound and chronic, in combination with constant personal sacrifice and unrelenting demands can place many physicians at risk for depression, anxiety disorders, anger issues, suicide, substance abuse and interpersonal conflicts. Inevitably, physicians become emotionally numb, often resulting in the depersonalization of patients. Thoughtful hospital administrators, physician leaders and physician advocates have long been aware of the stressors imposed on doctors. What to do about it, however, was always the open question.

This brings us back to Herdley O. Paolini and her small clinical staff. Ten years ago when Physician Support Services was established, Herdley was hired to create a program that physicians would utilize to help reduce the consequences inherent in the practice of medicine. She tells a very interesting story of how she went about embedding herself in the physician culture.

“I began by reading about the world of physicians,” she says. “I listened to the stories doctors told about their training, and I watched doctors interact with each other, other health care professionals and patients. In short, I came to learn about the physician ethos. I soon realized that physicians had their own special culture in the hospital and that if I was going to be helpful, I had to find a way to be accepted by members of the culture. To be accepted I needed face time with doctors — in their world.”

To accomplish this, she invested several months doing rounds with physicians, scrubbing in with surgeons and shadowing physicians in their office practices. She was there in the middle of the night as they responded to emergencies. She also qualified for medical staff membership by working emergency department call schedules. She was determined to be visible in as many venues as possible so physicians would come to know her as a human being and so that she could come to know them, their world and their language.

In time, members of the medical staff came to trust that she heard and understood them and that what was discussed would, in fact, remain confidential. Demand for her wise counsel grew rapidly. Today the service is highly utilized, often with a waiting list for nonemergency cases. More than 90 percent of the physicians in psychotherapy with the program at any given time are self-referrals.

In crisis and every day

The value of the embedded relationship was never more apparent than when, several years ago, a patient stalked and murdered a physician in the parking garage of Florida Hospital (see sidebar below). The Physician Support Services team was immediately activated. Attention was initially focused on the trauma experienced by the physicians and other medical personnel. Two hours after arriving, the Physician Support Services staff facilitated a support group for the transplant surgeons and medical students who had labored to save the life of their colleague. Nineteen surgeons gathered to share their shock, grief and fears and to remember their colleague and friend. Medical cultures in general and physicians in particular operate by the motto, “Illness (or trauma) does not belong to us.” As one surgeon explained, “[This tragedy] stripped away everything that I believed in and that held me together.”

That night and through the next six harrowing days, the clinical staff from Physician Support Services provided assistance to the widow and children of the slain physician. At the same time, in collaboration with a host of other mental health and spiritual caregivers, they assisted with trauma interventions for members of the entire hospital community. Predictably, these long days called on almost every clinical skill, including crisis debriefing, crisis intervention, grief counseling, consultation and group facilitation.

What was surprising, however, was the array of nonclinical skills and activities that were necessary. For example, lead administrators had great intentions but limited knowledge of the emotional needs of people during a crisis of this magnitude. Understandably, they were running on crisis mode and at times missed the multiplicity of needs on the ground. As a result, to be most helpful at this early stage of the unfolding crisis, the Physician Support Services staff had to communicate constantly, clearly and assertively with lead administrators and, at times, vigorously advocate for postcrisis best practices.

As the days unfolded, there were numerous opportunities for the Physician Support Services staff to assertively communicate, network, advocate, mediate, negotiate and recommend or access community resources. Fortunately, the respect and trust this embedded staff had established with physician leaders and hospital administrators made it possible to fulfill these nonclinical responsibilities.

Paolini expressed it best: “We are grateful that in this very difficult time, we were embedded in the medical staff and had previously established trust and credibility with both the medical staff and administration. This was crucial in our ability to deploy services with immediacy and to penetrate the various groups in a nonintrusive and welcomed way. We will continue to rely on these intentionally created dynamics to support the continued recovery and healing of the family, the medical community and the community at large.”

In terms of professional satisfaction, the rewards of being an embedded “corporate priest” revolve around knowing that your work makes a difference. This cannot be overstated. Every day at Physician Support Services, counselors are privileged to enter into an encounter with the physicians of Florida Hospital and their families. Every effort that is helpful to a physician has a ripple effect on his or her family, other health care professionals and, ultimately, on the patients served by this faith-based hospital system.


Successful embedding strategies

  • Identify an organization champion: Secure a highly regarded champion within the organization who can provide access and endorse your credibility.
  • Immerse yourself in the culture: Interview members of the culture, take people to breakfast or lunch, read about and observe the culture, and shadow members of the culture.
  • Create opportunities for face time: Be as highly visible as possible in the organization, including attending meetings and engaging in informal chats at lunch.
  • Build professional credibility: Make presentations and author articles or “think pieces” that speak to the felt needs of members of the culture.
  • Don’t get co-opted by power: Be mindful that you need the blessing of formal power to function, but avoid being seen as an instrument of formal power.
  • Avoid organizational politics: Whenever possible, avoid being perceived as taking sides.
  • Advocate “for” not “against”: Advocate for the best interests of the people you serve, but do so in a way that is not against opposing views.
  • Protect confidentiality: All is lost if your trust is compromised in any way.
  • Navigate dual roles wisely: You inevitably will have multiple roles with members of the organization. These must be managed with utmost integrity.
  • Appreciate your place: Never forget that you are an “inside outsider.” You will never be completely “in,” but you must be in enough to understand the perspectives and priorities in the culture.


Crisis response

Thursday evening, 5:45 p.m. My last counseling session ended 30 minutes ago. Two meetings, five clinical cases … it had been a typical day. I quickly responded to two “must return” emails and gathered the materials I needed to be ready for my 7:30 a.m. meeting the next day.

Physician Support Services is located on the edge of the hospital campus, near the Emergency Department, so it isn’t unusual to hear sirens, but I remember being vaguely aware of what sounded like a chorus of sirens. Without thinking much about it, I quickly selected items to include in my briefcase and headed home, just 10 minutes away.

I had been there only a few minutes when the phone rang. “There’s been a shooting in the parking garage … One of our doctors has been gravely wounded … in surgery … status of assailant unknown.”

I immediately alerted my team, and we all headed to the hospital. The victim was one of our surgeons; the assailant a former patient who stalked the doctor in the parking garage and shot him several times before committing suicide. Of course, in the beginning, all we knew was the identity of the physician. That knowledge was enough to understand that in all likelihood, the victim’s colleagues would be called upon to save his life.

The magnitude of the trauma was staggering. Before we arrived at the hospital, the tragic news came. The surgeon had not survived. The attacker who had been taken to another hospital in town was also pronounced dead. We were now in full-blown crisis mode. The enormity of the situation affected the hospital community at multiple levels: the family of the surgeon; the surgical team immediately involved; the medical colleagues of the surgeon; the larger medical, clinical and nonclinical staff; our patients; and the surrounding neighborhood.

Never in the history of the Physician Support Services program were we more thankful for the established relationships we had developed with so many members of our medical staff. The foundation of trust and credibility that we
had worked so hard to build would now be used to help our physicians cope
with this tragedy.

— Herdley O. Paolini, Ph.D., director of Physician Support Services at Florida Hospital



Physician Support Services

Physician Support Services at Florida Hospital was developed as a service that would be safe for and respectful of doctors — a place where doctors could access mental health services under their own initiative. Physician Support Services is much more than an employee assistance program for physicians. It provides an environment where physicians can grow and develop the human side of themselves, while also serving as a redemptive place to address their emotional and psychological fears and traumas.

The program offers self-referred individual, couples and family therapy for physicians and members of their immediate families. Medical staff leaders can also refer physicians for assessment and treatment. Additional clinical services include coaching for interpersonal effectiveness, human relations consultation and conflict resolution.

Physician development activities include continuing medical education (CME) units focused on physician self-awareness, emotional intelligence and leadership development. Some CME offerings involve retreat locations. For additional information, visit




Burt Bertram is a Florida licensed mental health counselor and licensed marriage and family therapist who provides clinical counseling to individuals, couples and families. In private practice in Orlando for more than 35 years, he also provides a range of consulting, facilitation, coaching and training services to a wide range of organizations, including Florida Hospital. He is an adjunct professor in the counseling program at Rollins College. Contact him at



Addressing clients’ prejudices in counseling

By Bailey P. MacLeod January 27, 2014

UmbrellasCounselors-in-training are often encouraged to be aware of and discuss issues that they think would be difficult for them to address with clients in counseling. A first-year counseling student recently disclosed that due to his values of multicultural awareness and acceptance, he would find it difficult to work with a client who expressed any prejudices in counseling. Given the counseling profession’s shift to a multicultural and social justice paradigm when working with clients, this is a valid concern but one rarely discussed when training counselors to work with culturally different individuals.

How should counselors handle prejudices that clients express in counseling? Do these prejudices need to be addressed if they are not related to the client’s presenting issue? The counseling profession has established values of awareness, knowledge and skills in multicultural counseling and social justice as a way to address power, privilege and oppression. Focus has largely been placed on how to guide treatment of culturally different clients in ways that acknowledge their unique worldviews. Under the banner of social justice and advocacy, counselors must also address the societal, historical and political issues that continue to oppress others. However, little information has been provided on how to address the biases of clients who may hold power and privilege in society, especially White clients who express prejudices.

Granted, prejudice is not a common presenting issue that brings clients to counseling. However, it is not uncommon for clients to express such values and beliefs in the counseling context. We are all cultural beings with unique values, histories and worldviews, and racism and prejudice affect everyone in some way. As counselors, we are taught to work within the worldview of the client, and social justice maintains that we must also work within a conceptual framework of how oppression at individual, societal and institutional levels can affect a person’s growth and development. By addressing biases that clients bring to counseling — biases that have the potential to be harmful to their own growth and the growth of others — we are addressing aspects of their worldview, while also adhering to the values of social justice.

I experienced this dilemma firsthand while working with college students during my training as a counselor. Feeling caught off guard, I struggled with how to handle a situation in which a client expressed racial stereotypes in counseling. I had little guidance from supervisors or professors concerning how to make sense of the situation. After researching the meaning of racism and prejudice and discussing with other counselors the best way to meet clients’ needs while also addressing power and privilege, I developed some considerations and interventions that counselors can use if they ever experience a client expressing prejudices in counseling.

In multicultural counseling and social justice training, counselors are primarily exposed to information that will help culturally different and oppressed clients, even as these counselors focus on awareness of their own prejudicial experiences and culture. This article addresses ways to work with clients who have the power to oppress. This is an issue that is aligned with the goals of social justice, albeit at an individual level, in an attempt to address biases in those who hold them.

Of course, culturally different persons can also express biases and stereotypes toward other groups, but these biases may have different meanings and origins. The interventions and conceptual issues presented in this article can be tailored to other situations, but the emphasis is largely around working with White clients who endorse stereotypes or biases toward people commonly oppressed in society. Therefore, the goal is to provide counselors with considerations and possible interventions to help these clients gain more insight and awareness that will potentially stimulate their personal growth.

Addressing prejudice: Is it ethical?

I have already made an argument concerning why it is important to address clients’ prejudices when expressed in counseling, both for the individual and society. However, I had many questions about my role as a counselor when I experienced this situation with a client. Was it my job to address prejudice if the client didn’t see it as an issue? Would I be promoting an “agenda” that was not part of the client’s worldview?

Ethically, we have a responsibility to respect the client’s worldview by maintaining an accepting and nonjudgmental stance. At the same time, it is our ethical responsibility to work within an understanding of social justice and advocacy. As with most ethical dilemmas, there are various ways to handle this situation but rarely a clearly defined “right” way to act. One possible path is to avoid addressing the client’s comments in therapy. But ignoring the issue could result in colluding with the client’s attitudes and maintaining the status quo of oppression. It could also send the message to the client that it is acceptable to avoid uncomfortable discussions. A counselor who experiences strong negative feelings toward the client’s values and beliefs but does not address the client about them may become resentful and critical of the client, possibly causing an impasse in counseling.

On the other hand, several consequences could occur if the counselor does address the client’s racist statements and beliefs. For example, the way the counselor addresses the issue may cause the client to feel embarrassed, ashamed or misunderstood, especially if the client is aware of the negative connotations of being viewed as “racist.” The context of therapy, the counselor-client dynamics and the way in which the client presents these beliefs are important considerations. For instance, let’s say a counselor who identifies as gay is working with a client who makes homophobic statements in counseling. This situation is both professionally and personally relevant to the counselor, who considers disclosing to the client that he identifies as gay. Before doing so, however, the counselor must ask who will really benefit from such a disclosure — the counselor or the client?

At a minimum, counselors should give clients the option and space to discuss racial and other prejudicial issues in the context of their own worldviews and experiences. Before deciding how to intervene in similar situations involving clients’ prejudices, counselors should take the following important steps.

  • Consider the client’s goals and how prejudice is related to these goals.
  • Assess the client’s racial identity.
  • Assess the function these stereotypes and biases serve for the client.
  • Consider how the racist comments relate to cultural racism.
  • Assess what cultural values and strengths maintain these beliefs.
  • Identify cultural strengths the client can use to stop relying on these biases.
  • Clarify your own motivations and reactions in the process of addressing prejudice.
  • Assess the client’s motivation for change in this area.

Conceptualization and interventions 

Similar to counseling for most other issues, it is not always feasible to expect clients who express prejudices and biases to completely resolve all of their issues. Much of the change in the area of prejudice depends on the factors just discussed and how much clients wish to change this aspect of themselves. However, at minimum it may be important to develop an awareness of the origins and functions of clients’ prejudicial attitudes as a means of better understanding their presenting issues. This can assist counselors in developing appropriate interventions that ultimately address clients’ concerns and possibly help them become more aware of their own biases.

One useful way to conceptualize White clients in relation to prejudices is through Janet Helms’ White racial identity development model. The idea of a White identity focuses mainly on the implications of having unearned, race-based power and privilege with the potential to oppress others who do not have that same privilege. The model emphasizes the transition from being unaware of one’s White racial background to an awareness and integration of one’s Whiteness into other parts of identity by giving up power and appreciating differences. The developmental status of a client will affect how he or she views other races and the relationship the client has with other races.

The first status in the White racial identity development model is contact. A client who is in the contact stage may claim not to see race (color-blind attitude) and may not understand the meanings associated with race. The disintegration status usually occurs when a White person is confronted with and feels guilty about racial inequality but experiences ambivalence about how this inequality relates to him or her. The reintegration status is usually triggered by an experience in which the White individual feels he or she has been treated unfairly or discriminated against. This individual may believe in the superiority of being White and in the intolerance of other races.

Afterward, the person may move into the pseudo-independence status, which is characterized by an intellectual understanding of White privilege. However, the person still may lack any concrete experiences related to this understanding. The immersion/emersion status involves the person having a more personal understanding of how he or she contributes to racism in society. However, the person may be hypervigilant to the point of having extreme reactions to perceived racism. Moving past this status will allow a person to attain autonomy, or a nonracist identity. These statuses are not fixed and absolute, of course, but they provide a useful tool in recognizing how clients see their White identity and understanding their reactions to issues of race.

When I work with clients who express certain thoughts, feelings or behaviors that they find problematic, I usually look for their origins and the functions that they serve in clients’ lives. I also apply this method in situations in which clients express prejudices during counseling, asking where these attitudes came from and what purpose they serve for the client. Assessing the client’s experiences with racism, social and familial history with prejudice, and parental reactions to race and culturally different people in childhood provides useful information about the origin of these values. It also allows the counselor to better empathize with and validate the client’s current experience instead of shaming the client or judging the client’s values.

The function of these attitudes is also very important for understanding the deeper meaning of the attitudes outside of the judgmental stance of “racism.” When a person’s self-esteem is threatened, especially in a racially charged situation, there is a tendency to defend with an in-group (pro-White) bias. The use of prejudicial comments or beliefs may be more powerful for White individuals who also hold another aspect of their identity that is oppressed. For example, a White gay man may express racist beliefs in reaction to a situation where his sexuality is threatened. This can lead to unhealthy and inaccurate distortions of information to preserve identity and avoid painful emotions associated with unearned privilege. Denial and rationalization of racial issues and prejudice is a way for clients to avoid painful aspects of race-related issues and any responsibility for privileged behavior. Stereotyping less privileged cultures can also allow clients to avoid changing the way they interact with others, while placing the blame for prejudice on those who are oppressed. These reactions tend to emerge when clients feel that some aspect of their identity is being threatened and they need to find a way to defend against those uncomfortable feelings.

Interventions can be loosely tailored to the client’s identity status and the function of these prejudicial beliefs to gain insight and move to a more integrated understanding of White privilege and oppression. For example, helping clients explore the origin of their beliefs can help them connect their past experiences to their current attitudes, which can raise awareness and increase insight. This also models to the client ways to address difficult conversations concerning race and prejudice. Counselors can also provide psychoeducation about the history of oppressed groups to clients who deny the existence of prejudice in society and in their own behavior or attitudes.

Ambivalence is a common reaction for clients in the disintegration status. Counselors could use interventions to help these clients understand and process ambivalent feelings such as guilt. Counselors who understand a client’s own history with discrimination can help the client connect those experiences and negative emotions with the experiences of others who are subjected to discrimination. This allows the client to develop empathy and understanding for others.

Clients who show a higher-level status of White identity may benefit from exploring what it means to be White and learning to be more flexible in their emotions and reactions to racism. Finally, counselors who understand the deeper meaning of a client’s prejudicial comments (for example, insecurity) can better tailor interventions to address the core issue so the client no longer has to rely on maladaptive coping strategies.

Counselor considerations

Broaching the subject of prejudice and privilege can be difficult for clients and counselors. Counselors first need to develop a solid therapeutic relationship with their clients to establish trust and prevent shame. Counselors also need to be aware of why and how they respond or do not respond to clients’ values so they can avoid reacting in ways that meet their own needs rather than those of their clients. Therefore, it is important for counselors to be aware of their own experiences and attitudes toward prejudices.

Counselors who are uncomfortable with the topic may avoid discussing it or deny its importance to the client’s concerns. Negative reactions such as guilt, anger or identification with a client’s values may cause a counselor to become blind to the client’s needs and appropriate interventions. Counselors who are not completely comfortable with their own White identity may unintentionally distance themselves from the client in an attempt to avoid White guilt and to identify as a nonracist White person. How a counselor responds to a client’s values has an impact on the effectiveness of counseling. It is important for counselors to monitor their own reactions and maintain self-awareness to properly meet their client’s needs.

Counselors work with important aspects of clients such as their attitudes, values and beliefs. A concern for many counselors, especially beginning counselors, is how to handle client values that conflict with their own. Counselors who are aware of potential problems that clients may present them with in counseling will be more prepared to respond and intervene in effective ways. Hot topics such as racism and prejudice can be especially problematic for counselors who value the tenets of multicultural awareness and social justice in their personal and professional lives, making it difficult to respond therapeutically. Regardless, it is our responsibility as counselors to respect clients’ values. This does not mean, however, that those values cannot be addressed in helpful ways in counseling.

I wanted to highlight this dilemma because it is infrequently discussed in counselor training or workshops. Therefore, the situation can be very jarring and unexpected for counselors. The ideas outlined in this article are just starting points for counselors to consider should they encounter clients who express prejudicial attitudes in counseling sessions. It is important to think about how interventions in counseling can best benefit the client, while also keeping in mind our professional values of multicultural awareness and social justice.





Those interested in more information on this topic can refer to Bailey P. MacLeod’s article “Social Justice at the Microlevel: Working With Clients’ Prejudices,” published in the July 2013 issue of the Journal of Multicultural Counseling and Development.




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


Bailey P. MacLeod  is a doctoral student in the Department of Counseling at the University of North Carolina at Charlotte. Contact her at




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