Monthly Archives: February 2015

Counseling clients with cancer

By Lynne Shallcross February 24, 2015

As of Jan. 1, there is official recognition that a cancer diagnosis can, and often does, affect a patient’s mental health. At the beginning of the year, a requirement was put in place for cancer programs to screen all patients for psychosocial distress in order to receive accreditation through the American College of Surgeons Commission on Cancer. The centers accredited by the commission treat almost 70 percent of newly diagnosed cancer patients in the United States every year.

The new guideline represents a step forward in terms of acknowledging the link between mind and body when it comes to cancer. But for Gary Patton, this “new” emphasis is really nothing new at all.

Patton has worked as a counselor in the cancer center at St. Mary’s Medical Center in Huntington, West Virginia, since 2008. Working at the time as the director of St. Mary’s employee assistance program, the hospital reached out to him after medical professionals there took note of increased mental health concerns among oncology patients.

St. Mary’s ultimately decided to establish a Department of Mental Health Counseling and Employee Assistance Program, which Patton directs. The main purpose for creating the department, he says, was to bring a counselor to the bedsides of patients, primarily in the oncology center. In addition to Patton, the mental health counseling department employs another full-time counselor and one part-time counselor. It also runs a medical-based counseling internship program for counseling students.

“The thing that St. Mary’s was looking at in 2008, [hospitals are] looking at across the nation now: What psychologically happens to patients when they hear ‘You have pancreatic cancer’ or ‘You have lung cancer’? You know, what’s happening to these patients and these families? If we’re not going to assess their distress levels with that, then we’re leaving a piece of their care unattended,” says Patton, a member of the American Counseling Association.

Patton says the new accreditation requirement means that hospitals “can’t just assume, ‘Oh, that patient looks like they’re OK. They’ll let us know if they need something.’ So just like [with] every patient, you check their vitals, you check their blood levels … but every patient needs to be assessed for the psychological reaction to cancer.”

According to the World Health Organization, the number of new cancer cases is expected to rise globally by about 70 percent over the next two decades. The news is better in the United States, where the cancer death risk is actually decreasing. But the numbers are still staggering. According to the American Cancer Society, an estimated 1,658,000-plus new cancer cases will be diagnosed in the United States this year. And if the vast majority of the country’s new cancer cases are treated in centers now required to screen for psychological distress going forward, a growing need may soon exist for mental health practitioners to work with these patients.

“Historically, psychologists and social workers are the most commonly found mental health providers in medical systems,” says Mary Jones, a counselor in private practice in Sioux Falls, South Dakota, who also teaches in Capella University’s mental health counseling graduate program. “I think we [counselors] need to be more involved in getting in on that turf.”

Jones’ background includes previously serving as a counselor in the oncology clinic at a hospital in Sioux Falls, where she worked with cancer patients, their family members and their caregivers as well as the health care providers treating those patients. To illustrate how well suited counselors are for this area of work, Jones points to recommended practices that she says were given to hospitals by the National Cancer Institute Community Cancer Centers Program a little less than a decade ago. The recommendations included facilitating communication between patients and health care providers, identifying the psychosocial needs of patients and engaging patients in the management of their care.

“All of those things are things that mental health counselors do,” says Jones, an ACA member who presented on the topic of working with cancer patients at the ACA 2014 Conference & Expo in Honolulu. “We work on communication, we work on coordination, we work on getting clients invested in their wellness journey, so it just seems to me like this is such a natural fit.”

The gamut of emotions

A man recently took a bad fall on his construction job, so he came to St. Mary’s Medical Center to get checked out. The doctors took X-rays and scans, but instead of finding an issue related to the fall, Patton says they discovered a cancerous mass.

People often get blindsided by a cancer diagnosis, Patton says, even when they sense that something is wrong. “Sometimes we find with these patients that their symptoms don’t seem to add up to the severity of something like cancer,” he says. “Many of our patients will say, ‘I’ve been tired, I haven’t had much of an appetite, I’ve lost a little bit of weight and my back’s been hurting.’ That could be the flu. [But] they come here and find out that it’s cancer.” Understandably, he says, they leave in total shock.

Patton describes other instances in which patients receive a cancer diagnosis and, instead of shock, immediately adopt a defeated attitude. “So on the one hand you have crisis and shock, and on the other hand, as soon as they hear it, [certain patients think], ‘Well, I’m not surprised. Most of my family members had cancer, and I’m going to die too.’ I think those are two unique dimensions of treating people who have cancer from a psychological perspective,” Patton says. “Because on the one hand, you’re doing crisis counseling. And on the other side, you’re talking about the will to live and trying to help people mobilize some resources.”

Jones says several clients told her that they prayed to God and tried to bargain even before a formal cancer diagnosis was made. “If you don’t give me cancer,” they’d pray, “I’ll do this or that in exchange.”

It may come as a surprise to learn that once those patients actually received a diagnosis and treatment plan, they often experienced some decrease in their anxiety and depression, Jones says. “Now they had a plan. Now they had knowledge. It [was no longer] scary, unknowable stuff that was happening,” she says.

But once treatments such as chemotherapy and radiation were set to begin, Jones says the patients’ fear tended to spike back up because they didn’t know what to expect. “Once they got through the first two sessions, there was again a lessening of anxiety because they knew what to anticipate,” she says.

When cancer clients have a history of severe mental illness, the cancer diagnosis has the potential to exacerbate that illness, so counselors should be on the lookout for increasing symptoms, Patton says. Along those same lines, he says counselors should be aware of what psychotropic medications the person is taking and what impacts the cancer treatments could have on those medications, and vice versa.

Patton worked with a client being treated for cancer who also had a history of schizophrenia. The client was on a medication for the schizophrenia that wouldn’t cooperate well with chemotherapy treatments. Patton, the pharmacist and the oncologist worked together to gradually move the patient to a different schizophrenia medication so she could safely begin the chemotherapy for her cancer.

ACA member Sejal Barden, an assistant professor of counselor education and coordinator of the marriage, couples and family therapy program at the University of Central Florida, says clients with cancer can also feel isolated. Although friends and loved ones often provide plenty of support right after a diagnosis is made, as time passes, they often don’t know what to say, explains Barden, who previously worked in a cancer center for two years and currently researches the impact of breast cancer on Latino couples. In cases in which a client feels isolated or abandoned, support groups for cancer patients can provide a good forum to vent and to feel less alone, she says.

Questions of a spiritual or religious nature are also common when patients are dealing with a cancer diagnosis and treatment, Jones says. “There was a lot of discussion in sessions over ‘What’s going to happen to me when I die? Where do I go? Where does my spirit go?’” she says. “Difficulties for me [definitely included] seeing them die but also trying to help them say goodbye to family members and trying to make meaning out of what was going on.”

In cases in which clients are unable to beat cancer, Jones says, counselors might be tasked with helping them consider end-of-life decisions or quality-of-life issues in their remaining time. Jones tried to connect clients in such circumstances with a variety of resources depending on their concerns, including helping them meet with a hospital chaplain or reach out to hospice care.

Predictably, Jones says that feelings of fear, depression and anxiety are quite common in clients throughout the cancer diagnosis and treatment process. Other issues she encountered regularly with her clients included changes in appetite, difficulties sleeping, financial concerns related to paying for the treatments and concerns about changes in sexuality due to the cancer or medication. “And then, almost without exception, somebody with cancer worries about it recurring,” she says.

Patton agrees. Even patients who get through cancer treatment and seem to be recovering well become very anxious again whenever the time comes for a regularly scheduled checkup scan, he says.

In the script of a television commercial Patton did for St. Mary’s about how counseling helps clients with cancer, he said, “Once that word cancer is used in the same sentence with your name, your life will never be the same again.”

That change can take two forms, he explains. “It could put a cloud over this person that never fully goes away, or it could show them a vitality and resilience for life they never had before because they know how close maybe they came to death or how close they came to chronic suffering. And they’re past that now, and they’re enjoying life more than ever because they’ve had that critical experience,” Patton says.

Taking a systemic approach

Although cancer traditionally has been conceptualized as an individual diagnosis, research has begun conceptualizing it as a couple’s or family’s disease, Barden says. The impact of cancer on loved ones became apparent to Barden in her work with a cancer survivor support group in North Carolina.

“What kept coming up for those women was how much the cancer had impacted their relationships, their marriages, their partners, but how there were no supports for their partners,” says Barden, who spent a month last summer as a fellow at the National Cancer Institute. “The cancer survivors felt there were adequate psychosocial groups, counselors, etc. [for them], but there was really nothing for their partners to be able to talk about how they were experiencing [it].”

“Sometimes the loved ones are actually more distressed than the patient is,” observes Patton, who also teaches in the online counseling program at the University of the Cumberlands in Williamsburg, Kentucky. “I’ve had patients tell me, ‘My family needs to settle down. … It’s like they’re more worried about me than I am about me.’”

Burnout can be a huge issue for loved ones and caregivers of a client with cancer, Jones says. “The thing I heard over and over again in my support group for caregivers was they needed a break, they needed to get away from it,” she says. “These are things we’d work on in our group sessions — being able to say to people around them, ‘I don’t want to talk about cancer today. I don’t want to think about cancer today. Can we just talk about anything else?’”

Jones says she would remind her caregiver clients that if they didn’t take good care of themselves, then they wouldn’t be able to adequately care for their loved ones with cancer over the long term. Caregivers and loved ones can also experience feelings of anger for bearing the heavy burden of caregiving, Jones says, and, oftentimes, they then feel a sense of guilt for having such feelings.

Additionally, Jones says, there are often concerns around parenting, especially related to deciding what to tell children about the cancer diagnosis and when. Jones recalls one client and his wife choosing to wait to tell their college-age children about his cancer diagnosis until he was in his third session of chemotherapy, primarily because that was when their children would be finished with their final exams.

The hospital where Jones worked had a program in place for parents with younger children. Jones would fill a backpack with age-appropriate information about cancer as well as toys and games to send home to the children.

When taking a systemic approach, counselors should also pay attention to how the actions of loved ones might be affecting the cancer patient now and what the dynamics of the family system were prior to the diagnosis, Patton says. “Maybe there have been disruptions of some kind — divorce or alienation from family,” he says. “Once that diagnosis of cancer comes, it can be a resurgence of all that. Either people try to overcompensate for the harm or the damage or the disruption that they’ve had in the past, or it can take those problems and make them worse.”

At times, Patton and his colleagues will notice loved ones hovering over the patient and drawing a negative reaction from the person. “Sometimes you’ll find that this [involves] family members who haven’t spoken for seven years, and now they’ve heard cancer and they’ve rushed in to be the rescuers. And it’s really irritating the patient.”

Helping the patient and his or her loved ones communicate about the realities of the diagnosis and treatment can also be a critical role for the counselor, Patton says. He has witnessed situations in which both the patient and the patient’s family thought the other didn’t truly understand how bad the cancer diagnosis was. Therefore, they completely avoided talking about it with each other.

Patton says he tries to “expedite a different type of conversation,” reminding the patient and the patient’s loved ones that “truth does not have to be projectile.” Meaning, he says, that they don’t need to share everything they know in one encounter but can instead slowly open up the lines of communication.

From theoretical to practical

Patton says that in his experience, cognitive behavior therapy (CBT), mindfulness and group work can be especially productive when working with clients who are dealing with cancer.

CBT allows clients to explore their emotions and feelings without allowing those emotions and feelings to control everything, Patton says. Behaviors and emotions are determined by thought processes, he points out. So while CBT gives emotions respect, it also enables clients to look at their individual situations again and think about them differently when tackling questions such as “Am I going to be compliant with treatments?” or “How will I live my last days?” says Patton.

A colleague of Patton’s practices mindfulness with clients at St Mary’s cancer center. Patton says this helps clients bypass some of the associated distress and experience some physiologic comfort and relief. Mindfulness can also help clients to reconnect with their bodies and their existence as a person, he says. For example, “I’m not just a cancer patient. I’m a patient who has cancer, but I’m also a patient tomorrow who’s going to see my grandchildren,” Patton says.

Group work can also be beneficial for these clients because it offers them a place to feel support, a sense of belonging and camaraderie. One of the support groups at Patton’s hospital is for cancer clients under the age of 40. One of the topics the group has addressed is being confronted by mortality at such a young age and how to respond to clichés from other people, such as “You’re young; you’ll be fine.”

Judy Green is an ACA member who teaches in the Walden University School of Counseling and co-presented with Jones at the 2014 ACA Conference in Honolulu. She says counselors must be aware of grief issues when working with clients with cancer and their loved ones. For example, Green says, even clients who have survived cancer go through a grief process. Counselors can help those clients validate their feelings of having survived cancer and navigate a new normal now that their life has changed. They might grieve the loss of what they thought their future would be or the loss of their self-identity as a healthy person, Jones adds.

When working with clients who have lost a loved one to cancer, Green says she gravitates toward William Worden’s “tasks of mourning,” which consist of accepting the loss, working through the pain, adjusting to the new reality without the person and finding an enduring connection with the person who died. Green adds that grief counseling groups can be therapeutic both for those who have received a cancer diagnosis and those who have lost a loved one to cancer.

Though each counselor may lean on his or her own preferred counseling approach or framework when working with cancer clients and their loved ones, Barden reiterates that counselors must not conceptualize cancer as an individual diagnosis. “Really understand how the whole system — the family and the couple — has been impacted, and [know] that while your cancer survivor might come to you an hour a week, they’re really going home to their family each day and every day.” Counselors should strive to educate and work with the whole system, Barden emphasizes. “Taking some kind of family, systemic, couples approach is probably what I would say is best practice,” she says.

Patton also supports taking a systemic approaching and says the family must be included in the counseling work. But he also advises counselors who might be treating cancer patients at bedside to recognize when these patients want and need family there with them and when they need to talk alone with the counselor.

Providing these clients with practical and educational information and resources is also a key element to counseling in this area. Jones points out that cancer patients are typically given a substantial amount of educational information before they begin treatment, but they may be in shock and have difficulty absorbing it all at that point. “In many cases, though they had been given that information, it was kind of my job to synthesize it in a more palatable way for them,” she says.

In addition to screening the oncology patients she worked with for psychological stress, Jones also screened them for the types of services they might need. She connected her clients with available resources such as a nutritionist to discuss what to eat when nothing appealed and the financial services representative at the hospital to discuss how they might afford all the treatments. She also gave out free cancer cookbooks to her clients at the hospital.

At St. Mary’s, Patton provides substantial psychoeducation and cancer education to patients, aiming to “simplify this complex, scary thing called cancer.” Patton often stays behind after the oncologist leaves so he can try to explain anything the patient didn’t understand. He says counselors should focus on simplifying the answers and information without resorting to clichés. “Don’t say, ‘Just hang in there. We’ll take care of things,’” he advises.

An opportunity for counselors to emerge

Even if providing mental health treatment to clients with cancer isn’t a specialty for counselors, Patton suggests that they become educated about it because it is highly likely that cancer will affect one of their clients to some degree. For instance, the client a counselor is treating for bipolar disorder might come to session one week and announce that his dad has cancer. “Well, that counselor needs to be able to understand that concept without becoming so alarmed or so anxious that they give the easy answers or give the clichés,” Patton says.

Because cancer can be a scary word, Patton says counselors should start by becoming comfortable with it themselves. They can take steps toward that by educating themselves about different cancers and treatment processes as well as increasing their awareness of cancer resources in their communities, including other mental health providers who may specialize in this area.

“Because it is so prevalent in our society, I think every counselor needs to become more proficient in understanding what this disease process is, who are the people involved in the treatment of it, what are the various kinds of cancer, how does one begin to understand the treatments available for it and [get] acquainted with the treatment process,” Patton says.

Jones says having education and experience in grief work is helpful for counselors who might like to work in this area, as is the willingness to be at the end of life with clients. She suggests checking the website for the American Psychosocial Oncology Society ( for free resources or even signing up for a membership and taking advantage of workshops and continuing education opportunities.

Barden recommends that counselors visit the National Cancer Institute website ( for resources and read the journal Psycho-Oncology.

Counselors interested in working with cancer patients should reach out to the human resources departments at local hospitals and cancer centers and keep an eye on job openings, Jones says. If there aren’t any current openings, she adds, counselors can explain the kinds of services they provide and investigate doing the work on a contract basis.

When a counselor successfully secures work in a cancer center setting, Jones suggests forming an alliance with the resident doctors and nurses as quickly as possible. Jones says that in her experience at the hospital, oncologists were often open to prescribing sleep and anxiety medications to patients. But oftentimes, she says, neither the doctors nor the patients thought to ask the other about this possibility. When counselors can make those connections and work collaboratively with doctors, nurses and other health care providers, patients will see that everyone is working together on the same team for their benefit, Jones says.

With the new accreditation requirements regarding psychological distress screening for cancer patients, Patton expects to see growth in the resources and continuing education opportunities surrounding this topic. And with that, he sees an opening for counselors, and ACA, to fill the new demand.

“What an opportunity for counselors to emerge here,” he says. “What an opportunity for the American Counseling Association to take a step forward and say, ‘Let’s start looking at this, look at resources, make resources available and become the leader in this field of medical-based counseling.’”


To contact the individuals interviewed for this article, email:


Lynne Shallcross is a former writer and editor at Counseling Today. She is currently pursuing her master’s degree in journalism at the University of California, Berkeley. Contact her at

Letters to the editor:

Stumbling blocks to counselor self-care

By Laurie Meyers February 23, 2015

As a counselor, which of the following elements are absolutely essential for you to do your job well?

a) Thorough grounding in counseling methods and techniques

b) A strong sense of empathy and compassion

c) Adequate sleep

d) Regular vacations or breaks

e) All of the above

The correct answer is e) All of the above. You probably knew that already. But do you also think that answers A and B far outweigh the importance of C and D? If so, you may not be tending to your own wellness the way that you should. All counselors need to regularly engage in a healthy self-care routine to help mitigate the very real risk of burnout.

Many people struggle to attain a healthy work-life balance. Counselors often work with clients toward achieving that balance by helping them understand the concept of self-care and how to nourish wellness. But sometimes counselors get so busy and focused on helping others that they neglect to monitor their own wellness. Counselors may also operate under the assumption that their training and emotional insight somehow inoculate them against burnout — or at least help to prevent it. That Branding-Box-stumbling-blocksis a fallacy. Counseling, like other helping professions such as medicine, nursing, psychology, social work and teaching, has a high burnout rate. Individuals in each of these professions are at greater risk for burnout because of the empathic and close relationships they must form to do their jobs.

“It’s important for people — for counselors in particular — to realize that this is hard work,” says Gerard Lawson, an American Counseling Association member and associate professor of education at Virginia Tech. Though counseling work is not typically physically demanding, emotionally it can take a toll, he says.

Research has shown that the strength of the therapeutic relationship between the counselor and the client is the most important predictor of successful outcomes. But forming, maintaining and operating within that bond are not easy tasks, notes Lawson, a licensed professional counselor (LPC) who studies counselor wellness and burnout. Due to the nature of counseling work, this bond is often forged with people who are struggling or in pain. Confronting those emotions day in and day out can take a toll over time, sometimes leading to vicarious trauma, Lawson explains.

“We are seeing some of the hardest things,” says ACA member Elizabeth Venart, an LPC and director of The Resiliency Center of Greater Philadelphia, where she practices and also provides trauma and resilience training to other mental health professionals. “We often meet people at the worst times in their lives.” In addition, the essential professional component of empathy is the “conduit” through which other people’s experiences can profoundly affect counselors, she says.

On top of that, it’s hard not to want to “fix” every client, says Charles Crews, an ACA member and associate professor in the Texas Tech University College of Education. Although it sounds cliché, many times counselors really do care too much, he notes. “They want to help every single person who comes in,” he says.

Although counselors should want to help every client, when a client isn’t progressing, it can be easy to become disenchanted or hardened, says Crews, whose doctoral dissertation focused on counselor burnout. Less experienced counselors may also start to battle discouragement, doubting themselves and their skills, he adds.

Jennifer Sharp, an ACA member and assistant professor at Northern Kentucky University, says that many of her students come in wanting to change the world. “They don’t understand the barriers,” she says. “We come in [to the profession], and we don’t have realistic expectations.”

ACA member Jonathan Ohrt, an assistant professor in the counselor education program at the University of South Carolina, agrees. He says that counselors-in-training need to give serious consideration to what their professional lives might look like, taking into account their individual work styles, interests and values. Understanding the potential challenges of the work environment for counselors is also particularly important because factors such as inappropriately heavy caseloads, inadequate supervision and poor peer support have a significant influence on burnout rates, say Ohrt and Sharp.

“We don’t necessarily think about what specializations we might be best at,” Ohrt says. He adds that students should ask themselves, “What is my job satisfaction if I work in this setting? Will I be happy? Will I be able to work with addiction? Am I going to be comfortable working in school settings where teachers, the principal and parents are all pulling me in different directions?”

Ohrt says graduate students should also ask themselves the ultimate question: “Do I want to be a counselor?”

Signs of burnout

Having realistic career expectations might help newer counselors to prepare for some of the job’s stresses, but even established counselors need to understand the signs of impending burnout and the steps they can take to avoid it.

According to Lawson, who served as chair of the ACA Task Force on Counselor Wellness and Impairment several years ago, research shows that burnout has three stages.

Emotional exhaustion: Every counselor experiences a bit of exhaustion at one time or another. But when practitioners feel drained as soon as they step through the office door, even with plenty of sleep and after time away to get recharged, that’s generally a sign of emotional exhaustion, Lawson says.

“Sometimes in session, you can see counselors might steer away from a topic that they know is going to be difficult to talk about because they just can’t do it,” he says. “They don’t have anything left there to give to this client, and that’s not good for the client.”

Depersonalization: At this stage of burnout, counselors start viewing clients not as people but as cases. “Sometimes it slips into our language,” Lawson notes. “You’ll hear counselors talk about ‘I have another borderline this afternoon.’”

Lawson acknowledges that this may occasionally be nothing more than a kind of shorthand in the counselor’s language. But usually, he says, it’s more serious, indicating that the counselor is no longer connecting with clients as people and instead reducing them to their problems.

Reduced feelings of accomplishment: At this stage of burnout, a counselor feels that whatever he or she does won’t make a difference. The counselor has, in effect, “checked out,” Lawson says.

Other signs that a counselor is burning out can include a decreased level of involvement with family and friends, a failure to engage in normal social activities and increased instances of tardiness or absenteeism. Sharp says that counselors in a downward burnout “spiral” may also display the inability to handle crises and a noticeable increase in negativism, cynicism and defensiveness.

Burning bright, not out

“I don’t know that there’s a specific antidote to how I keep [burnout] from happening to me, which is why we focus so much on wellness when things are going OK,” Lawson says.

An emphasis on wellness helps counselors to build up their emotional resources so they will be better able to handle bumps in the road when they occur, Lawson emphasizes. Counselors can do a number of things to engage in self-care. Maintaining professional boundaries, seeking supervision and support from colleagues, drawing a clear line between home and office, participating consistently in activities and hobbies, and taking regular vacations are all important parts of the wellness picture.

Perhaps nothing is more important to maintaining counselor wellness than refusing to navigate professional issues in isolation. That is why it is so critical that practitioners actively seek out peer support and ongoing supervision, Lawson says.

“Burnout is a long-term process, a long-term degradation,” he says. “But compassion fatigue, vicarious trauma, those things can happen very quickly. Good clinical supervision is top of the list [of preventive measures] — having someone you can debrief with, someone to help you shoulder the burden. And for people who aren’t in supervision, [having] a colleague or a peer [whom] you can turn to and consult with or debrief with, even if it’s not a formal supervision-type relationship.”

Lawson emphasizes that the supervision should be clinical in nature. “I think in our world, supervision has become a product of being sure that all the boxes are checked and all the t’s are crossed and all the i’s are dotted,” he says. “And that’s important to get reimbursed for the work we do and to be sure that we’re complying with all the expectations. But good clinical supervision is different from that, and that’s where a supervisor is able to ask, ‘What’s happening in the work you’re doing for this client?’ and ‘How are you doing working with this client?’”

If a direct supervisory relationship isn’t possible, counselors should look at the alternative resources available to them, Sharp says. “For example, in school counseling there are not a lot of opportunities for supervision. But one of the things I would do is talk to a more senior school counselor and set up a time twice a month to talk,” she explains. Sharp adds that if a counselor doesn’t have any colleagues within the same school, he or she could look to other schools within the district to find a senior-level counselor.

If counselors don’t have supervisory resources, they should turn to a colleague or peer, Lawson says. Ultimately, what matters is that counselors have someone they can check in with to gain perspective or just to talk to about how certain clients are affecting them.

Venart leads a regular supervision group for counselors who are working to obtain their licensure. Through the years, several group participants have decided to continue meeting together for peer supervision even after completing their licensure hours. Venart stresses the importance of educating new counselors to view supervision as an ongoing, careerlong necessity. She suggests that counselors look for colleagues to connect with in their current workplaces, from former jobs or past professional trainings, or perhaps among the people they met in their graduate programs.

While working on his dissertation, Crews found that if counselors felt they were part of team — even one of their own making — it seemed to have a beneficial effect on their job satisfaction and degree of wellness.

Lawson concurs. His research has concluded that participating in professional organizations plays an important role in peer support, and counselors who are part of such organizations are generally more “well.”

Accepting limits

In addition to offering encouragement, supportive peer groups can help counselors to recognize and accept their boundaries and limitations. This is important because one of the difficult realizations about being a counselor is that it’s not possible to help everybody, Lawson says.

“I think part of the struggle for counselors is when they meet somebody and they want desperately to help them solve their problem,” he says. “Sometimes we counsel people who have problems that are not really solvable.”

He explains further: “I am thinking specifically about things like domestic violence or intimate partner violence. I may meet with someone who is experiencing intimate partner violence … and they’re going to go home to the same violent situation because it’s unsafe for them to leave. [When under no legal mandate to report] I have to sit with that week in and week out knowing that I can’t solve that problem. So I need to have good boundaries about what I can do and what I can’t do. … For me to become more and more invested in them doesn’t help them more. It just means that it takes a greater toll on me.”

When the need is so great, it is easy for counselors to convince themselves that just a little more time or effort, either in the office or outside of it, will solve all the client’s problems, observes Crews. “I work with traumatized kids, and it is really hard not to want to get more involved in their lives,” he says.

However, in his practice and in his role coordinating the school counselor program at Texas Tech, Crews has learned that no counselor can control what happens in a child’s life outside of the counseling office. “Often, school counselors are dealing with parents who do not understand what is going on with their child. You do all this work with [the child] from 8 to 4,” he says, “but then they go home.”

Addiction counseling is another area that requires counselors to have a firm grasp of what they can and cannot do, Crews notes. “Counselors get tired out. They [feel like they] keep banging their heads against the wall because their clients relapse, but that is the nature of addiction,” he says. That doesn’t mean that clients struggling with addiction can’t be helped, but relapse is often part of the process, and counselors need to be able to make peace with that, Crews says.

Counselors also need to recognize when they have reached their limits. “I think one of the things that is really difficult for counselors is to say that ‘I can’t take on another individual who is experiencing such trauma or immediate risk, and there are a lot of good folks out there who can do that work,’” Lawson says. He emphasizes that it is crucial for counselors to realize these limitations before a potential client becomes an ongoing client, however. Disrupting the therapeutic alliance after it has developed can be damaging for the client.

Other times the solution might involve some creative scheduling rather than putting a moratorium on certain types of clients. “I had a period of time when I had many depressed adolescents on my roster in my practice,” recounts ACA member Stacey Chadwick Brown, a licensed mental health counselor with a private practice in Fort Myers, Florida. “Then I noticed that when I had six depressed teenagers in a row on one day, I got depressed.”

Brown didn’t want to turn any of the adolescents away, but she knew she needed to make some adjustments to safeguard her own mental health. After giving the situation some thought, she realized she just needed to spread the clients’ sessions throughout the week rather than scheduling them all on one day.

Sometimes, tweaking schedules can help counselors who are feeling overwhelmed. But other times, caseloads are simply too heavy, and that can be detrimental to both practitioners and their clients, Lawson says. “You have to have pretty good judgment and be able to say, ‘I’m already working 60 hours a week. I’m probably not the best person to take on this next client.’”

In certain environments such as large practices, clinics or agencies, counselors may not have total control over the number of cases they are handling, notes Sharp, a national certified counselor and former school counselor. However, with some planning, counselors may still be able to set some boundaries, she says.

“Counselors need to be careful about what boundaries they can set without putting their jobs at risk,” she cautions. “[But] there are small adjustments you can do to make things more manageable, such as not scheduling things after 6 p.m. or not working 10-hour days.”

Work and life in harmony

Another boundary proves exceedingly difficult for many counselors: leaving work at work and embracing some true downtime.

It took Brown a while to learn how to separate her work from her personal life. “When I was younger, my worldview was different. I thought I could do anything,” she recounts ruefully. “Once I had my first baby, I guess I was just exhausted — and still working. I think that’s when things changed for me. That’s when I realized I had to compartmentalize more.”

Whereas Brown had previously responded to clients in the middle of the night, she decided to stop putting herself “on call.” Instead, she made sure her clients had resources for off-hours crises and informed them she would check in with them the next morning. Brown also stepped up her self-care by making sure she got enough sleep, eating well, getting exercise and taking extra walks in between counseling sessions with clients.

But there was another instance when Brown felt the need to step away from her work for a week to regroup. It occurred when the mother of one of her clients died in an accident that was both extremely traumatic and very public. Brown didn’t know the woman’s mother directly, but the combination of her tangential connection to the woman and the tragic circumstances behind her death made Brown feel that she was experiencing secondary trauma.

Part of that had to do with the shocking and public nature of the story. “It was in the news everywhere, and everyone was talking about it, but I couldn’t say anything,” Brown recounts. She realized that she needed to take a step back and reground herself professionally, which included increasing her focus on self-care. Among other steps, she met and talked things through with colleagues whom she regularly turns to for support.

“Usually what we do as counselors is say, ‘I’ll take on this client, this committee or this task, and I know I have to give something up to have time to do it,’” says Lawson. “And the stuff that we give up is the stuff that’s good for us — like sleeping and time with friends and vacations and all of those things that we know are good for us.”

“I think counselors are notorious for not taking time off, and we have convinced ourselves that we are indispensable in the lives of our clients,” he continues. “As a result of that, we don’t take a week or two weeks off to go recharge our own batteries, and the results can be pretty dire.”

Lawson acknowledges that leaving work behind can be difficult but says counselors can take some intentional small steps to do just that. “I think it’s really important for folks to have rituals for how they take care of themselves,” he says. “Part of that is how do they leave work at work and not take it home with them? So, even with my students, I recommend that when they get home from their internships or when they get home from their work, the first thing you do when you come through the door is change clothes so that you can literally shed the day. I hate to say it this way, but [it’s] so you don’t take the ‘residue’ of work home with you. You put on comfortable clothes — clothes that you’re going to want to spend time with your family in.”

Lawson also knows many counselors who maintain rituals for “closing time” at the office as part of their self-care routines. “Some people have plants in their office, and the last thing they do in the evening is water the plants and tend to them,” he says. “It is sort of a very grounding thing for them. It’s a nurturing thing, but it’s also a closing sort of ceremony for them at the end of their day.”

Other counselors like to leave a clean desk, clearing papers and charts and putting away files. “Then, when you lock that file cabinet, it’s sort of a symbolic ‘I’m putting that stuff aside so that I can move on and go home without it,’” Lawson says.

Lawson asserts that when counselors incorporate a deliberate process of leaving the day behind, they’re less likely to take work home with them too often.

Lawson has a personal story that he keeps in mind: “My grandfather was a police officer back in the days when they didn’t have radios, so they had call boxes around town,” he recounts. “The police officers would carry around these call box keys, and when [my grandfather] got home, he would hang up that key and would be done for the day.”

Crews’ wife teaches theater, where a common directive is, “Leave your issues offstage.” Crews has altered that advice and adopted it as his mantra: Leave it at the door.

“I had an actual floor mat that said, ‘Leave it at the door,’” Crews recounts. “It was a very physical thing. If I wiped my feet, I could leave it there and go on.”

Venart suggests that counselors try “writing and ripping” to help them close the day and leave their work at work. She thinks that the practice of writing about whatever was stressful that day and then ripping up the pages and throwing them away offers a symbolic ritual to help release whatever stress has accumulated. Venart also recommends visualization. For example, counselors might imagine a strong container in which they can transfer the stressful events and emotions from the day. Counselors can then “seal” the container, lock it and put it away somewhere safe.

Leaving room for play

The ability to leave work behind, both physically and mentally, is essential to counselor wellness, and one element that goes hand in hand with that goal is making time to engage in activities that are personally enjoyable, Lawson says.

Some counselors find physical activities to be most helpful, while others enjoy tackling pursuits that sharpen the mind without being related to work.

Lawson likes to take a break from textbooks and other professional publications and read purely for pleasure, while Crews prefers playing video games and going out and being social.

Brown embraces her creativity. “I’m a crafter and a painter. That is really my therapy, my Zen,” she says. “When I am doing artwork, I am fully present.”

Venart is a proponent of grounding work, such as connecting with the body through deep breathing, posture and movement. She’s also a certified “laughter yoga” instructor. (“It’s an actual thing!” she exclaims.) The practice incorporates playful group exercises, laughter and deep yoga breathing. “Research has found that whether you are actually laughing or faking laughter, the [physiological] result is the same,” Venart explains.

Sharp advises counselors to embrace whatever brings them joy, community and a sense of belonging because those elements go a long way toward achieving wellness. “Develop a life outside work that is fulfilling,” she says, “because that can be a buffer and carry you through when work is not a source of fulfillment.”

Small town, big fishbowl

Practicing in a rural or small community poses a particular set of challenges to a counselor’s wellness, say Deborah Drew and Mikal Crawford, both of whom practice in, live in and have studied small rural communities. In these communities, counselors are isolated, yet never alone — and that’s not always a good thing.

“You’re living in a fishbowl,” says Crawford, who has previously presented with Drew on the ethics of self-care in small or rural communities at the ACA Conference. “When you’re living in the same community where you work, your personal life is exposed on a regular basis.”

It is difficult for counselors in rural or small communities to completely set aside work. Seeing clients at the gym, in the grocery store, on community committees, in clubs or at church is a regular occurrence, Crawford notes.

“It’s like, where do I go to let my hair down?” Drew exclaims, voicing a common lament.

Some practitioners cope with this fishbowl effect by finding social outlets in another community or by doing small things such as going to the grocery store or the doctor’s office somewhere else.

But the reality is that it is hard for counselors to truly relax when they’re constantly navigating such tricky boundaries, Drew and Crawford say.

“There is no such thing as avoiding dual relationships in rural areas,” Drew says, adding that they can pop up when a counselor least expects them. For example, Crawford says, imagine bringing on a new client, beginning to work with that client, then taking your car to the repair shop and finding out that the client is your mechanic.

The dual relationship could happen even closer to home. For example, the sole school counselor might have a child or relative who is also a student at the school, Drew says.

Sometimes, counselors in small or rural communities even discover that they are counseling two clients who are related to each other, Drew says. This circumstance is especially tricky because if the counselor discloses the link to the clients, the counselor could be breaking confidentiality. On the other hand, client A may disclose information in session about client B that client B hasn’t chosen to share with the counselor. At some point, the counselor will need to decide how — or whether — to manage seeing both clients. In some cases, it might be best to refer one or both clients, Drew says.

In these communities, seemingly everyone is connected by fewer than six degrees of separation, yet counselors often lack professional connections of their own, Drew and Crawford say. Counselors may have few colleagues to consult with and even fewer specialists to refer to. Practitioners in these communities have to learn to be generalists so they can handle a variety of needs, Drew explains. Counselors who are practicing or wish to practice in a rural area or small community need to ask themselves if they can learn to be OK with such challenges, Drew advises.

But for their own wellness, counselors in these environments still need to have people they can talk to about living and working in rural areas and who can help them work through the challenges, Drew says. She and Crawford recommend that these counselors seek out other mental health professionals, even if it involves driving a substantial distance. For example, Crawford cites a group of women practitioners that she talked to while doing research. They all lived and practiced in rural Vermont and New Hampshire and formed a support group that met monthly in a centralized location.

Professional organizations are also an important source of support, Drew and Crawford say, noting that in Maine, the rural practitioners are often the most active members in the state counseling association.

But they stress that counselors practicing in these comparatively isolated areas need additional support from colleagues and support networks to properly care for themselves and their clients. These counselors also need to be particularly intentional about practicing self-care by regularly engaging in activities that they enjoy.

At the same time, Drew and Crawford think that most counselors-in-training don’t truly understand how different it can be to practice in a small or rural area. Thus, they aren’t adequately prepared for the challenges — both personal and professional — that they will face.

“I think there is not enough training in the counseling profession that is specifically for rural areas,” Crawford says. “I think we need to focus on that. How can I not just survive in a rural area but thrive?”



To contact the individuals interviewed for this article, email:




Laurie Meyers is the senior writer for Counseling Today. Contact her at

Letters to the editor:

Behind the Book: ACA Ethical Standards Casebook

By Bethany Bray

The 2014 ACA Code of Ethics is meant to be a living document, applicable to a growing, changing and active profession.

It would make sense, then, for counselors to familiarize themselves with the code through the lens of real-life scenarios that might arise in their office.

Barbara Herlihy and Gerald Corey have provided that lens in the seventh edition of their ACA Ethical Standards Casebook.

The book fleshes out each standard of the 2014 ACA Code of Ethics with a case vignette and discussion points. Readers are exposed to various aspects of counseling, from issues that might Ethical-Standards_branding-boxarise with record keeping to whether a counselor should be friends with a former client.

“The work of the counselor is fraught with ambiguities. When we find ourselves navigating in waters not clearly charted by the code of ethics of our profession, we must be guided by an internal ethical compass,” write Herlihy and Corey in the book’s introduction. “… We believe that ethics is best viewed from a developmental perspective. We may look at issues in one way as students; later, with time and experience, our views are likely to have evolved. Ethical reasoning takes on new meaning as we encounter a variety of ethical dilemmas. Professional maturity entails being willing to question ourselves, to discuss our doubts with colleagues and to engage in continual self-monitoring.”


Q+A: ACA Ethical Standards Casebook

Responses by co-authors Barbara Herlihy and Gerald Corey


In this new edition, you mention that a counselor’s perspective on ethical issues may change over the course of his or her career. Besides revisiting the ACA Code of Ethics and related resources such as your book, what are some ways counselors can stay “fresh” regarding the ethics of the profession?

Ongoing supervision, seeking consultation when needed and self-reflection are essential routes in keeping current. Counselors can gain new ideas from attending conferences and participating in workshops, by reading professional books and journals, having dialogue with colleagues, keeping a personal journal, making efforts to write about topics that matter to them, developing a network of support, finding ways to engage in personal development, consulting on matters related to their practice and engaging in self-care.

The casebook can serve as a vehicle for continuing education that experienced counselors can use to further their aspirational ethics. Counselors with many years of experience can read and reflect on the material in the casebook and can discuss the material with their colleagues. They can also ask themselves: How can I best monitor my own behavior? How can I apply relevant standards to situations I encounter? How can I ensure that I am thinking about what is best for my clients, my students or my supervisees?


What do you hope students, recent graduates and new counselors take away from this book?

Our hope is that this casebook can be a tool to assist recent graduates and new counselors in obtaining a clearer idea of what is involved in the practice of aspirational ethics. Ideally, readers will not think about doing the minimum to avoid malpractice actions but will think of how they can always keep the best interests and welfare of their clients in mind.

Rather than foster a rule-based approach to ethics, our aim has been to help readers think of ways they can develop their own perspective on ethical practice. The variety of perspectives of the contributors and the case studies will help students think about their position of the issues. Each of the 12 chapters in the casebook is followed by two case studies that illustrate some of the issues examined in a given chapter. Each case study presents an ethical dilemma and is followed by questions for thought and discussion and an analysis of the case.

Students have often told us that they had never thought about certain ethical questions until they were confronted with cases that raised difficult issues or posed dilemmas that could not be neatly resolved. This casebook gives students an opportunity to examine many ethical issues before they confront them in practice.


What do you hope more veteran, experienced counselors take away from the book?

We hope that more experienced counselors will realize that ethical practice is a journey in which one never arrives at a destination. We believe that ethics is best viewed from a developmental perspective. As counselor gains experience, their views are likely to evolve. Ethical reasoning takes on new meaning as practitioners encounter a variety of ethical dilemmas. Becoming an ethical and competent professional entails being willing to question ourselves, to discuss our doubts with colleagues and to engage in continual self-monitoring.


What prompted you to release a seventh edition of this book? Please talk about the updates and changes readers will see in the new edition.

It was time for the new edition. The casebook is always updated so that it matches revisions to the ACA Code of Ethics. Thus, when the 2014 code was adopted, a new casebook was needed. Readers will find several new chapters in this seventh edition of the casebook that reflect new standards and sections of the 2014 code. There is a new emphasis on social justice and counseling across cultures, and new chapters on managing value conflicts; technology, social media and online counseling; research and publication; and the intersection of ethics and the law. Almost all the case studies are new and reflect the complexities of real-world counseling practice.


As you mentioned, this edition of the casebook coincides with the release of the revised ACA Code of Ethics. What are some topics from the revised code that you felt were most important to flesh out in your book?

There are 34 contributors to this edition of the casebook. The chapters have been revised, and many new case studies are presented. Some topics that were given particular attention (to reflect the changes in the revised ACA 2014 code) include:

  • Implications of recent court cases and dismissal of students who refused to bracket their values
  • Avoiding value imposition
  • Avoiding referral based on the counselor’s personal values
  • Implications of technology on the practice of counseling
  • Issues of privacy and confidentiality associated with social media
  • Ethical issues involving research
  • Ways that ethics and the law are both related and different
  • Becoming a culturally competent counselor in an increasingly global profession
  • Ethical aspects of addressing social justice concerns

The contributors provided a wide range of case studies that are geared to the 2014 ACA Code of Ethics. These case studies have reflection questions aimed at assisting readers to become actively engaged in the issues they raise. Each case study is followed by an analysis of the case based on the ACA code and further questions for discussion. These cases help translate sometimes-abstract concepts into practical and concrete terms. The depth of the case studies challenges readers to formulate their own perspectives on ethical issues involved.


Explain the thought process that went into the way you broke up the subject matter from the 2014 ACA Code of Ethics in your book.

We wanted to incorporate all aspects of the current code in the revision of the casebook. For example, in Part II of the casebook, we include the 2014 ACA Code of Ethics, yet we also have an illustrative vignette for each of the standards. The aim here was to provide concrete examples of ethical and effective implementation of the spirit of each standard. Many of these illustrative vignettes are new to this edition or are revised. Part II presents a kind of “micro” perspective on the code, illustrating each individual standard with a brief vignette.

We also thought it would be useful to readers to have a “macro” perspective, or a section that gives focused attention to larger issues such as values, confidentiality and implications of new technologies and boundaries. Part III presents chapters on these and other issues, and each chapter is accompanied by two case studies that demonstrate how the code of ethics can be applied to resolve ethical dilemmas that arise around these issues. These case studies, written by counselors with widely diverse experience and expertise, represent the complexities of real-world practice.


What originally inspired you to collaborate and write a book on this topic? What made you want to include case studies?

We have a common interest in ethics and have co-presented at conferences many times over the years. We agreed that writing about our views and experiences would be a meaningful endeavor. Thus, we have collaborated on various editions of two books [Boundary Issues in Counseling being the other] with ACA for over two decades, and we always find it challenging, interesting, rewarding and fun to work jointly in this manner.

We also have found it meaningful to involve our colleagues and students in contributing to the evolution of these books on ethics. The decision to include case studies in our books was based on feedback from students who consistently stated that actual cases stimulated their thinking and promoted discussion in class. This helped them to see the actual implementation of ethical standards into counseling practice.





About the authors

Barbara Herlihy is a licensed professional counselor and university research professor in the counselor education graduate program at the University of New Orleans.

Gerald Corey is a national certified counselor and professor emeritus of human services and counseling at California State University at Fullerton.




The ACA Ethical Standards Casebook is available from the American Counseling Association bookstore at or by calling 800-422-2648 x 222.





Herlihy and Corey will be at the 2015 ACA Conference & Expo in Orlando, Florida, to give a talk on both the ACA Ethical Standards Casebook and Boundary Issues in Counseling, another book that they co-authored for ACA.

They will be speaking Friday, March 13, at 4 p.m. and signing books Thursday, March 12, at 4:30 p.m. For more information, see




Interested in learning more? ACA recently produced a webinar with Herlihy and Corey about boundary issues, ethics and their two books, Boundary Issues in Counseling and the ACA Ethical Standards Casebook. More information here:





Bethany Bray is a staff writer for Counseling Today. Contact her at


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook:


Learning a world away

By Bethany Bray February 17, 2015

Husband-and-wife counselor educators Chris and Hande Briddick recently spent a one-year sabbatical in Turkey, joining the faculty of Bahçeşehir University (BAU).


Chris Briddick, left in blue, and Hande Briddick, partially hidden behind Chris, are pictured with Bahcesehir University faculty at a lunch overlooking the Bosporus, the strait that runs between Asia and Europe.

Although there to teach, the couple says they were in turn taught many things, from the connections forged with colleagues over tea and birthday cake to the thoughtful questions students asked about counseling topics in the classroom.

“How many meaningful, warm and humorous conversations can you have in one year of your life? Turns out it is too many to count,” Chris reflects.

The Briddicks are professors in the South Dakota State University (SDSU) College of Education and Human Sciences. They spent the past academic year teaching at BAU in Istanbul and at a local K-8 school, where they helped develop curriculum and worked with parents and teachers. They also brought their young son, Sinan, who attended a local preschool and learned Turkish over the course of the sabbatical.

Chris is an American Counseling Association member and leader of ACA’s Historical Issues and Counseling Network.

Hande and Chris agree that the experience allowed them to stretch and grow both professionally and personally. Experiencing the counseling profession through the lens of another culture offered an invaluable career highlight.

“The energy level of BAU is very high. It is a very dynamic institution,” says Hande. “BAU is also quite involved in education issues in Turkey. It was wonderful to see how a university can play a

(Left to right) Ilknur Guleryuz, principal of Bahcesehir Preschool Etiler; Hande Sensoy-Briddick; and Naime Demirbas, principal of Bahcesehir Koleji Etiler.

(Left to right) Ilknur Guleryuz, principal of Bahcesehir Preschool Etiler, Hande Briddick and Naime Demirbas, principal of Bahcesehir Koleji Etiler.

significant role in identifying and providing possible solutions to a country’s education system. Being part of a faculty highly involved in these issues was indeed the highlight of my experience there.”

For Chris, an “aha moment” arrived while on a river cruise on the Bosporus, the strait that runs between Asia and Europe, with other scholars as part of the European Educational Research Association conference, which BAU hosted last fall.

“[Hande and I] were working so hard to just get our feet on the ground and to adjust to being in a new setting,” he remembers. “I think it was then [on the cruise] that I realized our experience was not going to be ordinary by any means.”


Counseling Today caught up with the Briddicks to talk about their experience in Turkey and the benefits of work/study abroad. [Click on the photos to see in full size.]


Q+A with Chris and Hande Briddick

How long were you in Turkey, and what type of work were you doing?

Chris: We were in Turkey from July 2013 to July 2014. We served on the faculty of educational sciences at Bahçeşehir University. In addition, we worked with a private kindergarten-through-eighth-grade school (Bahçeşehir Primary School, Etiler Campus) which is associated with the university. We were mainly teaching, consulting and doing a bit of research.

Hande: Similar to our faculty positions here in the States, we taught several courses for their graduate and undergraduate students, did some informal advising, delivered workshops, etc. In addition, the college had a wonderful program called “University Within Schools.” This program allowed the faculty at the college to work closely with Bahçeşehir’s K-12 private schools. Within this program, we were able to spend time in one of Bahçeşehir K-12 schools. We worked closely with the principal and the school’s counselors. We concentrated on developing curriculum and working with students and parents — excellent opportunities for us both personally and professionally.


What made you want to spend your sabbatical in Turkey? How does it connect to your work at SDSU?

Chris: We wanted to do something different for sabbatical, and Turkey offered a great opportunity to experience higher education in a different culture firsthand.

Also, it seemed like a natural extension of [multicultural work] we had already been doing. Hande

Chris Briddick (center, in a black hat) pictured with members of the faculty of Bahcesehir Koleji Etiler at the Eyüp Sultan Mosque in Istanbul.

Chris Briddick (center, in a black hat) pictured with members of the faculty of Bahcesehir Koleji Etiler at the Eyüp Sultan Mosque in Istanbul.

and I have worked with a travel program for seventh- through 12th-grade schoolteachers, funded by the Turkish Cultural Foundation, for several years. I led a study abroad group to Turkey in 2011. We have also worked in support of campus programming related to Turkey and assisted with an excellent library grant to add books on Turkish culture to our university’s library.

Hande: I am from Turkey. I came to the United States in 1994 after receiving a full scholarship from the board of higher education in Turkey (YOK). The scholarship was to complete my master’s and Ph.D. degrees at Kent State University. While writing my dissertation, I accepted a position at South Dakota State University and began working at SDSU in 2002.

Although I love teaching at SDSU, I always dreamed about teaching in Turkey one day. Selçuk Şirin, one of my dear friends and college classmates from my undergraduate days in Turkey, currently works at New York University as an associate professor in applied psychology. He was incredibly helpful in getting us connected with Bahçeşehir University and Bahçeşehir K-12 schools. With his help, we presented our résumés, met with some of the faculty at BAU and were then invited to teach at their university.

To answer your second question, I coordinate the school counseling program here at SDSU. Bahçeşehir University had just opened their school counseling program. It was wonderful to be a part of this new program. In addition, I teach a multicultural counseling course in our department here at SDSU, which I had developed years ago. Consequently, it is not surprising that I am quite attracted to cultural experiences. After 20 years, going back to my home country did prove to be one of the true highlights of my personal and professional life thus far.

Career counseling and guidance are as important in Turkey as it is here in the U.S. I believe that they were interested and excited to hire Chris because of his knowledge, publications and interest in this area.


You spent your time in Turkey teaching. What are some things, in turn, that the students taught you?

Chris: Turkish students have many of the same preoccupations (social media, relationships, culture, music, etc.) as students here in the U.S. Still, I will say my students in Turkey were pretty amazing. I was quite impressed by their global perspective of life in general, including their education, as well as the emphasis on bilingualism.

Hande: It might sound a little cliché but, really, my Turkish students reoriented me to the importance of culture and how it can influence almost everything around us, which includes the way we communicate, the way we dress, the way we establish relationships, the way we teach … Basically, it defines who we are.

It may be too revealing, but in all honesty, my students and colleagues helped me remember who I was when I lived in Turkey years ago. Other international scholars might agree with me in saying that after years of living in a different country, a little bit of who we are is sometimes forgotten. Living in Turkey for a year became an empowering experience for me in this regard. And I owe that to my colleagues there — I consider them my friends now — and to my dear students.


Can you share some highlights or favorite memories from the experience?

Chris: My favorite memories will always be the students, faculty, staff and community colleagues, including our principal and staff at our community school site. They were so committed to education and so driven. I found myself comparing them with our students and colleagues here in the U.S., again realizing the similarities and preoccupations as well as differences. For instance, students in my graduate classes there had the same grit and determination I see in the best graduate students here at home. In a word, brilliant. They were a small group, but I think back fairly often to our discussions and individual conversations. My undergraduate students were much the same way.

And faculty colleagues? How many meaningful, warm, and humorous conversations can you have in one year of your life? Turns out it is too many to count. Getting to spend time in our office or at lunch talking about everything from academics to politics to pop culture to family made for some great moments. Dedicated, kindhearted and highly intellectual individuals, each and every one. One little thing that was indeed memorable was the commitment by our faculty to celebrate birthdays. Every few weeks, work came to a halt and we would all gather around the table in the center of the department and celebrate the birthdays of colleagues with cay (tea), Turkish coffee and cake. It was academic life in balance at its best.

Another memorable moment was when I arrived to give my first final and my students were there early patiently waiting. The classroom erupted into applause. Trust me, it was unwarranted, and I can say without hesitation that has never happened in all my years of teaching. We returned to Istanbul in December 2014 to visit, and we surprised our BAU students who were taking a final that day. When our colleague entered the room, she left the door open and we stepped in. I will never forget the looks on their faces and, frankly, we were a bit overwhelmed with emotion. We had a few minutes to visit before they took their final. It was incredible.

We worked at a private koleji (school) in the community. It was an amazing environment with its own Eko Ev (eco house) and large school garden, both of which served as classrooms at some point for the children. We even had a good selection of farm animals on campus right in the middle of a city of

The Eko Ev (eco house) at Bahçeşehir Primary School, Etiler Campus, in Istanbul.

The Eko Ev (eco house) at Bahçeşehir Primary School, Etiler Campus, in Istanbul.

over 14 million people, so students could better grasp how agriculture impacts their day-to-day lives. Students learned about their history and culture as well as current concepts such as sustainability.

The principal there, Naime Demirbas, was one of the most incredible individuals I have ever met and certainly a visionary leader. One of the highlights of my entire career will be working with her. I cannot count the number of meetings in her office where Hande and I worked side by side with her, watching in amazement how ideas were developed, refined and implemented with such precision and efficiency. One day we had a conversation about the importance of culture and its significance in education. She has a background in history and was quite proactive in making sure her students learned about their culture and history. The next thing I knew, I was being invited along with faculty from the school on a Saturday tour of parts of the city of Istanbul. Not only was it important for students to discover their history and culture, but so too was it important for the faculty, she maintained. Her commitment to the students in the school, the faculty and staff, as well as her progressive, innovative approach to education, will stay with me for the rest of my life.

Hande: It is really hard to choose one or two stories to share, as there are so many of them. I agree with what Chris shared with you. The faculty of educational sciences (at BAU) as well as faculty at Etiler Kolej were very supportive of us as we were making transition from the USA to Turkey and the Turkish [educational] system.

I learned a great deal about the importance of collaboration and professional support. I saw how [it] helped them create an intellectually rich and rewarding academic culture. The productivity within our faculty at BAU was impressive. Each semester they worked together on any number of valuable research projects. In the United States, we tend to place more value on individualism and less on collaboration, which I think results in more competitive academic environments. Both have pros and cons, of course.

BAU and the Bahçeşehir K-12 schools are quite dynamic and open to new ideas. The principal at Bahçeşehir Etiler Campus, Naime Demirbas, and school counselors were very welcoming. They helped us understand their school system and collaborated with us in developing and conducting various small but meaningful projects. For instance, I developed a four-week listening and friendship curriculum and had the privilege to deliver it in classrooms with the school counselors. It was so much fun.

Chris organized a father’s club discussion group for interested fathers with children enrolled in the school. Again, it was very well received. The biggest project that we completed there was a career curriculum for their first- through fourth-graders. The curriculum was published when we were there, but they just started using it in the schools last semester. Knowing that it is being used by Bahçeşehir students is a great pleasure.


Did you find there were major differences in counseling and counselor education between the U.S. and Turkey?

Chris: Yes and no. There is overlap in curriculum, as you might imagine. Interesting contrasts do exist as well. In terms of school counseling, for instance, preparation for entry into that profession is at the bachelor’s level, so university students go into the profession upon graduation. That was different. In addition, gaining admission into counseling programs is highly competitive.

School counseling is offered at the undergraduate level. After completing their four years, which includes an internship, students apply for school counseling positions. There is a significant shortage of school counselors in schools, so the job prospects are very positive. Consequently, many students are eager to enroll in school counseling programs.

Entering university happens through a very competitive national university entrance exam. Students who end up in the program are very academically strong because of the competition. Since it is a

Pictured in the Ekolojik Ev (Eco House) on the Bahcesehir Koleji Eitler campus are (left to right): Hande Briddick; Naime Demirbas, principal of Bacesehir Koleji, Etiler; Dean Jill Thorngren of SDSU’s College of Education and Human Sciences; and Greg Holdeman, spouse of Dean Thorngren.

Pictured in the Ekolojik Ev (Eco House) on the Bahcesehir Koleji Eitler campus are (left to right): Hande Briddick; Naime Demirbas, principal of Bacesehir Koleji, Etiler; Dean Jill Thorngren of SDSU’s College of Education and Human Sciences; and Greg Holdeman, spouse of Dean Thorngren.

four-year degree, students are exposed to a more global perspective. They take courses such as educational psychology, learning theories, exceptional children and families, statistics, current issues in the Turkish education system, etc. I find that when compared with our school counseling programs, they emphasize more education, learning and development rather than mental health issues.


What would you want American counselors to know about your experience?

Chris: Though I have traveled to Turkey numerous times over the years, living there proved to be transformative in ways I am still discovering months down the road. I think any time counselors can find opportunities to work and learn outside their usual environments, it is well worthwhile. Even a short-term experience can be educational beyond imagination. I know the American Counseling Association has made a practice of promoting international travel programs for counselors. I think these should continue.

Hande: I think I would like them to know that international experiences are so valuable that I am ready to do it again. I learned not only about myself but also about American and Turkish culture, if it makes any sense. My Turkish students challenged me in a very different manner. For instance, I did not get the same questions that my students in the USA ask when I teach a topic. I saw a different way of living or existence from what I experience day to day in the U.S. Though I am from Turkey, this experience reminded me of the differences between Turkish culture and the dominant culture here in the U.S. I saw how mental health and wellness were defined differently in terms of what we might think of here.

To summarize, if you would like to challenge yourself in a rather fundamental way, living and working in a different culture is certainly one way to do it.


What advice would you give to counselors who are considering work or study abroad? In your experience, why is it a good thing?

Chris: I would highly recommend it, though I admit it took me a considerable amount of time to re-enter life back home.

Do your homework and consider all options, [both] long and short term. There is a wealth of opportunity for personal growth and learning in these experiences. Sometimes I think a good number of us in the U.S. are quite insular with regard to the rest of the world. Opportunities, large and small, that allow us to share ideas and experience the lives and cultures of others stand to benefit all involved and empower a better understanding of the world that is not so close at hand — a more global perspective, if you will.

Hande: Culture defines everything, including how people will treat you, what you will learn in a class, how you will introduce yourself to your client or students, etc. The challenge is deciphering the culture.

Although I am from Turkey and I had spent my first 23 years in Turkey, it took me at least six months to completely reorient myself to the system there. Here is one example: It is possible that your department chair will ask you at the last minute to teach a class. It is not because they are disorganized but because they are more flexible and would like to accommodate the needs of their students. Of course, you always have the right to say no. If you are going to live in Turkey, you need to be flexible and creative. Some of my colleagues there were a little surprised when I told them that I knew what I would be teaching here in at SDSU about four to six months before the start of the academic year.

It is important to learn about a culture before you visit or stay for an extended period of time. Read books, watch movies and, more importantly, talk with people who are from that culture. It is a good idea to have a short trip to the country before you start living there for a year if at all possible. Experience abroad is invaluable.

From a broader perspective as a person from a culture that highly values interpersonal relationships and family, it has great benefits for other family members. If you have a child, they learn a second or

(Right to left) Hande Sensoy Briddick, Sinan Briddick and Gulseren Sensoy (Hande’s mother) inside the courtyard of Cafer Aga Madrasah which was designed by Mimar Sinan in 1559. The Briddicks named their son after Mimar Sinan, an architect who designed many significant structures in Istanbul.

(Right to left) Hande Sensoy Briddick, Sinan Briddick and Gulseren Sensoy (Hande’s mother) inside the courtyard of Cafer Aga Madrasah, which was designed by Mimar Sinan in 1559. The Briddicks named their son after Mimar Sinan, an architect who designed many significant structures in Istanbul.

third language and make international friends. Being able to live in a different culture challenges them to learn different skills — skills different than those to which they are accustomed, which enhances their resilience. You can end up being much closer as a family. You learn to support each other better and you begin to see each other’s different strengths and appreciate them more.

But I am not trying to say that absolutely everyone should or could work and live abroad. It does have many challenges. If you are up for the challenge and are a little bit — or a lot — inclined toward adventure, then an international experience will likely be an invaluable opportunity for you.




Bethany Bray is a staff writer for Counseling Today. Contact her at


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A first step toward stemming veteran suicide

By Bethany Bray February 11, 2015

A bill aimed at improving suicide prevention and mental health services for veterans has sailed through both houses of Congress this winter.

President Barack Obama signed the Clay Hunt Suicide Prevention for American Veterans Act (also veteranflagcamoknown as the Clay Hunt SAV Act) into law on Thursday, Feb. 12.

The bill, named for a Marine sniper who died by suicide in 2011, calls for an audit of all mental health and suicide prevention practices and programs at the U.S. Department of Veterans Affairs (VA).

“Today, we honor a young man who isn’t here, but should be,” President Obama said at Thursday’s bill signing. “Every single veteran in America has something extraordinary to give to this country. Every single one. … If you are hurting, know this: You are not forgotten. You are not alone. You are never alone. We are here for you.”

Although the bill is a good step, supporting and helping veterans ” is not just a job for government,” said Obama. “Every community, every American can reach out and do more for our veterans. This has to be a national mission.”

Passage of the bill is good news for the veteran community and a first step toward further improvements, says Jeff Hensley, a Navy veteran, American Counseling Association member and licensed professional counselor intern.

In 2012, the VA reported the eye-opening statistic that 22 American veterans die by suicide every day of the year.

“This seems so counterintuitive to those who are part of this [veterans] community, and very scary,” says Hensley, a program counselor at a therapeutic riding center in Wylie, Texas, who does equine-assisted therapy with veterans.

Veterans met the 2012 report with “shock, followed by indignation that we were allowing this to happen here in this country,” Hensley says. “That was the motivation [for the Clay Hunt bill].”

The legislation introduces several measures meant to improve veterans’ access to mental health care, including:

  • Evaluating all mental health care and suicide prevention practices and programs at the VA for the purpose of making recommendations to improve care
  • Requiring the VA to create a website to serve as a centralized source of information regarding all VA mental health services for veterans
  • Authorizing the VA to set up a student loan repayment pilot program to recruit and retain psychiatrists
  • Extending by one year the “combat eligibility” period that veterans of the Iraq and Afghanistan wars have to register for VA health care without having to first prove a service-related disability
  • Establishing a peer support and outreach pilot program to assist newly discharged service members with accessing VA mental health care services


“Getting help really does make a difference, and this legislation will encourage more veterans to get help,” says Hensley. “It will make a smoother transition for those going from active duty to civilian life – continued access to care, all the way.”

The Clay Hunt SAV Act is the culmination of an intense year of grassroots and lobbying work by the Iraq and Afghanistan Veterans of America (IAVA), a nonprofit organization that represents post-9/11 veterans.

Hensley, an IAVA leadership fellow, came to Washington, D.C., last March to talk with legislators and campaign for the bill. He was part of an IAVA team that planted 1,892 American flags in the ground of the National Mall between the Washington Monument and the U.S. Capitol. Each flag represented a veteran who had committed suicide between January and March of that year.

A poignant image of the event, captured by a news photographer, shows Hensley having an emotional moment as he knelt among the flags. A retired Navy commander, Hensley was a fighter pilot who saw combat deployments in Iraq.

Thanks to the efforts of IAVA, the Clay Hunt SAV Act went from conception to the president’s desk in a little less than one year, says Hensley. Both houses of Congress passed the bill unanimously, an exceptional feat in an age known for partisan gridlock. It was passed by the House of Representatives in January and by the Senate on Feb. 3.

“It’s not a perfect bill, but it’s a foot in the door,” Hensley says. “It creates a national conversation about the problem. … It’s not a perfect piece of legislation, but it’s a very good start.”

When veterans come off of active duty, it is up to the individual to take the initiative to register with the VA. This can be a big obstacle for those who are hurting, according to Hensley.

It is estimated that less than half of post-9/11 veterans register with the VA, and it is impossible to know whether those who don’t register are getting mental health care outside of the VA or not at all, Hensley says.

“A lot of veterans fall off our radar,” he says.

Hensley sees the impact of this reality firsthand in his work with veterans at the therapeutic riding facility in Texas.

“Most of the [veterans] who are coming to us aren’t in the VA system. We may be the only help they’re getting,” he says. “I see it every day. If they reach out and get help, it can make a big difference. … From a counseling perspective, it’s hard to watch this population not get help, to be struggling. But because of stigma [surrounding mental illness], or limited access to care, or whatever reason, they don’t reach out.”

IAVA polls its members each year to collect data and find out what issues are most important to them. The Clay Hunt SAV Act was borne out of member survey data that indicated suicide prevention was a top priority.

(IAVA has 300,000 veteran and civilian members; the 2014 survey was taken by a little more than 2,000 of its veteran members.)

Last year, 40 percent of IAVA members who took the annual survey reported that they knew at least one veteran of the Iraq or Afghanistan campaigns who had committed suicide. Thirty-one percent of respondents said they had thought about taking their own life since joining the military.

Clay Hunt, a Purple Heart awardee who served in Iraq and Afghanistan, was seeking care from the VA for post-traumatic stress disorder before he committed suicide at age 28.

“While we are a little bittersweet, because it is too late for our son Clay, we are thankful knowing that this bill will save many lives,” said Susan Selke, as the bill named for her son was passed by the Senate last week. “No veteran should have to wait or go through bureaucratic red tape to get the mental health care they earned during their selfless service to our country. While this legislation is not a 100 percent solution, it is a huge step in the right direction.”




For more information on IAVA and the Clay Hunt SAV Act, visit


More details and the full text of the bill is posted here:




Bethany Bray is a staff writer for Counseling Today. Contact her at


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