Monthly Archives: October 2014

Responding to the rise in self-injury among youth

By Brent G. Richardson & Kendra A. Surmitis October 23, 2014

The prevalence of nonsuicidal self-injury (NSSI) among adolescents and young adults has rapidly and significantly increased in recent years, leading mental health professionals and researchers to describe its pervasiveness as epidemic. By definition, a person does not engage in NSSI with intent to die. Rather, NSSI is a means of regulating emotions, relieving tensions, managing dissociative symptoms and influencing others. It is critical that counselors working with youth gain an understanding of NSSI and recognize its prevalence within the adolescent population.

There is growing evidence that many teenagers who engage in NSSI have been influenced by their peers. In 1985, Barent Walsh and Paul Rosen defined self-injury contagion in two ways:

1) When acts of self-injury occur among two or more persons within the same group within a 24-hour period

2) When acts of self-injury occur within a group of statistically significant clusters or bursts

The primary focus of this article is to identify environments that present a high risk for self-injury contagion and to suggest opportunities for counselors to minimize and prevent contagion when working with adolescents.

Benefits and pitfalls of group work

Many programs designed to treat adolescents who self-injure include group therapy as an essential ingredient in the treatment milieu. S.A.F.E. (Self Abuse Finally Ends) Alternatives, founded in 1985 by Karen Conterio and Wendy Lader, was the first treatment facility designed specifically for people who self-injure. Since its inception, clinicians at S.A.F.E. Alternatives have used group therapy as a central feature of its treatment programs. Dialectical behavior therapy (DBT), which combines individual therapy, group skills training and family education, has emerged as one of the most effective treatments for adolescents who are suicidal and/or self-injure. Many of the key skills needed to reduce self-injurious behaviors (for example, emotional regulation, distress tolerance and interpersonal communication skills) are learned and practiced in group therapy. Solution-focused therapist Matthew Selekman recently developed a nine-session Stress-Busters’ Leadership Group geared specifically toward adolescents who engage in self-destructive behaviors. The group is applicable in both school and community settings. While these group approaches (S.A.F.E. Alternatives, DBT and Stress-Busters) have several differences, it is important to note that each is largely didactic, highly structured and skill-based.

Group work is appealing both to adolescents and counselors for a number of reasons. For logistical and developmental reasons, group homes, residential facilities and hospitals typically utilize various forms of group work as their primary mode of treatment. Groups are more efficient and cost-effective than individual approaches because they enable counselors to work with more clients. In addition, group work tends to be a better developmental fit for adolescents than individual therapy, and adolescents often prefer it because a significant amount of social learning occurs in the context of formal and informal groups (for example, family group, classroom group, social group and sports teams).

Youth who self-injure tend to feel isolated and disconnected. Although individual counselors can inform youth that they are not alone, the group process allows them to experience a sense of universality with their peers, while learning from others who are at different stages in the recovery process. By assisting and supporting others, members begin to see themselves in a different light. One of the most effective ways to boost a youth’s self-esteem and self-confidence is to structure situations in which he or she can help others and feel altruistic.

Despite the potential benefits of using groups as a component in treating those who self-injure, there are also possible pitfalls that could disrupt the process or even increase self-injurious behaviors. Walsh, author of Treating Self-Injury, says counselors should be mindful that anytime individuals who self-injure are treated in groups, there is an increased risk for a contagion effect. In addition, he warns that groups that are largely cathartic in nature — wherein youth are encouraged to openly express their emotions and share traumatic experiences — are often counterproductive with this population. These types of groups can increase the risk of contagion because open discussion of self-injury antecedents, behaviors and consequences can be exceptionally triggering for some young clients.

Many clinicians and researchers assert that group leaders should structure activities that focus on empowerment and replacement or coping skills training, while prohibiting detailed discussion of self-injury. This can be challenging for counselors because sharing and hearing details about self-injury can be so alluring for both counselors and group members. Adolescent clients may view group therapy as an opportunity to compare wounds and share stories. These disclosures should be severely limited or prohibited from the onset, however. Counselors may want to acknowledge that discussing self-injury in great detail may be important but emphasize that those details should be shared in individual therapy rather than with group members.

In summary, NSSI groups are most likely to be effective if:

1) Group leaders have significant training and understanding of treating self-injury and managing contagion

2) Membership is closed to enhance cohesion and trust

3) The group is governed by strict rules prohibiting the discussion of details of self-injury and the sharing of wounds or scars in the group

4) As with DBT groups, the sessions are highly structured, didactic and focus on teaching new skills and behaviors (for example, emotional regulation, mindfulness, self-soothing, distress tolerance and exercise) to help reduce further incidents of self-injury

Benefits and pitfalls of residential facilities

Similar to treatment in group therapy, clinicians who work with youth in residential treatment can be effective in counteracting self-injury, provided they follow the proper precautions.

The residential population is likely at higher risk for contagion due to peer influence and the prevalence of severe psychopathology such as eating disorders and issues with affective regulation. In fact, a number of researchers have observed that NSSI occurs in significant clusters in residential settings, including community-based group homes, special education boarding schools, juvenile detention facilities and psychiatric inpatient settings. Recognizing the potential for contagion in a residential population allows for appropriate precautions when determining the benefits of residential treatment on a case-by-case basis, and it can aid in the appropriate response to NSSI.

Several studies have found that self-injurious behaviors often increase for adolescents, regardless of whether they have a prior history of self-harm, during residential treatment. Clinical settings that feature multiple youth living together who exhibit emotional dysregulation can aggravate dysfunctional behaviors, including NSSI. Consequently, the increased likelihood of exposure to self-injury in a residential facility leads to the question of whether the benefits of inpatient care are worth the potential risks associated with contagion.

Despite concern for social contagion, several arguments can be made in favor of choosing residential treatment for NSSI. For example, cases that include high-risk behaviors such as clinically significant disordered eating require structured, intensive treatment. In similar circumstances, placement in a residential facility may be warranted, even if nonresidential treatment may pose less risk of self-injury contagion.

The first step in response to the risk of social contagion is making the appropriate referral to residential care on an individual client basis, while avoiding unnecessary hospitalization. Within the residential setting, precautions guide clinicians toward the appropriate response to NSSI. These responses include educating the individual client, confronting triggers of social contagion and using encouragement to motivate youth to build and share healthy coping skills.

Subsequently, many of the challenges and recommendations for counselors who work in residential facilities are similar to those provided for group counselors. Although communicating with peers in a communal environment is beneficial for those who feel isolated and may benefit from peer support, mental health counselors are advised to educate residents on the negative effects of sharing stories of self-injury. These clients should instead be instructed to share stories of healing and healthy coping behaviors.

Benefits and pitfalls of websites and message boards

Although the Internet is a potentially valuable source of support and information for self-injurers, various websites can also be breeding grounds for social contagion. Approximately 93 percent of American youth ages 12 to 17 use the Internet, and nearly two-thirds of adolescent Internet users go online daily. These numbers are growing every day. In the past decade, the number of websites intended for or about people who self-injure has increased. Research conducted in 2007 by Janis Whitlock, Wendy Lader and Karen Conterio revealed there were more than 500 message boards focused on self-injury. These researchers also observed the parallel between the increase in self-injury websites and the growth in self-injury awareness in society. Internet message boards provide a potent medium for bringing together adolescents who self-injure.

These self-injury websites and message boards offer a number of potential benefits. The Internet may have particular relevance and appeal for adolescents who are socially avoidant or feel marginalized. These youth may feel extreme relief upon finally being able to make meaningful connections with individuals who share similar concerns and experiences. The anonymity of these sites might also encourage youths to share more frequent and truthful disclosures about their feelings and behaviors. Positive peer pressure is another potential benefit. As is the case in group counseling, these adolescents might more readily accept online feedback from peers that encourages them to practice safer, more productive ways of expressing their emotions.

Thus, it is important that counselors not minimize the perceived value that these sites have for young clients who self-injure. Though social scientists and mental health professionals often focus on the potential harm of these discussion groups, adolescents who use them tend to self-report positive experiences as a result of their participation. For example, in one survey of self-harm discussion group members, Craig Murray and Jezz Fox found that the majority of respondents reported having reduced the frequency and severity of their self-injurious behaviors. The respondents attributed this largely to the support and guidance they found online.

Whitlock and her colleagues were some of the first researchers to study the content of self-injury message boards to better understand their role in sharing information about self-injurious practices and influencing help-seeking behaviors. These researchers found that the most common type of exchange on the message boards involved providing informal support to other posters through comments such as “We’re glad you’ve come here” and “Just relax and try to breathe deeply and slowly.”

However, in addition to the supportive communication found on NSSI-related sites, researchers also found dangerous messages. While 44 percent of all help-seeking posts presented favorable attitudes toward seeking mental health treatment, approximately 20 percent of the posts discouraged individuals from seeking treatment and/or voiced negative views about therapy. There was also considerable discussion about better ways to conceal scars and maintain secrecy.

These researchers warned that self-injury message boards expose vulnerable youth to a normalizing environment of encouragement for self-injury and hold the potential for fueling social contagion. On several sites, members shared new and often more dangerous techniques and instruments for cutting and even offered links to sites where self-injury paraphernalia could be purchased. Sites that feature graphic depictions of self-injury, including many videos on YouTube, can be highly suggestive or triggering to other self-injurious participants. Unfortunately, those who self-injure can become better at self-injury by learning from others they meet online. Some posters use chat rooms to coerce others, model self-destructive behaviors, compete with others and discourage others from stopping their self-injurious behaviors or seeking help.

As is evident, self-injury websites and message boards are helpful for some and counterproductive for others. Regardless, this needs to be an area of therapeutic inquiry. In fact, the popularity of the Internet among adolescents presents a crucial argument for assessment of Internet use in general, as well as specific assessment of Internet exposure to self-injury. Mental health professionals should therefore educate themselves about various websites for self-injurers (some recommended sites are included in the next section).

Whitlock and her fellow researchers suggested that clinicians maintain a curious, neutral, nonjudgmental tone when asking questions such as the following:

How comfortable do you feel hearing stories from others who self-injure?
Have you shared your own story? How did you feel?
What do you like most about having friends whom you really know only through the Internet?
How honest are you when you share information on the Internet? (Do you minimize or tend to embellish?)
Do you ever take advice from Internet friends? If so, can you provide examples of advice that you used?

Some NSSI sites have minimal or no monitoring for potentially dangerous content. If there are moderators, they typically have minimal or no training in mental health. With certain clients, counselors might assess that it is best to be direct in encouraging or discouraging particular sites or interactive behaviors. Counselors can clarify concerns about why some sites might be traumatic or triggering and therefore countertherapeutic. These direct suggestions will likely be more fruitful with adolescents who have entered counseling voluntarily, begun to develop a therapeutic relationship with the counselor and voiced a desire to stop or reduce self-injury.

Summary recommendations

In this article, several mediums have been identified as environments at high risk for social contagion of NSSI — namely group treatment, residential facilities and social media. Key considerations for the prevention of social contagion were identified. These include:

Developing a clinical understanding of social contagion and its significant impact on the adolescent population through training and further research
Working with clients who engage in NSSI to develop awareness of appropriate environments to discuss their self-injury stories, such as individual therapy sessions
Asking clients who self-injure to cover up scars, wounds and bandages that can be triggering
Prohibiting graphic detail of NSSI at the onset of group therapy
Incorporating strength-based strategies that encourage healthy coping behaviors in treatment
Assessing client Internet use, with specific attention paid to exposure to self-injury imagery
Determining the appropriate level of treatment and avoiding unnecessary hospitalizations that may invoke NSSI in vulnerable clients
Instructing clients to share stories of healing and healthy coping behaviors to decrease the opportunity for contagion, while inspiring altruistic motives in a group environment

Furthermore, the role of mental health counselors working with youth engaging in NSSI extends past the therapeutic relationship encountered in treatment to the family system and school setting to which the child is connected. Providing appropriate referrals to information for concerned individuals in the child’s life, such as parents and other caretakers, is an important action in attending to NSSI and contagion among peers. The following websites provide helpful information grounded in clinical research and professional standards.

S.A.F.E. Alternatives: selfinjury.com
Mayo Foundation: mayoclinic.org/diseases-conditions/self-injury/basics/definition/con-20025897
Self-Injury Outreach & Support: sioutreach.org

Empowering family members and other members of the client’s care system to understand self-injury will help them to comprehend the messages sent by the child who is engaging in the behavior, while promoting an atmosphere of awareness to counteract opportunities for contagion. As a provider of information, it is crucial that the counselor is clear when it comes to appropriate Internet material, such as empirically validated information for families, and the potential misinformation provided by sites containing blogs and graphic imagery. The prevention of contagion begins with understanding NSSI in youth and empowering the people in their lives who also share in the opportunity to preclude self-injury among adolescents.

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This article was adapted from a previous article published in the American Mental Health Counselors Association’s Journal of Mental Health Counseling.

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

Brent G. Richardson is chair of the Department of Counseling at Xavier University in Cincinnati. Contact him at richardb@xavier.edu.

Kendra A. Surmitis is an assistant professor of counseling in the Department of Educational Psychology at Northern Arizona University. Contact her at kendra.surmitis@nau.edu.

Letters to the editor: ct@counseling.org

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Unethical supervision practices and student vulnerability

By Vanessa Dahn October 22, 2014

During my practicum and internship in a private practice several years ago, I remember often looking up on the wall at the doctorate degree diploma hanging beside my supervisor’s desk. (I’ll refer to this supervisor as Dr. S.) Something about its design didn’t seem right, but I couldn’t put my finger on what exactly seemed out of place. The imperfect calligraphy made the framed document seem manufactured, but who was I to proclaim that?

As a counseling master’s student, I was there to learn through observation and experience, not to question Dr. S’s academic journey. On occasion, however, I would inquire about the college listed on the diploma, only to be told that it no longer existed. Dr. S often stated that he carried his transcripts in his briefcase in the event he ever needed to provide proof of the courses he took. Still, the longer I spent time at his practice, the more unsettled I became. Mental alarms began going off.

The treatment rooms in the former Victorian train station had paper-thin walls. Because I positioned myself in an empty room adjoining Dr. S’s office to work on my tasks, hearing client sessions was not difficult. One particular red flag surfaced early in my time in the office when I discovered that Dr. S felt a need to be dishonest with me. As each client settled into his or her room, Dr. S was supposed to ask permission to include me in the session. Most of the time, he would summon me to join the session. But other times, he would tell me — after the client had left — that the client had not wanted me in the room. What was disturbing to me on these occasions was that Dr. S had not really asked the clients whether I could join their sessions. Eventually I noted that I was excluded from sessions in which clients had issues related to workers’ compensation.

On the occasions when I did accompany Dr. S in sessions, it became more and more evident that he did not have any formal training in psychotherapy. The large majority of the words spoken during these sessions belonged to him. Dr. S mainly talked about himself, not about the clients’ issues. According to the CACREP-accredited training I was receiving at the University of Colorado, counselors were not supposed to talk about themselves but rather should be present for the client in person-centered mode.

I’ll never forget witnessing one client who was crying. Dr. S didn’t offer any empathy or professional help. Instead, he began talking about himself and then swiftly stated that time was up for that session, leaving the client an emotional mess.

A series of red flags

Another red flag arose when Dr. S allowed a troubled young teenager access to all of the client files for sorting as a way to earn community service hours to appease the courts regarding her juvenile sentence. This teen was the daughter of a famous rock star who had died years earlier. Dr. S had previously provided therapy to this girl and her sister and developed a friendship with their mother. As a new student, I had difficulty determining whether this crossed the lines of the dual relationship we were learning about. But it became very evident that Dr. S reveled in associating with others who had attained fame. His walls reflected this, with framed photos featuring what now would be called selfies.

Dr. S took me out to a country club and other restaurants for luncheons. He often promised to introduce me to important professionals in the community but never followed through. A few months into my practicum, Dr. S began making plans for me to join his practice as a colleague and to turn my time there into a paid position as an unlicensed psychotherapist. He freely began uploading my photo and mini bio on his website and declared me an associate, only afterward sharing with me what he did.

One thing became clear almost immediately: a penchant for demonstrating his grandiose personality. Dr. S often bragged about where he had been in life, what he had accomplished and his service in the Navy. He was quite proud of having been a student at the University of Notre Dame, where he claimed to have earned his bachelor’s degree. He also spoke fondly of supporting the Make a Wish Foundation. His experiences as a forensic psychologist in the courtroom were often described with pride. His curriculum vitae (CV) was laden with court cases he said he had been hired to testify in as a forensic psychologist. Another achievement he proudly discussed in my midst regarded how he had secured contracts with the military and a local law enforcement office to provide psychological evaluations for soldiers serving overseas and potential police officer candidates. Many times, Dr. S tasked me to score these exams. Years later I discovered that one significant criterion for scoring these tests was for the scorer to possess a Ph.D.

Nearing the completion of my first semester of internship, Dr. S invited my spouse and me to his house for dinner. Following dinner, he guided us to the living room where he laid out various blueprints of potential new office complexes he was considering moving his business to. He had recently received a notice to vacate from the landlord of the Victorian. While explaining the benefits of each office space, he peppered the conversation with promises of one of the offices being mine — potentially the nicest one. As I listened to him, it became very clear that he was asking me to invest thousands of dollars to secure the lease of one of the offices. He gently reminded me that his credit was wrecked because of a divorce and trouble with the IRS.

Red flags began billowing all around me, fervently waving me in the direction of the door. My discomfort was evident to my spouse, so on my cue, we excused ourselves, thanking Dr. S for a lovely dinner.

An abrupt ending

Late one evening following the dinner, Dr. S and I were instant messaging, planning out the following week. Dr. S indicated he was inebriated. Soon thereafter, I was the recipient of inappropriate comments that crossed the line of professionalism. As the conversation waned, I gathered the strength to call Dr. S out on his expectations that I would max out my student loans to finance his move. Immediately, he realized that I was on to his scheme.

His response was to tell me not to come into the office and that he would be notifying my professor that he was breaking my second semester internship contract. In turn, I contacted my internship professor and relayed my concerns regarding Dr. S, his credentials and my contract. This professor set up an appointment to meet with Dr. S and me to gain greater clarity of the situation.

As I sat in the office with my professor, it took all the strength I could muster not to cry over the manner in which I was being treated. Along with being dismissed came an inability to access my clients for closure. When I voiced these concerns, Dr. S stated that I did not have clients — they were his clients. Dr. S disclosed to my professor that the reason he could no longer supervise me was because the company with which he had the defense contract said it would no longer do business with him as long as I had access to his clients’ records.

That moment solidified for me the lengths Dr. S would go to in constructing his lies. As we left the office, I confided to my professor how embarrassed and humiliated I was to be put through the meeting. I also explained how I knew Dr. S was lying. Tears surfaced quickly as I stood on the sidewalk, feeling the need to defend myself to my professor. She reassured me that she didn’t think any less of me and encouraged me to stay strong. She voiced certainty that I would be able to find another place at which to spend my second internship semester.

As the months passed and I gained more academic knowledge of counseling concepts, the easier it was for me to identify Dr. S’s questionable practices. Intrigued by the inconsistencies I had uncovered, I began digging deeper. It didn’t take long to find that his Ph.D. was a fraud, as were his other degrees and many of the claims on his CV. This meant that Dr. S’s counseling license in Colorado had been obtained with false credentials that were never verified by the state.

At the same time I was researching the validity of Dr. S, a psychologist whom I’ll call Dr. P was looking for me. Dr. P had compiled a massive amount of evidence concerning the fraudulent practices of Dr. S. Her investigation had uncovered several associates of Dr. S who also had false credentials, and Dr. P wondered if I might be among them because she had found the information Dr. S had posted about me on the practice’s website. Although Dr. P had been speaking out against Dr. S for years, no one would listen. In fact, the state of Colorado had reprimanded Dr. P, deeming her a nuisance because she repeatedly brought concerns to the state’s attention. Dr. P refused to give up because she believed that what Dr. S was doing not only constituted fraud but also represented a danger to the mental health industry.

Finally, award-winning investigative journalist Dave Phillips paid attention, patiently listening to Dr. P, taking a plethora of notes and asking a multitude of questions for clarification. Phillips then immersed himself in an investigation. For months, Phillips contacted all of the higher education institutions from which Dr. S claimed to have graduated. In the process, Phillips uncovered deep inconsistencies in the CV that Dr. S so proudly posted on his website and provided to professional associates, as well as other egregious fallacies related to Dr. S.

Finally, in February 2011, Dr. S surrendered his counseling license to the Colorado Department of Regulatory Agency. However, it would take another year for the surrender to be finalized. Most recently, Phillips discovered that although Dr. S lost his license, shut down his business, filed bankruptcy, sold his house and moved, he is once again using his “skills” to continue working in the mental health industry.

A vulnerable population

This story is so important to share. I have had several years now to reflect on the impact of Dr. S’s actions. Professional counselors are taught about the vulnerable nature of clients and how they can be deeply harmed by ineffective therapy practices. But what seems largely overlooked is the harm that counseling students can experience when the supervisors whom they trust have not been properly authenticated and licensed by state regulatory agencies.

Students are in between two entities — their counseling program and their supervisor — both of which are overseeing the student’s performance. Students are as vulnerable as our clientele. They are still learning how to perform psychotherapy techniques along with the theories of therapy. Students don’t possess the proper experience, nor is it their responsibility, to ferret out fraudulent practices. They are just learning ethics in counseling, the purpose for regulatory agencies and procedures for reporting abuse.

It took me years to speak out about my experiences in Dr. S’s practice. Once I realized that Dr. S might be a fraud, I was very concerned about the legitimacy of my time under him in supervision. I even had concerns about finding a place to complete my internship requirements in a community already saturated with counseling students from various academic institutions. But now that Dr. S has been outed and has lost his license, I feel relieved.

So students, beware! Report your suspicions to your professors. And if they don’t take you seriously, keep moving up the chain until someone hears you.

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Vanessa Dahn is a licensed professional counselor, national certified counselor and executive director of Safe Landing Group Center LLC. Contact her at poisonaero@live.com.

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Related reading

For an in-depth article on counselor supervision, see the November cover story “A steadying hand”: wp.me/p2BxKN-3J1

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

Through a Glass Darkly: Unequal opportunity and invisible scholars

By Shannon Hodges October 20, 2014

One of the criticisms I have noted during my regular overseas travels is that a number of cultures view Americans as overly idealistic. A steady diet of fairy tale conclusions, Hollywood films and “reality” TV seem to set many Americans up for serial disappointment.

I’ve lost track of the number of times a student, a client or simply someone on the street has professed “You can do anything you want.” Certainly hard work and a good attitude can take one far, but parameters are a reality. (Sorry, but hard work seldom makes you rich.) Political candidates play on this theme of golden opportunity, often espousing unrealistic goals. Students generously meriting a B-minus are furious they didn’t get an A-plus, and college rankings tout the supposedly “best” schools, all of which are ridiculously expensive and chock-full of highly privileged students. The common denominator in these societal myths and ersatz rankings is a Horatio Alger-like philosophy that “everyone who wants to can succeed, and if you don’t, it’s your own fault.”

Of course I’m overgeneralizing somewhat, but the have-nots know all too well of society’s callous indifference. “Poor? Well, you deserve it” seems to go another mantra. Never mind the stark realities and stacked odds against those lottery losers born into impoverishment.

When I think about it, we appear obsessed with positive outliers. This is reflected in numerous examples: a multibillion dollar cosmetics industry, plastic surgery, expensive SAT/ACT test prep courses and colleges willing to say anything to attract students. But how is one to manage the harsh reality that eventually the bill comes due? After all, the hardest-working people often are among the poorest, and studying at elite colleges often leads to crushing debt — with no brighter occupational prospects than graduates from more pedestrian institutions have.

In the shadow of the ivory tower

Nineteen years ago I taught general psychology at a community college. My students were an amalgamation of ages, ethnicities and backgrounds. Most were high school graduates, others dropouts, with a couple having served a stretch in prison. The commonality was that all my students hailed from the lower socioeconomic caste and sought a better life through the vehicle of education. Sadly, the statistics on community college attrition, another correlate of lower socioeconomic status, are demoralizing. A college education, long a freeway to the middle class, has too often been a cul-de-sac for students in the community college system.

While some of my more promising community college pupils possibly matriculated to four-year institutions, most were severely underprepared for college work. Few knew how to construct a grammatically correct sentence, to say nothing of writing according to the style guidelines of the Publication Manual of the American Psychological Association.

Some were painfully clueless. One student stopped me after the first class wondering whether she was in the wrong general psychology section. “Your name is Hodges, but the schedule says my instructor is Staff,” she said, concern lines etched across her brow. (She was serious!)

An assignment required students to critique a journal article. In the syllabus, I had listed the parameters and provided a list of possible academic journals available in the college library. Yet one student critiqued a National Enquirer story — if heaping praise on a UFO-type story could be termed a critique — and couldn’t fathom why that periodical didn’t fulfill the requirement.

Still, the majority of the students were eager-to-please types, at least once they shed their façade of false bravado. As I became more familiar with these students, my empathy for them increased exponentially. One lived out of an old station wagon. Another worked the graveyard shift at a convenience store, never missing a class despite coming off shift bereft of sleep. A single parent with children from several different men worked diligently, bolstering her GPA in hopes of gaining admission to the college’s nursing program. Practically all (roughly 30 in both classes) were likable people whose misfortune was being born on the wrong side of the socioeconomic demilitarized zone.

I won’t stretch credulity by promoting all as hardworking, diligent students. Some scarcely cracked their text, and the excuses from a couple for missing an exam were downright ludicrous. One, notorious for his dying uncle story, seemingly had his poor relation succumb each semester, only to resurrect, expire and need reburying.

Candles in the darkness

A select few, however, seemed positively heroic, including the homeless student, the convenience store clerk/scholar and the nurse aspirant. Another memorable example was a 30-something man in recovery (successfully) for alcohol use. His dream was to become an addiction counselor and help people like himself. Because I was a counselor and director of the local mental health clinic, he often sought me out.

“Practically everyone in my family’s an addict,” he confessed over stale coffee during my ersatz office hours in the cafeteria. When I inquired how he was able to beat the odds, he replied in a matter-of-fact manner, “God woke me up, of course” — as if everyone should know this.

But the student I recall best was a twice divorced, middle-aged woman holding down two jobs, one of which involved bartending at a dive tavern serving a rough clientele. I’ll call her “Mary.” General psychology was the last course she needed for her associate degree, a significant accomplishment given that no member of her family had ever earned any type of college degree. She wasn’t the “best” student in the scholastic sense, but she attended every class and, diligent as a church deaconess, habitually claimed a front-row seat. Mary was always the first to raise her hand to answer questions, although her enthusiasm far exceeded her precision.

Mary was the type of student who never would win awards or acclaim or draw much attention outside of her immediate circle. Yet there was much pathos in this working-class woman’s quixotic pedagogic pursuit. Born into multigenerational poverty, like too many others she became pregnant in her teens, married an abusive addict and dropped out of high school. At some point after her second abuser left, she earned her GED and matriculated to the community college. Her meandering scholastic path involved passing some courses, failing and retaking others, all while juggling long work hours and caring for her kids. “I love learning,” she offered without guile when I inquired what kept her going.

During the term, Mary faced yet another life crisis. My mind is now foggy on the details, but she called me in tears one afternoon, something about an adult son arrested for drugs and no resources for bail. Stretched perilously thin between work and school, financially and emotionally, she was frantically working to pass the course and participate in the graduation ceremony. Listening as empathically as possible during her rambling monologue, I made a referral to a counselor in our mental health clinic and put her in touch with Legal Aid. Meanwhile, the final exam loomed large as a great white trolling shallow water.

Two weeks before the final, she sought me out after class, desperately seeking advice beyond the trite “reread the chapters and study hard” mantra. I offered a review session, but her dual work schedules made this impossible. So I suggested she call me anytime she had questions (this was before the days when email was common). She took me up on my offer, calling each night during idle moments at the tavern!

The week of the exam, I noted the sheer exhaustion on Mary’s face. Due to unexpected staff changes, she was pulling double shifts at the bar. Concerned, though lacking constructive ideas, I asked how I might be helpful. Shaking her head ruefully, she thanked me for all my help. That night, she didn’t call. No call the following night either. The evening before the exam, the clock hit 9 and again no call. Apprehensive, I decided to call her, then realized that despite all the times we’d spoken, I didn’t have her phone number.

With no other option, I reluctantly drove to the tavern where Mary worked. The watering hole had a reputation as a low-end, seedy dive for serious drinkers, with the occasional brawl tossed in for entertainment. As I crossed the threshold of the dimly lit establishment, rough-looking men and women gave me a cursory glare before returned to drinking or billiards. Mary stood behind the bar expertly working the taps, textbook in hand. Upon glimpsing me, utter shock registered on her face.

I could sense her patrons’ rapierlike eyes on me, and fear crept up my spine as the bar went silent as a funeral home. I’d like to say that undaunted, I went forth like a modern-day Childe Roland to the Dark Tower. Frankly, however, I lacked the courage to turn and face such animus. Suddenly, it dawned on me that Mary’s world was as alien to me as my world was to her. The difference was that each day she took the risk, crossing over that invisible though ever-present social class Checkpoint Charlie.

“What are you doing here?” she asked. Feeling awkward, I stammered out my offer to review the exam. Shaking her head, Mary chuckled, then withdrew her textbook from underneath the bar area. “It’s OK,” she said to her customers, breaking the tension. I occupied a vacant stool, accepted a pint of Pabst on the house and began reviewing course material.

Mary explained that each night, she would reread the chapters in the murky light, frequently consulting flash cards between refilling customers’ drinks. Surprisingly, at least to my middle-class sensibilities, most of the punters accepted me. One even patted me on the shoulder in approval, rough paw as huge as a grizzly’s.

The ends and the means

I like to consider both education and counseling as lifeline occupations — professionals pulling unfortunates from the wreckage of self-destruction, while patched up clients and graduates venture forth with a renewed sense of optimism and purpose. Clearly, my philosophy is ideal at best and naïve at worst.

Fortunately, Mary’s story had a happy ending as she passed the final and walked through graduation, head held high as any Ivy Leaguer. Soon thereafter, I moved from the area and, unfortunately, do not know Mary’s continuing story. What I do know is that in all my years as a counselor and educator, never have I seen a love of learning so manifest in one individual. No, she wasn’t the type of student profiled in glossy magazine pages or an alumnus for whom buildings are named. But I often think of her as a raving success and a far better exemplar of transformative education than all the magna cum laude graduates from the “best colleges.”

As a professor of counselor education, I have met many intellectually gifted people, including some who have earned prestigious awards and often are seated at places of honor during banquets. But if I could choose to hand out awards, the Marys of the world would be my honorees. Unfortunately, the best I am able to do is my marginal prose.

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Shannon Hodges is a licensed mental health counselor and associate professor of counseling at Niagara University. He writes the “Through a Glass Darkly” column exclusively for CT Online.

Voice of authority

By Robin Switzer October 16, 2014

As a counselor and counselor educator, I am often pondering the recent trend of developing professional identity and what that means in applicable terms. Professional identity development has been heralded as involvement in professional organizations, legislation, mentoring, continuing education and supervision. These are effective ways to develop your own personal identity as a counselor, but how do we develop the identity of counselors as professionals?

In my experience as a counselor, I have on occasion been asked to provide a professional opinion and subsequently encountered one of two very different experiences. If others agreed with me, I was heralded as an expert; if others disagreed, I was no more than a feeling practitioner who could be dismissed. I have witnessed fellow clinicians treated in the same fashion and yet have seen other clinicians’ opinions treated with deference.

The difference, I discovered, was not in the education of other professionals I might encounter but in the manner in which I represented myself as a counselor. The manner in which I treated my own professional experience determined the manner in which it was received by others. I had to learn to speak with authority.

Although there is no direct research on this topic and its relationship with the field of counseling, there are continuing conversations throughout professional organizations in fields such as business, medicine and law. It appears the need to demonstrate authority is a part of most professional identities.

Authority is not to be confused with arrogance. Personal opinion and conjecture have no place in the determination of appropriate services and treatment of mental health disorders. However, making this determination on the basis of data provided by the client, in combination with research and experience, is what counselors are trained for and work to do so in a manner that is professional in all aspects. So why do counselors struggle with this concept?

Authority is a skill to be developed and harnessed, but it is not necessarily discussed or taught directly in counseling programs. In an attempt to leave room for the individualization of experiences, we (as counselors) may have skewed our view and ability to communicate professional opinions with authority. In our attempts to be open to all ideas and concepts, we may have inadvertently watered down the validity of our observations and work with clients.

The trouble may lie in the role we must engage in as clinicians. The role we establish to work with clients is a hat we continue to wear outside of the therapeutic process. We listen, we understand, we may even lightly challenge, but we do not engage in full on conflict and we encourage others to form their own opinions. This makes us excellent clinicians but, at times, it also makes us lousy ambassadors for our profession.

As counselors, we engage and collaborate with many other professions depending on the level of care being provided. Judges, lawyers, police officers, social workers, physicians and probation officers can all be part of a team approach in community mental health and may all turn to us to be the mental health expert while attempting to fulfill their own specific roles. This can lead to varied opinions that, in my experience, rarely wish to overrule counselors. Rather, they work to convince counselors to change their opinions, not as an act of malice but as an attempt to find middle ground. The problem occurs when we, as counselors, defer our professional opinions to the point that they are no longer supported by the data we accumulated and thereby appear to be personal opinions.

How can we as a profession speak with the same authority that we witness in other professions? In terms of social sciences, our profession is relatively new and still works to demonstrate valid and reliable data results. The tools of our trade — diagnosis, assessment, symptom observation, client self-report and behavioral patterns — are the data points we use to understand, treat and advocate for those struggling with mental health issues. These tools require training to be used appropriately, and it’s time we remember this as counselors.

One observable obstacle is the language counselors use to represent themselves and the profession. Although we work to assist our clients with healthy communication, in part by using “I feel” statements, this does not portray expertise to other professions. Lawyers do not win simply by arguing what they “feel” is right; their arguments need to be based in the law. Many would run from a surgeon who “feels” that surgery might be needed; an exam or some test is first warranted. Yet counselors state diagnoses, goals and treatment recommendations with “I feel” statements, inadvertently representing a personal opinion and thereby making it easier to dismiss. As counselors, we do not “feel” a diagnosis; we base it on tangible identifying markers and symptoms.

One concern that is often discussed in the field is the concept of omniscience. A counselor who thinks he or she knows everything has at that moment made a major mistake. Speaking with authority is not having the correct diagnosis, treatment plan and prognosis; it is about having the diagnosis, treatment plan and prognosis supported by the data. If the data change, it supports a change in all of these areas. The data are where professional opinions stem, and they do not include the personal. This makes it easier to adapt, alter and evolve in a manner that is more consistent with client experience.

Recognition of and utilization of our authority as counselors not only assists the profession as a whole but also places us in a better position to advocate for our clients as necessary. Authority as counselors is ours if we desire it, but it must resonate from each of us. Counselors will only be considered vital professional contributors if we conduct ourselves in that manner.

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Robin Switzer is a licensed professional counselor and counseling core faculty in the College of Social Sciences at the University of Phoenix who has a doctorate in counselor education and supervision. Email robin.switzer@phoenix.edu with comments about this article.

The good in “Good Will Hunting”

October 13, 2014

Every once in awhile, a movie comes along that really seems to “get it,” portraying mental health struggles or the counselor-client relationship in an authentic, meaningful way.

For Ryan Thomas Neace, that movie is Good Will Hunting. The 1997 film portrays the back-and-forth between a therapist, played by Robin Williams, and client, played by Matt Damon, as complicated, imperfect – and real, says Neace, a licensed professional counselor in St. Louis.

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The good in Good Will Hunting

By Ryan Thomas Neace

Clients often come into therapy expecting us to be soothsayers or magicians or know-it-alls, but we’re not. Hollywood tends to reinforce these kinds of notions when they depict therapists, as well as humans and human interactions, with the same kind of naïve romance. In the movies, therapists usually sit on swanky, leather furniture in offices with ceiling-to-floor windows. Men have six-pack abs and chiseled chins, and women have unrealistically tiny waists and large breasts. People are heroic or villainous, but usually not both. Initially complicated interactions tend to resolve in 120 minutes or less.

But in real life, most of the therapists I know are sweating it out each week to keep costs down and clients coming in — and into offices with wood paneling and florescent lighting no less. Men and women have physical imperfections, and people are capable of all manner of admirable and despicable acts. And much to our chagrin, life doesn’t wrap up neatly and people often remain in some level dysfunction, even after therapy.

I love Good Will Hunting because it portrays all of this, seemingly without trying. The characters possess a tremendous amount of depth and realism. Therapy takes place in the basement office of a community college. Thick Boston accents abound in conversations fueled by fear, sadness and booze, and laced with enough curse words to make you blush. It becomes obvious from the get-go that the therapist, client and supporting characters aren’t going to have everything neatly wrapped up by the end. They remind us that we’re just broken people trying to help one another make sense of a complex world.

Therapist Sean Maguire (portrayed by Robin Williams) is more than capable of executing therapeutic maneuvers, but they aren’t flagrant and obvious, and his emphasis is clearly on relationship over technique. Instead of trying to “be a therapist,” he’s just himself, and in his authenticity, he is therapeutic. That means that when his client makes him mad, he gets mad. When his client weeps, he weeps with him. And when his client challenges him, he has to do some soul searching of his own to keep up his end of the bargain in therapy to be mutually vulnerable. When therapy terminates, his client has made real and substantial progress, but he’s not out of the woods yet.

In short, nothing is perfect. And, thus, neither is the process of therapy perfect.

But Good Will Hunting portrays therapy and, indeed, life as good and worth the while. And good things happen as a result, sometimes in large ways and more frequently in still, small exchanges that we usually overlook.

This is much closer to my actual experience of therapy and life.

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Ryan Thomas Neace is a licensed professional counselor in Virginia and Missouri and a national certified clinical mental health counselor. He works extensively with teens, adults and families at his St. Louis private practice, Change Inc. He blogs for the American Counseling Association and The Huffington Post.

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Related reading:

See “Counseling goes to the movies,” our list of counselor’s favorite movie portrayals of counseling or mental health themes

Also, “All things connect: The integration of mindfulness, cinema and psychotherapy”

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