Monthly Archives: June 2015

Counseling Today, CT Online recognized for excellence

June 29, 2015

Counseling Today and its companion website, CT Online, received three awards in APEX 2015, the 27th annual awards program celebrating publication excellence among communications professionals.

Senior writer Laurie Meyers won two Awards of Excellence. One was in the feature writing category for her April 2014 cover story, “Ages and stages,” which looked at the need for counselors to help older adults as they encounter new life challenges and transitions. The second award, in the category of health and medical writing, was given for her June 2014 feature article, “Tossing and turning in the digital age.” The article examined the connections being made between sleep quality and a range of physical and mental health issues.

CT Online (ct.counseling.org) received an Award of Excellence in the category of best WordPress sites. This is the second straight year that APEX has honored CT Online. Staff writer Bethany Bray handles day-to-day oversight of the website and wrote approximately 40 of the online exclusives posted to CT Online during the past year.

This is the 11th consecutive year that Counseling Today has been recognized in national publication competitions. In total, the staff has won 36 awards for writing, design and website content since 2005.

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Technology Tutor: HIPAA security compliance made easy (or at least easier)

By Rob Reinhardt June 26, 2015

Most counselors I speak with are not fully compliant with HIPAA/HITECH (the Health Insurance Portability and Accountability Act and the Health Information Technology for Economic and Clinical Health Act, respectively). One of the primary areas in which they are not compliant is in the documentation of a risk assessment, along with security policies and procedures. Although some elements within HIPAA are merely recommended, these are items required of every “covered entity,” whether that entity is a hospital or a solo practitioner.

A number of consultants and tools are available to help create these required items. Unfortunately, most of these tools are cost-prohibitive for counselors and have a very strong medical-centric focus. The Office of the National Coordinator for Health Information Technology provides a free tool for completing a risk assessment (see bit.ly/1B7BvkL). It is cumbersome, however, and many people can’t make it through the HIPAA and techie speak.

When I first started my consulting business, I had thoughts of creating a user-friendly tool to walk mental health professionals through this process. One of the many topics I discussed in a podcast interview with Joe Sanok of Practice of the Practice was prioritization (see bit.ly/ctaugpop). I told him that I come up with more ideas than I have time to work on, and a major factor in choosing which ones to pursue is whether I will enjoy them. The idea for developing a HIPAA risk assessment tool was one that quickly fell into the “I really don’t want to do that” basket.

Thankfully, along came Roy Huggins of Person-Centered Tech. Roy is to HIPAA compliance what I am to implementation of technology to make practices more efficient. He not only “gets it” but also is able to communicate it to counselors in a way that makes sense.

I interviewed Roy to learn more about his approach to these topics and how he translates them for mental health professionals. At the time of this interview, he was completing phase one of a workbook that will walk mental health professionals through the steps of creating required documents for HIPAA, such as a risk assessment and policies and procedures.

Rob Reinhardt: What is the HIPAA security rule all about, and how is it different from the privacy rule?

Roy Huggins: The security rule is the part of HIPAA that is concerned with the safety of digital info. As you can imagine, that wasn’t such a big deal for counselors back in 2003, but it is a big deal now. The more we use digital tech in our practices, the more relevant the security rule becomes.

The privacy rule is the part of HIPAA that tends to get better coverage in HIPAA trainings. It covers things like the notice of privacy practices (aka “the HIPAA form”), the “minimum necessary” rule, requirements to provide clients with copies of their records and all that jazz.

The security rule is pretty focused on how we protect our clients’ sensitive information, particularly when it is in a digital form.

RR: The security rule seems enormous and overwhelming. Can you sum it up in terms we can all understand?

RH: I think it seems so large partly because it is pretty large, but also because they wrote it so that it would cover the needs of everything from solo counseling practices to big hospital systems. So the law talks about all kinds of technical requirements that a solo counselor may or may not need to specifically worry about. It’s hard to know which is which, however, so it just comes across as overwhelming. The short version is this:

1) Do a needs assessment around keeping your clients’ information safe. This is what is called a risk analysis or risk assessment — either is fine. It’s a lot like a community needs assessment but for the safety of your clients’ information. Take a holistic look at your practice to see how your clients’ info is being kept safe or not, and make a list of the places where your clients’ info is at the highest safety risk right now.

2) Make a plan to meet those safety needs. This is called a risk management plan, and it’s where you come up with a list of strategies to meet the safety needs you discovered in step one.

3) Make a policies and procedures manual. While thinking about your risk management plan, you’ll come up with a list of ideas that sound something like, “I will back up my computer every Friday” or “I will make a better password for my email.” The policies and procedures manual is where you would document these good ideas and enshrine them as official policies going forward.

That last step is where the security rule’s apparent bigness comes in, in my opinion. The rule defines a bunch of things that we’re supposed to address in our policies and procedures. The way the rule is written, however, is really opaque and technical. It’s very difficult to understand what HIPAA wants without guidance or interpretation.

The truth, however, is that your policies and procedures don’t need to be written in tech speak, legalese or anything else but the kind of plain English that you and anyone else working in your practice can understand. You’ll probably need guidance to convert HIPAA’s abstract policy requirements into your own real policies and procedures manual, but once you’ve got them written, they’re written. The ongoing piece of HIPAA security is mostly about following your own policies and doing an abbreviated version of the three steps every year or so.

RR: It still sounds like there’s an awful lot a covered entity has to do to be in compliance. If counselors had to choose a starting point to work forward from, where would you suggest they begin?

RH: The upfront work of doing those three steps does take a chunk of time. That’s the unfortunate truth. The good news, however, is that you don’t necessarily have to do it all at once or do it quickly.

The powers that be are surprisingly willing to be gentle with people who demonstrate ongoing progress toward HIPAA compliance. This is especially true with the security rule, and it’s especially true right now, when most of American health care is still working out the kinks in that whole “health care information technology” thing. The important thing is just to start. Document what you do, just like in therapy!

For the security rule, the first thing is to find out the best way for you and your practice to perform that risk analysis project. Most people start with some kind of training to help them figure out where to get started on the actual compliance projects.

RR: How might this process be different for counselors from, say, medical doctors or hospitals?

RH: The compliance process is technically the same, but your outcomes might be different. Hospitals usually don’t have the freedom to collaborate and work with clients the way we do. This has a significant impact on how we manage security and, thusly, it can have a real impact on how we manage certain parts of HIPAA compliance.

Differences in the process of compliance are more about a practice’s size than about the profession in that practice. A hospital needs a compliance team and often needs professional consultants because their equipment and systems are just so much more complex than ours. Also, HIPAA’s expectations set a much higher bar for hospital security than for small counseling practice security.

Small-to-medium mental health practices can often manage most or all of the compliance work on their own if they feel confident they can do the work. I have seen many solo and small group practices do a good job of risk analysis with just a little consulting to help them out. The best way of going about it depends on the person and the practice.

RR: You’re developing a workbook that helps counselors get through this process as painlessly as possible. Can you tell us a bit about that?

RH: I’ve spent so much time over the years teaching counselors and other mental health pros about the three steps described above, but every time people ask for resources to get started, I have found myself unsatisfied with the referrals available to us. There is a lot of guidance, but it is highly technical and difficult for counselors to identify with. So I decided to finally make my own tool that counselors can feel comfortable with.

We discovered through testing that it works best as a website service that can “railroad” the counselor through simple questionnaires and creative exercises. The software then produces a risk analysis with recommendations for risk management planning. The software also has prewritten policies and procedures that meet requirements set out by HIPAA, and it will provide the counselor some guidance on how to amend those policies to meet the counselor’s specific needs. HIPAA security is quite individual, however, so the tool includes group consultation sessions to help when people hit snags.

RR: I’ve had a look at the beta version of your workbook. You do an excellent job of translating HIPAA and techie speak to language everyone can understand. How did you manage to do that?

RH: There are a surprising number of parallels between what we do as clinicians and what HIPAA asks us to do for security. One reason for the crossover is that security is heavily oriented toward risk management. We’re already accustomed to risk management because that’s how we approach working with self-harm risks in clients. We assess their risk of self-harm, then we respond with measures appropriate to the level of risk — e.g., a no-harm contract for lower risks, hospitalization for imminent and ongoing danger, etc.

We also do security already. We just don’t label it that way. Instead, we just call it “confidentiality.” In my life, I’ve never been so interested in locking file cabinets and white noise machines as I am now that I’m a professional counselor.

RR: Are there any special circumstances that would necessitate someone getting help in going through your workbook?

RH: Every situation is unique. Our tool can anticipate a lot of people’s needs but not 100 percent of them. That’s why the workbook subscription includes the online consultation meetings. That can fill in the gaps that the software doesn’t anticipate.

We have also found that therapists are much more successful in doing their security work when they do it with a group. HIPAA compliance need not be solo drudgery — it can be a shared and joyful experience if approached in the right way.

RR: How do you see the workbook developing in the future, and how do you plan to keep up with changes in technology and HIPAA/HITECH?

RH: My dream for the workbook is for it to become rather like the holographic doctor in Deep Space Nine — pardon my nerding — except for practice tech instead of medicine. This tool has the potential to one day anticipate, track and support the health information technology needs of all the counselors who use it, like a holographic technology staff for our practices that takes care of the hard stuff for us.

The tool will let us — the staff behind it — do the work of keeping up with tech and HIPAA/HITECH changes and helping counselors adjust to them as needed. I think this is a necessary part of future practice, and it’s also necessary for the tools to be affordable and easy to use.

Ten years ago, we weren’t as concerned about HIPAA because our own professional ethics were generally tighter than [HIPAA] was. We’re starting to see that happen again with digital tech. For example, the 2014 ACA Code of Ethics has a higher threshold than HIPAA does for informing our clients of security risks in using email. If we can take ownership of digital information safekeeping the same way we took ownership of paper information safekeeping long before HIPAA came along, then HIPAA will become significantly less of an overwhelm. I’m really hoping that the tool we’re building will help counselors and our colleagues to do that.

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Readers can find out more about the workbook at bit.ly/CTJuly2015.

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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

Emotion, personified: What “Inside Out” gets right about mental health

By Erin Shifflett June 25, 2015

A person’s mind is a mysterious labyrinth of thoughts, feelings, memories, ideas and compulsions; the mind of a young girl is likely even more complex. Disney-Pixar’s latest animated offering, Inside Out, bravely delves into that intricate world in a way that effectively captures the nuances of the way people feel and think—and maybe helps them understand why they act the way they do sometimes.

Developed with the guidance of University of California, Berkeley psychologist Dacher Keltner, the film tells the tale of Riley, an 11-year old whose family relocates from Minnesota to San Francisco. Through the move, Riley loses her friends and beloved hockey team and is forced to transition to a place where pizza is served with broccoli as a topping and the cool girls in school wear eye shadow, much to Riley’s surprise. Guiding Riley on a consistent basis are the five emotions operating at Headquarters (Riley’s brain): Joy, Sadness, Disgust, Fear and Anger. Each is displayed with a

Image via Wikimedia Commons

corresponding color (Anger is a fiery red, for example). The emotions take turns ensuring that Riley reacts appropriately to everything that occurs in her life. This is where the viewer can begin to see how this film might resonate with those in the counseling profession—and their clients.

The dominant emotion in Riley’s life is Joy; she’s the “IT” girl, always front and center and determined to ensure that she has a big presence in Riley’s day-to-day activities and any memories that are formed. The other emotions are supportive of this because, well, they want Riley to be happy, and Joy is certainly the best one to make that happen. A shift occurs, though, when Riley finds herself trying to adapt to her new surroundings. Suddenly, Sadness starts to forcibly interject herself into Riley’s day. When the other emotions become frustrated and ask her why she’s behaving in such a manner, Sadness states simply, “I don’t know what’s wrong with me—I can’t help it.” This translates to Riley crying on her first day in her new school, and the other emotions become alarmed and concerned. This scene is a prime example of what this film “gets right” about mental health and also provides an opportunity for working with clients who feel “not themselves” or find that they’re behaving in an unusual manner after a trauma or sudden change in their lives.

People can’t expect to feel Joy all the time, and though we often attempt to push Sadness aside, it’s a normal emotion and it has a place in our lives as well. This scene might be particularly useful when working with young children as it provides a tangible, visual representation of something they might not have the ability to verbalize—being able to see Sadness in all of her gloomy, blue splendor will likely allow a child to better understand that particular feeling.

The importance of Sadness and, indeed, the other less pleasant emotions such as Fear, Disgust and Anger, is highlighted multiple times throughout the film when their roles and functions are explained. Disgust’s job description includes keeping Riley safe by ensuring that she avoids things that could harm her (poison, for example). Fear allows Riley to pause and consider a situation before acting. Anger makes it possible for Riley to express her frustrations and defend herself. These three-dimensional representations of normal, healthy emotions that are often regarded as negative or harmful open the door to conversations about feelings which might otherwise be difficult to address.

One of the characters in the film that will likely spark conversations between parents and children and, perhaps, counselors of children is Bing-Bong, Riley’s imaginary friend. There are some truly poignant scenes revolving around Bing-Bong’s dawning realization that Riley no longer needs him and has in fact begun to forget about him. One scene in particular takes place in “Pre-School Land,” which has a landscape littered with the usual artifacts of early childhood: building blocks, primary colors, dolls, etc. When Bing-Bong arrives on the scene, he witnesses a demolition team tearing down all of these items in order to make room for the other stages in Riley’s life. This scene presents a prime opportunity to talk with children about how they feel about the changes that are occurring in their lives as they make similar transitions from preschool to elementary school to middle school and beyond.

Lest anyone think that children are the only ones likely to benefit from the lessons learned in this film, it is worth noting that Inside Out is frequently touted as an adult movie made for kids. It offers multiple images and scenes that are likely to spark a note of reflection in even the most cynical and hardened adult hearts while the children in the audience are marveling at the bright colors and playful characters.

A primary example lies in the imagery of Riley’s “Islands of Personality.” These concepts— presented as literal islands tethered to Riley’s brain—are named after the most important qualities that make Riley who she is at this point in her life. There’s Family Island, Friendship Island, Goofball Island, Hockey Island and Honesty Island. In a particularly effective approach, when something interferes with the essential quality of these notions, the tethers to one or more of the islands are destroyed and the islands themselves crumble and disappear. The first to go is Goofball Island—it represents Riley at her most silly, playful self. There are images of her running around after a bath as a toddler, making monkey faces with her parents, etc. As she begins to evolve emotionally, Riley no longer displays that particular side of her personality and, as a result, Goofball Island goes dark and falls into nonexistence. Other islands follow suit, and it is likely that adults watching this film will feel pangs of nostalgia as they recall—perhaps for the first time in years—which parts of their personalities have been lost along the way due to factors such as age, environment, obligation, etc. It is conceivable that counselors working with those who feel as if they’ve lost a clear idea of their identities and purpose may be able to reference this idea (Islands of Personality) as a way of identifying what has been surrendered and abandoned along the way, what the effects have been and whether or not it’s possible, necessary or appropriate to reconstruct some of them.

Inside Out marks the first animated foray into the world of emotions and mental health and presents everything in a way that is, above all, accessible. It is a certainty that those who filed into a cool, dark theater hoping for some escapism and an opportunity to be amused for ninety minutes came away with something much more significant—an opportunity to reflect on how emotions impact all of us and the importance of giving each feeling its due.

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Avid movie buff Erin T. Shifflett is director of the American Counseling Association’s Ethics and Professional Standards department.

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Related reading: See “Counseling goes to the movies,” Counseling Today‘s list of counselor’s favorite movies: http://bit.ly/1AWKDcq

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A ‘problem’ of perception

By Thomas Hofmann June 24, 2015

Many counselors now identify themselves as having a strength-based counseling approach, often as part of an eclectic theory base. Yet how do we know we are thinking within a strength-based model and operating with strength-based strategy? Most of our historical theory base developed from a Westernized medical model worldview, and many writers of strength-based literature distance themselves from that paradigm. Most of our agency forms, as well as the Diagnostic and Statistical Manual of Mental Disorders (DSM), demand a problem-focused, labeling-oriented view of our clients. Is it even possible to be a strength-based counselor in our current practice environment?

In a 2006 edition of the journal Psychotherapy, Joel Wong proposed a strength-centered therapy model that is both social constructionist in its philosophical background and virtues based. Social constructionism argues that complaints are based solely on client worldview, as described by Steve de Shazer in his 1985 book Keys to Solution in Brief Therapy. A virtues-based perspective originated with philosophers such as Aristotle and St. Thomas Aquinas and was amplified by positive psychologists Christopher Peterson and Martin Seligman. Aristotle emphasized the care and nurturing of human virtue; Peterson and Seligman developed a taxonomy of virtues in their 2004 book Character Strengths and Virtues: A Handbook and Classification.

The DSM is itself a handbook and a classification. Reported pathology must be classified by behavior and client self-reports. To be given a pathological diagnosis, the client must meet certain criteria. Yet what are these criteria? Normal human behaviors and internal subjective states include a bit of anxiety, depression, loss of appetite or binge eating, as examples. The majority of symptoms for most diagnoses stem from prevalent human states that have become a significant detriment to a client’s quality of life or to those around them. Aristotle argued for moderation in virtues rather than extremes. Could we identify codependency as a misuse to the extreme of the human virtues of persistence, love and hope?

Wong argued for a philosophical use of moderate constructivism. Perhaps it is not only client perspective that creates problems, as de Shazer contended. As opposed to radical constructivism, positivist philosophy contends that everything can eventually be measured and then operationally defined so that everyone can give it the same meaning. As we become more sophisticated with evidence-based treatment and our advancing knowledge of biological causes of internal states and behavior, we can explain client complaints as consisting of more than just client worldview. Schizophrenia was once thought to be triggered by a schizophrenogenic mother, but recent fMRI (functional magnetic resonance imaging) data show the presence of abnormal brain structure and activity. However, even cognitive behavior therapy, current champion of the evidence-based model using clear clinical pathways and treatment manuals for each diagnostic category, still depends on challenging client worldview to a very large degree.

Counseling simultaneously in both worlds

How can we use a strength-based approach while diagnosing our clients to provide them with the accurate and appropriate classification to report to other professionals and insurance companies? Now that I have a smartphone I constantly hear, “We have an app for that!” As counselors, we can choose to use reframing as a kind of translation app, translating the pathological information in our heads to strength-based verbalizations for clients.

My definition of reframing is providing a perspective that is equally true or more true to the client than the view that she or he currently holds. Can we argue that diagnoses, made up of human internal states and behaviors, are very often coping mechanisms? Generalized anxiety keeps a person hyperalert to danger. Over time, with hyperalertness as the predominant choice of reaction, the limbic system does not function as well, nor does the client.

Motivational interviewing suggests that one way to reduce client defenses is to respect all client choices. We can argue that most choices have a positive intention. Underlying the choice is a virtue, or multiple virtues, that often is expended in vain efforts. Generalized anxiety shows a person ever watchful for danger. Remember that our frame of codependency is as an overzealous use of the virtues of persistence, hope and love, which turns the effort to counterproductive ends. We would not begrudge a turtle its shell. Yet we sometimes look at a person with depression and forget to honor the protective mechanism of retreat. Substance abuse is a means of seeking escape from what the client perceives to be an intolerable internal state, which is not a bad intention in itself.

When we find a way to first honor the client’s coping behaviors, the associated positive intention behind them and the virtues that propel them, we can enhance our chances of also having conversations about the problematic parts of the condition and encourage the client to be more forthcoming. Counseling students are often taught to view ego defenses as pathological when doing client assessment. But for a young child who is trapped in a horrific situation with no way to escape, dissociation is a brilliant way to escape. Children who are browbeaten with repeated verbal abuse can introject that belief (take it on as their own) to survive a childhood in which fighting for their self-esteem might be quite dangerous. In certain situations, denial helps us all to live a more calm and happy life.

In a nutshell, strength-based counseling theories proceed from an immediate view of clients possessing their own answers. Solution-focused therapy focuses on solution talk from an imagined future in which the problem does not exist. Motivational interviewing engages clients in a very honest dialogue in which they face their own ambivalence while the counselor stays out of the way. Narrative therapy takes the same story content and, by externalizing pathology as an oppressive outside force, reframes that content in a way that is just as true, yet more empowering, for the client.

So, how can we follow a strength-based approach even as our agencies require problem-focused assessments and insurance reimbursement requires a diagnosis? One way, right out of the gate, is to perceive the positive intentions behind our clients’ inefficient behaviors and the virtues that drive them in wasted directions. Clients have a harder time dismissing enduring virtues as their own when the positive intentions are pointed out to them.

We also need to ask if we are sure of the client’s goal. James Prochaska and Carlo DiClemente proposed that counselor awareness of a client’s level of motivation to make a certain change is critical in the success of the client actually making that change. Assessing the client’s motivation helps us ensure that the client is fully engaged when it is time to take action. Until then, work can consist of enhancing motivation or determining a goal with which the client is genuinely engaged.

In the July 2002 Journal of Mental Health Counseling, Victoria E. White adapted the groundbreaking work of Michael White and the narrative therapy technique of externalization to suggest a method for presenting a DSM diagnosis to a client in a nonpathologizing way. She proposed working with the client to externalize the diagnosis so that it is perceived as an oppressive force “outside” of the client rather than as a pathological label with which the client identifies.

Assessing pathology within strength-based approaches

In their 2009 book Solution-Focused Substance Abuse Treatment, Teri Pichot and Sara A. Smock discuss the dilemma of obtaining necessary problem-focused assessment data while utilizing a solution-focused approach. They contend that the normal tools and approach of solution-focused therapy do allow counselors to infer problems through inconsistencies in statements and reports, objective evidence and use of scales for assessment, among other ideas. And if there are missing data that are needed, the counselor can ask. This may briefly interfere with the purity of the approach. However, the counselor’s skill at redirecting toward solution talk is important.

How we conceptualize cases in our heads and how we talk to clients can often occur from different frames. But as we become more experienced at framing the pathological as strengths and virtues that are used with good intentions, it is possible that our own inner and outer frames will begin to merge. And by assertively and immediately pursuing a strength-based approach from the get-go with our clients, they might be more motivated to open up and honestly discuss their situations, while simultaneously feeling empowered by our approach.

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Thomas Hofmann is a full professor in the master’s in clinical mental health counseling program at Hodges University in Florida and also teaches in the certified addiction professional track in the undergraduate program. He has experience in both mental health and substance abuse settings across the continuum of care. Contact him at thofmann@hodges.edu.

Letters to the editor: ct@counseling.org

Preparing tomorrow’s counselor for post-conventional faith

By Zvi J. Bellin June 23, 2015

The Pew Research Center’s 2014 survey on the landscape of religion in the United States showed a drastic change in the way people relate to religion and spirituality. Those who identified with the categories of “unaffiliated” or “nothing in particular” reached 38.6 percent of the population, suggesting a crack in the United States’ identity as one of the world’s most religious countries. However, 84.1 percent of those surveyed who identified as unaffiliated or nothing in particular still demonstrated some degree of belief in God or a higher power or deemed religion as important. Furthermore, there was an increased level of diversity within every category of religion.

Counseling students can expect to encounter clients who no longer fit neatly into conventional religious categories. So the question becomes, how can counselor educators adequately prepare tomorrow’s counselors for the evolving landscape of religion and spirituality? The answer is in our ability to provide expanding definitions, examples, theoretical frameworks and training activities.

Definitions

It is crucial for counselor educators to define the nuanced relationship between religion and spirituality. Both concepts require separate, though related, awareness on the part of counselors. Informed by the writings of P. Scott Richards, Allen E. Bergin and Kenneth Pargament, religion can be explained as a subset of the spiritual. Religion tends to focus on institutionally held dogmatic beliefs, practices and feelings, while spirituality is a relationship with the sacred that tends to be more personal, fluid and affect-oriented.

When teaching about this distinction, I project an image of a framed photograph — for example, a picture of a flower — that is growing out of its frame. The frame represents the necessary religious rules and dogmatic boundaries that provide the structure for expressing one’s religious or spiritual identity. The subject of the picture (the flower growing out of its frame) is symbolic of the spiritual and gives purpose to the frame. However, in its transcendence of the frame, the subject of the picture also represents the function of spirituality that might lead an individual to explore beyond the defined rules.

Creating a distinction between religion and spirituality can sometimes lead to seeing the two as dichotomous. Perhaps religious dogma takes on all of the negative qualities of faith — for example, in the concept of rejecting a community member on the basis of sexual orientation. Spirituality, on the other hand, may be given all the credit for the transcendent aspect of faith practice. A more objective picture will see each side of the religious-spirituality coin as containing both beneficial and challenging characteristics. It is important to emphasize that religion and spirituality have been associated with both mental health benefits and struggles.

Post-conventional faith speaks to the emerging and blended religious and spiritual identities that defy the classically neat categorizations of Jewish, Christian, Muslim and so on. Post-conventional faith can be seen in James Fowler’s stages of faith development as an individual moves from an acceptance of a socially prescribed faith framework to a complex resolution of a conflict between the individual’s experience of the world and the previously accepted faith.

What follows in the next section is an example of an organizational expression of post-conventional faith. Although this example can be used to educate counseling students, it is important to emphasize that the allowance of diversity and fluidity within the group speaks more to post-conventional faith than does the group itself.

Example of post-conventional faith

Since 2007, the organization Kohenet (which means “priestess” in Hebrew) has trained and ordained Hebrew priestesses. The mission statement of Kohenet (kohenet.com) includes that it “revives and re-embodies Judaism through the gifts of women spiritual leaders and through experience of the sacred feminine. Kohenet facilitates the creation of transformative Jewish ritual that is embodied, earth-based, feminist and inspired by traditions of women’s spiritual leadership.” This statement is in stark contrast to the traditional male-dominated leadership of the Jewish community and the traditional image of the Jewish God as characteristically masculine.

The “mission” page on Kohenet’s website provides further insight into the organization’s post-conventional faith expression: “We seek to serve the Shekhinah [sacred feminine] through traditional mitzvot like the practice of caring for the mourner and rejoicing with the bride, and also through honoring ages and stages of women’s lives that previously went ignored. We seek to be transmitters of Jewish tradition and practice, and also to evolve Jewish tradition and ritual to acknowledge the emerging needs of Jewish women and the planet as a whole. We seek to honor traditional images of the Divine, and also to make the Divine feminine a full part of our liturgy, ritual and lives. … This experimental model of spiritual practice and leadership offers an embodied, ecstatic earth-based approach that is interconnected with all life.”

Kohenet is an organization rooted in Jewish culture, but it in no way fits into, or intends to fit into, a conventional Jewish framework. The organization’s inclusion of Goddess spirituality, “Jewitchcraft” and paganism can be seen as directly opposed to traditional Jewish beliefs and practices. The founders of Kohenet and cohorts of Hebrew priestesses challenge these conventional assumptions and make space for their religious and spiritual paradigm in part by using the same tools of hermeneutics and creative interpretation that allow the conventional Jewish perspective to be redefined from generation to generation. (For example, see Sisters at Sinai by Jill Hammer.)

Kohenet’s work is making space for the voice of Jewish women to be heard in new ways and is drastically challenging the classic boundaries of Judaism in general. Kohenet has stepped far past convention, serving as an example of a movement that is inspiring post-conventional faith.

Theoretical frames for post-conventional faith

To help counseling students understand post-conventional faith from a theoretical perspective, I suggest teaching Crystal Park and Susan Folkman’s Meaning Making Model and Kenneth Pargament’s concept of search for the sacred. Both frames have been used to explain the nature of growth in the face of spiritual struggle. The first takes on a meaning perspective, while the second deals directly with language of the sacred. The theories help explain how post-conventional faith develops for clients.

Meaning Making Model

Post-conventional faith can be explained in terms of meaning because religion and spirituality are ultimately meta-meaning frameworks in which people orient their lives and provide a sense of cohesion. The Meaning Making Model deals with two levels of meaning: global and situational.

Global meaning is the comprehensive meaning framework held by an individual. It is composed of one’s beliefs and values about the way things are and how they ought to be. For example, a traditionally religious Catholic will most likely believe in God’s eternal goodness and that everything happens for a reason. Situational meaning, on the other hand, is the appraised meaning ascribed to a situation that one encounters in life. The meaning of a situation is appraised from the perspective of one’s global meaning. The Catholic believer encountering serious illness, for example, might be challenged in his or her belief in God’s ultimate goodness.

From this conflict between global and situational meaning, meaning making can arise in at least two ways. The believer might reappraise the situation so that it can be better assimilated into the global meaning framework. Thus, illness becomes a test that brings a person to a deeper level of faith. God remains good and in control. Alternatively, one’s global meaning can be altered to accommodate the appraised meaning of a situation. In our example, the Catholic believer might consider that not everything happens for a reason but that God ultimately can be found in the community support that brings comfort and nurturing.

The Meaning Making Model can be used to help counseling students understand the narratives from which a post-conventional faith identity emerges. Most clients and counseling students themselves are born into some faith tradition (global meaning) that becomes a source of struggle (situational meaning) at different times in their lives. One might imagine the variety of possible life narratives that would result in someone finding a spiritual home in an organization such as Kohenet. Similarly, the Meaning Making Model can help make sense of the high percentage of people who believe in some form of a higher power yet remain unaffiliated in their religious identity.

Search for the sacred

In this construct, sacred is defined as any aspect of life that is seen as connected to divinity. A person first encounters something sacred through a social or personal experience. For example, an individual is born into an Orthodox Jewish family and is raised to conceptualize the sacred through the lens of Orthodox Judaism. Once established, a person will go to great lengths to conserve his or her relationship with the sacred. Thus, at first, an Orthodox Jewish man will most likely deny any homosexual desires that might arise because, according to the Orthodox Jewish interpretation of the Bible, homosexuality is abhorrent.

At some point, one’s relationship to the sacred is challenged by internal or external changes. To continue our example with the Orthodox Jewish man, his same-sex attraction becomes so strong that he can no longer pray with his community without becoming aroused. These spiritual struggles challenge his relationship with the sacred so fiercely that conservation is no longer possible. He may now experience an interruption in his search for the sacred. For example, he may disavow the Orthodox Jewish conception of God completely or be propelled to seek out the sacred in a new way, such as embracing a more personal experience of the divine that accepts the spiritual potential in same-sex attraction.

This search for the sacred can be applied to the spiritual journeys of clients and students alike who have transcended conventional faith identities in favor of more nuanced and complex sacred expressions.

Training recommendations for counselor education

Classroom experiential activities are one way that future clinicians can gain both comfort and competence in working with clients who express post-conventional faith. An important step in training counselors is to help them become aware of the potential biases that exist when they encounter religious and spiritual language.

An exercise to uncover these biases involves preparing several PowerPoint slides, each containing a single word or phrase that is associated with religion and spirituality. For example, separate slides might contain the following words or phrases in large, bold letters: God, Divine Mother, Blood and Body of Christ and Pagan. Instruct students to attend to the physical sensations, emotions and thoughts that arise as they are shown each new word or phrase. After displaying each word or phrase, ask students to share what they are experiencing. Trainees can witness their own automatic internal responses to a variety of religious and spiritual language, and they can see how their peers might react in ways that are different or similar. At the conclusion of the exercise, ask participants to reflect on how their reactions might have surprised them or what insights arose knowing that their peers experienced different internal responses.

With these personal biases exposed, counselor educators can facilitate an exercise in which students expound on their own religious and spiritual identities, values and beliefs, increasing the sense of religious and spiritual diversity that exists within and between individuals. Janine Roberts shared the following exercise in a chapter appearing in the text Spiritual Resources in Family Therapy, published in 2009. The exercise is called On the Line: Voices and Views.

In this activity, students are asked to clear a space in the middle of the classroom stretching from one end of the room to the other. One end of the line across the classroom is designated as “highly agree,” while the other end is designated as “highly disagree.” The instructor projects multiple PowerPoint slides, one at a time, each containing a different phrase that shares an opinion held about religion and spirituality. For example, I use the following statements:

Everyone should be able to find their unique blend of religion — the more choices the better.
Everyone is spiritual, even if they identify as agnostic or atheist — even if they choose not to express their spirituality.
I believe there is a force of goodness in the world and that everything happens for a reason.

As each statement appears, participants stand along the line in the place that symbolizes their degree of agreement or disagreement with that particular statement. Students can be asked to turn to someone standing near them to discuss why they chose that position. Next, they can be directed to find someone standing elsewhere on the line and discuss why their positions differed. Alternatively, a selection of students along the line’s continuum can share out loud why they chose their current position.

The goal of these exercises is to tune students in to their own religious and spiritual beliefs, expose them to a variety of other religious and spiritual beliefs, and learn how to manage their expectations and reactions to an endless array of faith identities that exist outside of themselves.

Conclusion

Counselor educators have a responsibility to help students think beyond conventional faith designations. Post-conventional faith speaks to the increasing diversification of religion and spirituality in the United States.

Groups such as Kohenet provide real-life examples of post-conventional faith expressions. The two frames of meaning making and the search for the sacred can help students understand how post-conventional faith develops. Because of ever-expanding faith expressions, counseling students need to be taught to take a narrative approach to assessing for spirituality and religion.

Finally, I shared two experiential exercises that I use to help future clinicians achieve greater comfort and competence in dealing with post-conventional faith. Please be in touch with me as you try these exercises and as you create your own.

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This article was adapted from a previous article published in VISTAS 2014 (see counseling.org/knowledge-center/vistas).

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

Zvi J. Bellin is an assistant professor of holistic counseling at John F. Kennedy University. Contact him at zbellin@jfku.edu.