Monthly Archives: February 2015

Technology Tutor: Are you prepared for the unexpected?

By Rob Reinhardt February 27, 2015

Denial is a powerful defense mechanism, and despite all of our knowledge and training as counselors, many of us still stick our heads in the sand concerning the potential for the unexpected to affect us, our practices and our clients. In dealing with insurance companies, taking notes, handling phone calls or creating a contingency plan for emergencies, the counselor mantra seems to be, “I don’t want to have to deal with all that. I just want to be doing counseling.”

Most of the mental health clinicians I speak with do not have an emergency transition plan or disaster recovery plan in place despite the fact that the 2014 ACA Code of Ethics calls for one and HIPAA/HITECH require such a plan in the case of electronic data.

Standard C.2.h. in the ACA Code of Ethics states, “Counselors prepare a plan for the transfer of clients and the dissemination of records to an identified colleague or records custodian in the case of the counselor’s incapacitation, death, retirement or termination of practice.”

HIPAA/HITECH requires covered entities to have a contingency plan (see Standard § 164.308(a)(7) at hhs.gov/ocr/privacy/hipaa/administrative/securityrule/adminsafeguards.pdf). Among the requirements, covered entities and their business associates must be performing frequent, off-site, recoverable backups of data. As can be expected with HIPAA (the Health Insurance Portability and Accountability Act), you must have your backup and recovery plan documented.

The ACA Code of Ethics focuses on protecting continuity of quality care for our clients, whereas HITECH (the Health Information Technology for Economic and Clinical Health Act) focuses on safeguarding their electronic protected health information. The summary version is that we need to be doing all of these things to ensure quality care for our clients, both now and in case of transition. When we are thinking about our desire to focus on counseling, it is important that we integrate these requirements into our routines. Just as we recognize the importance of treatment plans and progress notes (even though many of us do not particularly enjoy those tasks), so must we implement contingency and transition-of-care plans.

When developing these plans, we must consider the wide array of situations in which they may be used. Although I started this discussion in the context of disasters and the unexpected, it’s possible that these plans will be useful during expected events as well. The list that follows includes just a sampling of situations, both expected and not, in which you may need a transition-of-care plan, a contingency plan for data or both.

Retirement
Pregnancy (maternal or paternal leave)
Failed hard drive, computer or other system
Fire, flood or other natural disaster
An offer for an amazing new job that requires you to leave your current practice or agency
Death (either yours or a family member’s)
Closing of your business (or the one for which you work, or the one that runs your billing or electronic medical records service)
A move out of state

The remainder of this article focuses on some actions you can take to ensure that your data is safe and to prepare an emergency plan. Although I present a focus on the technology implications of these requirements, please be aware that you may also need to explore and create plans for other facets of your practice (for example, what happens if a fire destroys all of your paper files/records?). In addition, because each practice is unique, you may have items that aren’t covered by the options below. Be sure to examine all parts of your practice that may be involved in an emergency plan and all data that may need to be backed up.

Use a practice management system

There are many potential benefits (e.g., increased efficiency, better cash flow and reduced overhead tasks) to using a practice management system, especially one that is cloud-based. (For a complete explanation of these systems and reviews of those available, check out tameyourpractice.com/blog/cloud-practice-management-system-table-contents.)

Using a cloud-based practice management system from a HIPAA-compliant vendor is also an excellent way to significantly reduce your HIPAA compliance risks and responsibilities. The HIPAA final/omnibus rule of 2013 greatly clarified and expanded the responsibilities of covered entities for securing electronic protected health information. Fortunately, it also required business associates (third-party vendors that covered entities use to store or transfer electronic protected health information) to comply with HIPAA as well. By entering into a business associate agreement with a cloud-based practice management system vendor, counselors can offload much of their security compliance responsibilities for electronic protected health information to that vendor.

Among the many things that vendor will now be responsible for are redundant storage, encryption and backup of electronic protected health information. Despite the vendor taking on these responsibilities, I still encourage users to keep their own backup of the electronic protected health information being stored in the cloud-based practice management system. Which brings us to …

Use a backup solution

Even if you are using a cloud-based practice management system, there are reasons to keep your own backup of the data. Most of us who provide clinical services like to review notes from previous sessions before going into session with a client. Even the most rock solid of cloud-based practice management systems can go offline occasionally. Counselors may also experience downtime with their Internet connections. According to Murphy’s law, this will eventually happen at just the wrong moment. For this reason (and because you may one day wish to switch cloud-based practice management system vendors), it is prudent to keep your own backup. The challenge becomes how to do this while remaining compliant with HIPAA. There are many specific requirements to consider, but the overriding principle is to ensure that the data are secure.

Perhaps the most obvious place to store this backup is on the computer you use regularly at your workplace because you’ll want to be able to quickly access it should the need arise. Because the data already exists in the cloud-based practice management system, you may not need your own redundant backup. However, I generally suggest that you use one to be on the safe side. For those of you not using a cloud-based practice management system to begin with, this process is imperative.

When creating a backup of anything (even a backup of a backup), it’s important that you remember to do two things: verify and back up remotely. To verify, you need to regularly ensure that the backup is operating properly, that the data is indeed being backed up completely and that it can be restored properly. Backing up remotely means storing the backup in a location that is different from the primary physical location of the original data. This is important in case the primary location experiences a fire, theft or other disaster.

There are far too many ways to perform adequate backups to cover in this column. However, once again, one of the simplest solutions is to use a cloud-based service. Several cloud-based services report being HIPAA compliant, including (but not limited to) Carbonite (carbonite.com), Box (box.com) and Mozy (mozy.com). It is important to note that prices for these services may vary widely, and some require you to get more expensive plans to get a business associate agreement.

One very affordable alternative is Google Apps for Work (google.com/work/apps/business/). At only $5 per user per month, Google Apps provides a business-level version of the Google solutions with which most of us are familiar (Gmail, Google Calendar, Google Drive). Plus, Google will enter into a business associate agreement. By using Google Drive, a user can have a set of data on his or her computer that is also automatically synced to a location on Google’s servers.

Although I bring this up in the context of backing up data from a cloud-based practice management system, this same logic applies to backing up any electronic protected health information or other data related to your practice. As always, when storing electronic protected health information on any device, I strongly encourage counselors to use full-disk encryption because of the HIPAA breach notification rule (see personcenteredtech.com/2013/04/hipaa-safe-harbor-for-your-computer-the-ultimate-in-hipaa-compliance-the-compleat-guide/). When dealing with electronic protected health information, it’s imperative that counselors educate themselves on what they need to do to reduce risks and remain compliant with HIPAA. For those attending the ACA 2015 Conference in Orlando, Florida, Roy Huggins and I will be presenting a Learning Institute that covers this in detail.

Have an emergency/disaster recovery plan

Backing up data is only one piece of having a disaster recovery plan. A complete disaster recovery plan considers not only potential technical disasters but also other types of emergencies. For example, how might your practice recover if your office was flooded? What if you or a loved one became critically ill for an extended period of time? What if you were evacuated from the area for several days or weeks because of a human-made disaster (chemical spill, rioting, etc.)? Or what if you simply want to plan for retirement?

Although you may not need to plan for every distinct possibility, it is possible to create classifications of possibilities for which to plan. One possible set of classifications might be:

My plan if I have limited access to the office
My plan if I have no access to the office for an extended period of time
My plan if my office has been destroyed or is closing
My plan if I have been incapacitated

Note that this list assumes working out of an office. Each counselor’s plan should be customized on the basis of his or her particular situation. Many counselors are aware of professional wills, and some have even followed through with preparing one. A professional will can be an important part of an emergency plan, but it likely won’t cover everything. The obvious challenge is that, as a will, it’s primarily targeted for use if the counselor dies. Furthermore, most professional wills don’t go so far as to provide all of the information a records custodian or emergency response team might need to effectively address the transition.

It is important that any disaster recovery plan, emergency plan or transition plan includes all of the information needed to run a practice. Although the most important factor is ensuring continuity of care for clients, simply having a plan to pass them off to a new provider isn’t enough. To provide the best possible care for those clients, the new provider should have access to their records. Someone should also be prepared to inform clients, help them with the transition and answer any questions they have about billing, insurance and other information. Each practice may be handling these pieces of information differently, so it is important for the practice to make it very clear in its transition plan exactly where everything can be found. Even things as simple as the location of the office keys and the password to the cloud-based practice management system won’t be obvious to someone taking over in an emergency. And in an emergency, that person doesn’t need to be spending precious moments trying to figure those things out.

A very short list of things counselors should have in their emergency plan includes:

Basic information: National Provider Identifier number, license information
Location of client records
Location of any computers and devices used in your work
Passwords for any computers and devices used in your work
Login information for your cloud-based practice management system and other software containing pertinent business information
Insurance companies with which you are paneled
Information about your accountant, attorney and other professionals with whom you consult
Information about business banking accounts

Ideally, every facet, tool and important piece of information about your practice will be documented so that someone could quickly step in and take over the operations of your practice if you were incapacitated or unable to perform your duties for whatever reason. As an exercise in developing a comprehensive plan, imagine your workday from start to finish, noting all of the tasks you complete, the devices you use, the locations of your tools and paperwork — essentially, everything you need to complete your work. For more details on the importance of such a plan, watch an informative free episode of Therapy Tech in which Nancy Wheeler and I talk with Roy Huggins about the development of our e-book that addresses this issue and includes templates (see youtube.com/watch?v=GxUDSCj8UZI).

Developing these plans may not sound like a day at the beach, but they are a requirement of our profession and essential to providing quality care to our clients. As always, I recommend that you consult with a qualified attorney about the legal aspects of HIPAA and emergency plan development. Also, bear in mind that the information presented in this column is generalized. Because each practice is unique, it may be beneficial for you to talk with a consultant to develop the best plan for your practice.

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Rob Reinhardt, a licensed professional counselor supervisor, is a private practice and business consultant who helps counselors create and maintain efficient, successful private practices. Before becoming a professional counselor, he worked as a software developer and director of information technology. Contact him at rob@tameyourpractice.com.

Letters to the editor: ct@counseling.org

From the President: Intentional collaboration, licensure and portability

By Robert L. Smith February 26, 2015

Robert L. Smith, Ph.D., ACA 63rd President

The American Counseling Association’s professional staff and ACA elected leaders have intentionally collaborated with a number of sister associations, individuals and groups during the past year, including government agencies that are instrumental in decisions involving TRICARE, Medicare and hiring practices by the Department of Veterans Affairs. This collaboration takes place at individual meetings, group sessions, Skype sessions and through electronic communication. The focus is always on what is best for all professional counselors and the future of the counseling profession.

In this message, I am highlighting licensure and portability, areas of significant importance for counselors and the profession. There is reason to celebrate the fact that licensure for professional counselors exists in every state, the District of Columbia and Puerto Rico. This historic accomplishment took years of endless effort by professionals across the country. We are currently experiencing a parallel process regarding licensure portability.

The relevance of intentional collaboration was evident at the American Association of State Counseling Boards (AASCB) Conference this past January in Savannah, Georgia. AASCB, the body of governmental agencies responsible for the licensure and certification of counselors throughout the United States, has a major role to play in obtaining counselor licensure portability. One of AASCB’s mission statements is to “encourage and aid collaborative efforts among Member Boards in developing compatible standards and cooperative procedures for the legal regulation of counselors in the several jurisdictions toward the goal of simplifying the licensing, registration and certification process.” AASCB continues to work with state licensure boards toward the goal of nationwide portability. A significant number of state licensure board officials are also members of ACA.

It is essential for state licensure board regulators and affiliate organizations to collaborate if we are to reach licensure portability in the near future. The following things must take place for counselor licensure portability to become a reality.

Currently, more than 30 state licensure boards are members of AASCB. As many state licensure boards as possible need to become participants.
There needs to be an agreed upon set of core educational standards among licensure bodies.
Licensure boards need to have an agreed upon number of hours required from preparation programs (60 semester-hour programs compare favorably with other competing disciplines such as social work).
There needs to be a common set of direct contact hours required in practicum and internships.
There needs to be a common set of post-master’s supervision hours required for licensure.
There needs to be a common licensure title and a common scope of practice for counselors. The 20/20 Building Blocks to Portability Project, co-sponsored by ACA and AASCB, concluded this past year with widespread endorsement of both a single licensure title for counselors and a scope of practice for professional counseling.

At the AASCB meeting, I heard stories of problems confronting licensed professional counselors who try to move from one state to another. The obstacles mentioned most often included the number of hours required, course work requirements, testing requirements and post-graduation supervision hours.

Lack of uniformity among state licensure boards clearly exists, and it serves as a deterrent to the mobility of licensed professional counselors. It is our professional and ethical responsibility to correct the existing problem of limits to licensure portability for professional counselors.

Details of some of the recent efforts to move the counseling profession toward licensure portability will be featured in the April issue of Counseling Today.

All the best,

Robert L. Smith, Ph.D., NCC

Counseling is a professional relationship that empowers diverse individuals, families and groups to accomplish mental health, wellness, education and career goals. u

CEO’s Message: The counselor’s role in ‘You are not alone’

By Richard Yep

Richard Yep, ACA CEO

Last month, ACA served as a co-presenting sponsor of the Human Rights Campaign’s Time to Thrive Conference. This is a gathering specifically focused on the safety, inclusion and well-being of young people who are lesbian, gay, bisexual, transgender or questioning (LGBTQ). Keynote and content sessions for practitioners and those working in the public policy arena were numerous. In addition to mental health professionals, community advocates and those who work for government agencies, however, there was an incredibly important group in attendance. In fact, the conference was organized for this group — youth who are LGBTQ.

For me, the Time to Thrive Conference is a powerful experience because of the nexus it creates for mental health providers, community advocates and LGBTQ young people who benefit by learning that they are not alone. All of us were under one roof and could learn from one another.

What I said at the opening plenary was simple: “You are not alone.” Rather than just focusing on the young students in attendance, I was also speaking to the many organizations and professionals who were there. What I wanted everyone to know was that the conference was designed to educate, train and create a dialogue among all who were in attendance.

I know many of you who work with clients and students make sure they understand that, regardless of the issue, “they are not alone.” Quite simply, they have you, as a professional counselor or counselor educator, to confide in, and they know you will help them as they face life’s challenges.

It’s one thing for me to stand on a stage and say “you are not alone,” but I am overwhelmed (and grateful) that so many of you follow this same mantra in your work with clients and students each and every day. I think the positive impact of professional counselors is amazing. In fact, you may not be aware of how your role, combined with those of your colleagues from across the nation and the world, results in protection and advocacy for literally millions of people.

So, now I am going to ask you to do one more thing. I know you are busy, but I hope you will agree that we need to make sure that potential clients, students, families, couples and organizations also understand that they are not alone. Next month is Counselor Awareness Month, and I hope you will join me in raising the knowledge level of as many people as possible regarding the good work that you and others are doing.

We have planned a number of activities and provided resources to make this the best Counseling Awareness Month campaign ever. Be sure to follow ACA’s Counseling Awareness Month 2015 coverage by using the hashtag #CounselorsCare on social media. You will also want to check out the social media photo challenge at counseling.org/CAM2015. While you’re there, learn more about our plans for national media coverage, our free car magnet giveaway and the 2015 Public Outreach Contest (you could win a free registration to the 2016 ACA Conference & Expo in Montreal). Watch your email for more information about this exciting month!

As always, I look forward to your comments, questions and thoughts. Feel free to call me at 800.347.6647 ext. 231 or email me at ryep@counseling.org. You can also follow me on Twitter: @Richyep.

Be well.

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Beyond LGB

By Stephen P. Hebard and AJ Hebard

Counselors are familiar with the meaning of the word oppression. We take a multicultural counseling course that covers the definition during the early developmental stages of our counseling career. Many of us feel the weight of a biased system that puts immense pressure on us, both systemically and individually. We may even advocate for ourselves and others who are underprivileged and overburdened.

Still, we may unknowingly perpetuate oppression through a lack of awareness of our privilege. Whereas sources of oppression such as racism, sexism and heterosexism are familiar, we infrequently consider privileges granted by gender identity status. Transgender individuals — those

Laverne Cox, the first openly transgender person nominated for an Emmy award, appeared on the cover of Time magazine last year for an article about the relatively recent rise of transgender awareness in society.

who do not identify with their assigned gender at birth or whose expression of gender differs from societal expectations — are perhaps one of the most oppressed and least supported populations that counselors must acknowledge.

According to the 2012 report by the National Coalition of Anti-Violence Programs (NCAVP), 41 percent of transgender individuals have attempted suicide, which is more than 25 times the attempted suicide rate of the general population (1.6 percent). Fifty-three percent of all anti-LGBT homicide victims were women who were transgender. Youth populations are not excluded from transgender oppression. In grades K-12, more than 75 percent of transgender students experience harassment, more than 33 percent are physically assaulted and 12 percent experience sexual violence. Also according to the NCAVP report, 29 percent of respondents on a housing survey who identified as transgender or gender nonconforming said they had been denied access to shelter because of that identity. An overwhelming 41 percent of black transgender individuals reported being incarcerated “due only to gender identity/expression.” Unfortunately, these glaring statistics represent only the tip of the iceberg regarding transgender oppression and transphobia in society.

Clearly, a massive gap exists between counselor competency and the lived experiences of transgender people. Our helping profession must make a conscious shift in its understanding of gender as it relates to the human body. As part of multicultural competency, it is imperative that we fully understand that cissexism is oppressive and begin to advocate for a more inclusive paradigm. We must understand diversity and identity beyond lesbian, gay and bisexual (LGB) and develop a comprehensive knowledge of transgender identities to truly practice nonmaleficence. This shift must occur in our textbooks, our curriculum, our intake processes, our communities and, perhaps most importantly, our interactions with transgender clients.

Glossary of terms

The following list of words and phrases is intended to explain only the basics of the language surrounding transgender issues today.

Male: Someone who identifies as male. There are no other requirements.

Female: Someone who identifies as female. There are no other requirements

Cisgender: Someone who identifies with the gender they were assigned at birth (not transgender).

Transgender: Someone who does not identify with the gender they were assigned at birth or whose expression of gender differs from societal expectations.

Gender binary: Social structure that says there are only two genders: male and female.

Nonbinary: Those who identify themselves other than male or female.

Gender identity: The gender with which a person identifies (e.g., male, female, agender, genderfluid).

Agender: Not identifying with any gender or having no gender.

Genderfluid: Identifying with different genders at different times, which change from one to another in a fluid manner (e.g., “Today I feel like a boy, but last week I didn’t have a gender at all”).

Sexual orientation: Clarifies what gender(s) an individual is attracted to (e.g., gay, straight, bisexual).

Cissexism: An axis of oppression that privileges cisgender (not transgender) people.

Heterosexism: An axis of oppression that privileges heterosexual people.

Intersectionality: The study of the interactions of multiple systems of oppression (e.g., transgender status and race/ethnicity).

Genital essentialism: The belief that bodies are gendered based on their genitals or “biological” sex (e.g., male bodies or female bodies).

Cisnormative: The assumption that a person’s gender identity is the same as their sex assigned at birth (i.e., cisgender).

Transsexual: Made by heterosexual cisgender men, this word describes a person with a disordered and unnatural disease for which the only cure is physical transition. Alternatively, transgender is a word created by and for transgender people and doesn’t carry the stigma that transsexual does, nor does it imply physical transition. However, some transgender people still choose to identify with or reclaim this word.

Doing our homework

Many people feel overwhelmed the first time they encounter these words and phrases, and counselors should remember that being an ally means doing their homework. It is important for counselors to understand that heterosexism and cissexism are two very related but still separate axes of oppression. An individual can be any sexual orientation while still identifying as cisgender and being cissexist. Straight transgender people can be heterosexist as well. In fact, the LGB population that is cisgender does not experience cissexism and is often oppressive to transgender people. Cissexism is a massive institutionalized structure that takes work for the privileged to understand, just like more familiar forms of oppression such as racism or sexism. In addition, most media is made by cisgender people and is therefore decades behind in portraying the experiences of transgender people.

To be competent and respectful in working with transgender people, it is helpful to identify their preferred words. This can primarily be done through social media, where transgender people speak loudly and unstifled by the threat of violence that is sometimes posed in face-to-face conversations. Engaging with sites such as blackgirldangerous.org, Twitter and Tumblr, reading blogs, watching YouTube, learning from transgender people themselves, referring to self-identification and being open to listen are all strategies for expanding one’s understanding of transgender issues.

It is imperative that counselors do not make assumptions that dismiss a transgender client’s independence by asking that client to act in accordance with the counselor’s values rather than the client’s own values. Counselors who place their cisnormative value system on transgender clients are committing both invalidation and harm. Likewise, counselors who are aware and understanding of differences without treating the individual as “less than” provide a safe space for the client.

In the spirit of nonmaleficence, the “do no harm” principle, counselors must avoid acting in any way that could potentially inflict harm on a client. If we are to serve and protect such a vulnerable population, we must put an emphasis on understanding the needs of transgender clients. Counselors have a unique opportunity to provide a corrective experience for these clients by giving them an interpersonal exchange with someone who is willing to learn, listen and empathize without insult.

Beyond doing no harm, it is crucial that we act as allies and advocates when working with transgender clients, being proactive in our attempts to provide optimal services. Many transgender clients feel unsafe with “LGBT-friendly” counselors because these practitioners may have competence related only to sexual orientation. Indicating a specific competency with transgender issues and your status as a cisgender individual (if applicable) can be much more welcoming.

How can you make a difference?

It is important for counselors to have familiarity with privilege and oppression as social constructs that create power dynamics within our work. Microaggressions, which are subtle and often unintentional forms of discrimination, remain commonplace even in counseling spaces. Such invalidations, although less obvious or harshly intended as an overtly cissexist or anti-trans remark, still must be understood as assaults that dismiss and denigrate transgender clients. Even the most empathic counselor can make the mistake of misgendering or committing a microaggression toward a transgender client that sends the message, “This is not a safe space.”

Although knowledge of current transgender issues and how to work with this population may be limited, counselors should consider the following suggestions.

1) Always refer to self-identification

“What language do you prefer when referring to your body?”

How do you know when a transgender client walks through your door? You don’t. Many transgender people do not “look transgender.” According to the National Transgender Discrimination Survey, 71 percent of respondents said they hide their gender identity, and this figure only encompasses those who were willing to respond to a survey about being transgender. It is quite possible that many others did not feel comfortable responding because of their “closeted” status.

To facilitate healing in this population, it is important never to assume a person’s gender or pronoun preference. Instead, gender can be thought of as something you learn as you get to know someone, just like their name or hometown. Before you learn someone’s gender or pronoun, use neutral language such as they/their/them pronouns and “that person” to refer to them. In this way, always refer to self-identification and use the language that reflects what your client chooses. Furthermore, counselors must be clear on the fact that a transgender woman is a woman and a transgender man is a man. A transgender woman is not a man who thinks he is a woman, and vice versa.

2) Offer your pronouns

“My name is Stephen. I prefer he/him/his pronouns.”

Especially in the intimate setting of a counseling session, one of the best ways counselors can indicate a safe space to clients is by offering their pronoun preference first. Offer your pronouns by simply sharing them when introducing yourself. Ask the client’s preference and then respect that preference. This sort of initiative is not only an invitation to the client but also a recognition of privilege. It communicates to the client, “I know it is frustrating and exhausting to constantly correct and inform strangers, so I will take the burden for you.”

Furthermore, correcting oneself when misgendering a transgender client is a sign of commitment to inclusivity. Additionally, introductory paperwork that reflects the respect of one’s counseling staff can go a long way toward provision of safety and comfort. By offering your pronouns, you begin to build a safe environment and establish the therapeutic relationship.

3) Recognize more than two genders

“How do you describe your gender identity?”

Some transgender clients, mostly those who are nonbinary, will prefer to use they/them/their pronouns, which take the place of he/him/his or she/her/hers in sentences referring to them. (That’s why we use they/them/their pronouns throughout this article). Others may use pronouns you may never have heard of. Even Facebook, the popular social media outlet, has updated its website to be inclusive of gender diversity by allowing for more choices than the male-female binary and by asking for an individual’s preferred pronouns.

Although some counselors may at first find the use of this language a feat of grammatical acrobatics, it is important to keep in mind that your client’s sense of safety is predicated on you respecting their gender identity. In addition, keep in mind how your language excludes those who are not male or female: saying “he or she” when attempting to describe everyone is a very common microaggression in communication that excludes nonbinary individuals.

4) Start de-gendering strangers

“Your body is your own, and you can define it how you like.”

The easiest way to avoid misgendering strangers is simply to not gender strangers. We need to eliminate the coercive attribution of gender based on physical characteristics such as breasts, wide hips or facial hair. If a transgender person identifies as female, then they have a female body. Instead of viewing transgender women as “trapped in male bodies,” we must broaden our definition of “female body” to make room for the bodies of women with wide shoulders, facial hair and external genitalia.

In working with transgender clients, it is important to recognize that there is no such thing as a “biological” gender. Rather, bodies only have a gender when designated by the owner. Another way of describing this phenomenon is to describe sex as a social construct just as much as gender. For example, if most people with type “A” bodies are female, but some are not, we can assume that type “A” bodies are not inherently female or do not inherently cause female-ness.

5) Practice seeing and hearing gendered language

“Women’s rights should include more than individuals with a uterus.”

The role of an ally is not simply to know how to avoid misgendering and committing other microaggressions. An advocate for transgender clients has the responsibility of correcting others who misgender, stereotype, tell inappropriate jokes or oppress transgender communities in any other way, whether overt or subtle. Your courage as an individual of privilege and power can save or, at minimum, improve the life of someone who is all too familiar with being “other.” Systemic changes can eventually happen when they start at the individual level.

Conclusion

This article is meant to serve only as a brief introduction to working with transgender clients. There is no step-by-step formula to providing guidance for any individual of the transgender community. However, the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC) Competencies for Counseling With Transgender Clients (approved by the American Counseling Association Governing Council in November 2009) provides practitioners with a baseline position from which to begin one’s education.

Counselors, and not only those of cisgender privilege, must be pursuing continuing education and self-awareness to provide optimal services to transgender clients. This includes lesbian, gay, bisexual and other nonheterosexual individuals who don’t identify as transgender. Counselors must also remember that the language of oppressed communities is always changing and growing. Therefore, continued education is necessary. Addressing these action steps to change your language is not a simple task. However, your efforts will be catalysts for the healing process and may represent the first time that a client has had a health professional show empathy for their identity.

Continued opportunities for awareness and advocacy may include reading the World Professional Association for Transgender Health Standards of Care and obtaining membership in ALGBTIC, a division of ACA.

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Stephen P. Hebard (he/him) is a licensed professional counselor associate in North Carolina, a national certified counselor and a doctoral candidate of the Counselor Education Department at the University of North Carolina at Greensboro. Contact him at sphebard@gmail.com.

AJ Hebard (they/them) is a transgender counselor education master’s student at North Carolina State University. They are currently the social advocacy chair of the Nu Sigma Chi chapter of the Chi Sigma Iota honor society and are passionate in their advocacy for transgender communities. Contact them at ajhebard@ncsu.edu.

Letters to the editor: ct@counseling.org

Empowering youth victimized by cyberbullying

By Janet Froeschle Hicks February 25, 2015

Technology has changed the way adolescents bully one another. What once happened during an eight-hour school day now happens online within the home environment. This form of bullying is inescapable and occurs at all hours of the day and night. For victims, the consequences of being targeted by this behavior can range from lowered academic achievement to mental health issues such as anxiety, depression and even suicide. When assisting victims of cyberbullying, I find a combination of principles from Rudolf Dreikurs’ mistaken goals, Betty Lou Bettner and Amy Lew’s Crucial C’s, Alfred Adler’s social interest and Steve de Shazer’s solution-focused brief therapy to be helpful.

Dreikurs contended that children mistakenly seek out attention, power, revenge and inadequacy in lieu of healthy personal goals. This might explain some of the behavior associated with cyberbullying. For example, adolescents might bully one another to gain attention or power from others. The victim may then choose to perpetuate the behavior by seeking revenge or choosing a stance of inadequacy and hopelessness.

Fortunately, Bettner and Lew describe four Crucial C’s that I find helpful to positively displace a youth’s mistaken goals. These Crucial C’s consist of feeling connected, feeling courageous, feeling capable and feeling that you count (or are important). In my opinion, shifting the focus from Dreikurs’ mistaken goals of revenge, power, attention and inadequacy to those of courage, capability, connectedness and importance may change the outcome of cyberbullying from victimization to empowerment. This change of focus could alter the cycle of cyberbullying so that victims do not choose revenge and therefore avoid becoming perpetrators themselves. Additionally, victims become focused on improving internal characteristics and, in turn, enhance mental health.

Adler’s social interest may be used to further reinforce these Crucial C’s. Victimized youth who become involved in helping others demonstrate courage as part of initial engagement and experience connectedness as a result of their community involvement. Furthermore, I believe they experience a sense of counting or importance as a result of their contributions, as well as self-evidenced proof of their capabilities. As youth victimized by cyberbullying experience these Crucial C’s firsthand, they become empowered and feel more in control of their feelings and reactions. Self-efficacy and self-esteem begin to replace anxiety, depression and hopelessness.

The theoretical principles mentioned above become even more productive when combined with de Shazer’s solution-focused brief therapy techniques to assist victims of cyberbullying. Complimenting youth when they avoid mistaken goals and demonstrate positive attributes and behaviors builds a foundation on which courage can thrive. Instead of exhibiting retaliatory behaviors, the victim of cyberbullying may exhibit developmentally appropriate coping skills. According to de Shazer, complimenting involves pointing out a person’s strengths so that self-efficacy is instilled and recognized. Exception questions allow victimized youth to uncover times when they responded to difficult times without negative behaviors or emotions. This encourages a focus on what works rather than replicating self-defeating mistaken goals and behaviors. Solution-focused brief therapy feedback allows the counselor to reinforce the client’s strengths at the end of a session, connect ideas by agreeing with the client’s stance and suggest a task for the client to undertake.

In short, a synthesis of Dreikurs’ mistaken goals, Bettner and Lew’s Crucial C’s and Adler’s social interest with de Shazer’s solution-focused brief therapy techniques may empower victims of cyberbullying and improve their mental health. The case of “Elizabeth” that follows illustrates how I specifically combine these elements within a counseling session.

Case study

Elizabeth is a 14-year-old high school freshman. Her teacher referred her to the school counselor because her grades are falling and she is skipping classes. Not surprisingly, Elizabeth reveals that she is spending most of her nonschool time communicating with others through social media. It doesn’t take long for the counselor to discover that another girl is cyberbullying Elizabeth. Elizabeth indicates that her self-esteem has fallen, and she thinks about the social fallout constantly.

Because Elizabeth’s self-esteem and grades have declined, she needs to believe that she is capable of succeeding and that she has value (or that she counts). At the same time, she requires the courage to overcome feelings of inadequacy, thoughts of revenge and a desire for power and attention. The connectedness she already possesses with friends and family may help Elizabeth overcome some of the negative feelings associated with being cyberbullied.

To accomplish this in the counseling session, I use a five-step model:

1) Build rapport

2) Identify and express emotions

3) Integrate feelings and experiences

4) Develop coping strategies

5) Administer feedback

The initial use of solution-focused brief therapy may be effective in building rapport with Elizabeth and changing the overall tone of the session from a focus on the negative to a more positive position. Elizabeth needs to be genuinely complimented so that she minimizes feelings of inadequacy and refocuses on her personal strengths. Asking Elizabeth exception questions helps her to focus on instances when she has been successful. When followed by solution-focused complimenting, this also helps her to reframe the situation and begin to feel empowered.

Next, Elizabeth must identify and express the emotions she feels at home, at school and online. To accomplish this, I ask Elizabeth to describe how she feels in each setting and to associate a color with each feeling. Next, I have her draw a line using a different colored marker for each emotion on three separate pages (school, home and online). Each colored mark is labeled and discussed as a representation of an emotion she feels within that particular setting. I then use solution-focused brief therapy complimenting and exception questioning techniques to demonstrate ways in which Elizabeth is positively handling these emotions. Pointing out times when Elizabeth has handled similar emotions adequately ensures a focus on her strengths and a repetition of the Crucial C’s as demonstrated in her response behaviors.

To integrate feelings and experiences and to expand on ways that Elizabeth is demonstrating the Crucial C’s, I find it helpful to assist her with associating mistaken goals and the Crucial C’s. When shown separate index cards, each containing a written mistaken goal, Elizabeth reads the word and describes a time when she experienced each feeling. For example, Elizabeth might read the word inadequacy and say, “I feel inadequate every time that girl posts something about me.” Or Elizabeth might say, “The word revenge reminds me of the time I got even with her by telling lies about her to others.”

After Elizabeth elaborates and finishes the story, I ask her to tell me which of the Crucial C’s she needed to improve the situation. She then retells the story using the selected Crucial C. For example, Elizabeth might retell the story about revenge with a new focus on courage and connectedness. For instance, “That girl said I was ugly, but instead of making up lies about her, I logged off and texted my best friend. We talked about other things until I forgot all about it. It took courage not to get even, but because I have other friends, I was able to do it.”

Finally, I ask Elizabeth to generate short-term and long-term coping mechanisms. Exception questions help Elizabeth recognize and generate this list of ways she has previously coped in similar situations. These strategies may include creating art, journaling, playing video games, playing with pets, exercising or participating in sports, playing or listening to music, doing guided imagery, visiting with friends, talking to parents and numerous other ideas. To strengthen her long-term coping strategies, I ask Elizabeth to find a social interest activity. Suggested activities include mentoring younger children affected by cyberbullying, creating safety tips for children who surf the Internet, reading empowerment stories to younger children, reading to or visiting elderly adults, volunteering to work in community agencies and countless other possibilities. I then ask Elizabeth to contemplate these ideas, generate a list of both short-term and long-term coping strategies to use during the next week and return to the next session with social interest ideas.

At the end of the session, I incorporate de Shazer’s solution-focused brief therapy feedback technique. I compliment Elizabeth once again so her strengths are evident to her as she leaves the session. For example, I might say, “I recognize the courage it took to share all of this with me this week. I think that shows you have strengths to help you get through this.” Then I might add, “I agree that you need to feel better about yourself. Over the next week, I suggest using the short- and long-term coping strategies you listed as well as finding a project to help others while helping yourself.” To conclude, I ask Elizabeth to report on her success at the next session.

Subsequent sessions focus on self-reported improvement and implementing social interest activities. There is also continued focus on implementing the Crucial C’s in lieu of mistaken goals. Solution-focused brief therapy techniques, including complimenting, exception questions and feedback, are used throughout all sessions to continue reinforcing Elizabeth’s strengths. Finally, I incorporate Internet and online safety and social media trainings for Elizabeth and educate her parents on what Elizabeth is experiencing all day, every day online.

Why include parents?

Parents are included in future sessions for several reasons. First, upon hearing about cyberbullying, many parents fear the Internet and insist that their children avoid all technology. Although this may be an effective short-term solution, I do not believe it helps long term. Eventually, youth find themselves required or tempted to use the Internet for employment, homework or socialization.

As a result, I teach Internet and online safety skills both to parents and youth. These safety tips provide education about privacy and restraint when posting online, decrease fear and allow youth to continue using the Internet provided that their parents are involved in Internet communications. Youth and parents must understand the importance of keeping specific personal information private as it relates to the long-term and worldwide reach of the Internet. Once parents understand how to use social media appropriately, they have an opportunity to become role models for the proper use of technology. Learning strategies to avoid harm while using the Internet may be an important mechanism for personal empowerment for both victims of cyberbullying and their parents.

Another reason counselors should involve parents is related to the mistaken goals discussed earlier. Initially, parents often respond to their child’s victimization with inappropriate feelings of attention, revenge, inadequacy and power. These feelings could result in parental behaviors that perpetuate bullying rather than improving the situation. For example, some parents initially respond to knowledge that their child is being cyberbullied with feelings of revenge. These parents may confront the bully or the bully’s parents and unknowingly increase, rather than decrease, their child’s victimization.

I teach parents to first empathize and communicate with their child. It is important that any parental response to bullying first be discussed with the child. If nurtured, the bond between parent and child may become the greatest protective element for youth who have been cyberbullied.

Conclusion

As Elizabeth experiences the Crucial C’s firsthand through social interest, feels secure in the bond with her parents and focuses on her strengths, she begins to feel empowered rather than victimized. Internet safety tips that illustrate the importance of privacy and restraint when posting online further demonstrate to Elizabeth that she possesses courage and has control over life events. Eventually, Elizabeth is able to focus on her own value rather than on the unhealthy stigma perpetuated by others.

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

Janet Froeschle Hicks is an associate professor of counselor education and chair of the Educational Psychology & Leadership Department at Texas Tech University. She is both a licensed professional counselor and a certified school counselor in Texas. Contact her at janet.froeschle@ttu.edu.

Charles R. Crews, associate professor of counselor education at Texas Tech University, also contributed to this article.

Letters to the editor: ct@counseling.org

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