Monthly Archives: July 2015

When tragedy hits close to home

By Lynne Shallcross July 24, 2015

Aurora, Colorado. Fort Hood, Texas. Virginia Tech. The Washington Navy Yard. And, most recently, Charleston, South Carolina. Each of these places transitioned from being a name on a map to an instant reminder of the devastating aftermath of mass violence. Another is Sandy Hook, the Newtown, Connecticut, elementary school where shooter Adam Lanza killed 26 people, including 20 children, in December 2012.

In a report published last year, the FBI found that mass shootings in the United States have risen dramatically in recent years. In a study of 160 active shooter incidents between 2000 and 2013, the agency stated that an average of 6.4 incidents happened each year between 2000 and 2006. Between 2007 and 2013, that average rose to 16.4 incidents each year.

Deb Del Vecchio-Scully is the clinical recovery leader of the Newtown Recovery and Resiliency Team, formed out of a $7.1 million grant from the U.S. Department of Justice (DOJ) to bolster the Connecticut town’s mental health recovery and community resiliency in the wake of the shooting. According to Del Vecchio-Scully, this is the first time that a DOJ grant has been awarded specifically to provide mental health services following school-based violence.

When the grant was being written, Del Vecchio-Scully says, it was nearly impossible to gauge what Newtown’s needs would be in the months and years ahead. “There’s no road map,” she says, adding that the tragedy was unique because of the age of the children who were murdered and the impact the event had worldwide.

“What I’ve really come to understand about trauma is that in the aftermath of tragedy, regardless of how it happened — if it’s natural tragedy, if it’s violence — the reactions are extraordinarily complicated,” says Del Vecchio-Scully, a member of the American Counseling Association and the executive director of the Connecticut Counseling Association, a branch of ACA.

Since 9/11, psychological first aid has become the preferred modality suggested by the Federal Emergency Management Agency for use in the immediate aftermath of a disaster such as a mass shooting, says J. Barry Mascari, an associate professor and chair of the Counselor Education Department at Kean University in New Jersey. He explains that three core actions are involved in psychological first aid: protect, direct and connect. Protect survivors from further vulnerability, direct them to other services and connect them with their families and communities.

Counselors should think about that concept in terms of Maslow’s hierarchy of needs, Del Vecchio-Scully says. People’s basic needs must be met first, and the type of event will determine what those needs are — financial, social, psychological, emotional or practical.

Traditional counseling treatment and interventions are not part of psychological first aid. The goal of counseling is often to help people change, Mascari points out, but the goal in the immediate aftermath of a disaster is to help people get back to normal, which is the objective of psychological first aid. “You don’t want to start bringing in your other bag of tricks because [psychological first aid is] not treatment,” says Mascari, a member of ACA who is a co-editor with Jane Webber of the forthcoming book Disaster Mental Health Counseling: A Guide to Preparing and Responding, due to be published by the ACA Foundation next year.

Psychological first aid is also based on the recognition that individuals involved in a mass tragedy are experiencing normal reactions to an abnormal event, and the majority of people will return to normal in time, Mascari says.

Wait until called

After the events of 9/11, the United States learned one lesson in particular, Mascari says, “and that was that we weren’t prepared as a country to respond to these kinds of events.”

In the years since, individual states and the federal government have developed better-organized plans for responding to various types of disasters, including events of mass violence, Mascari says. Today, the response includes a hierarchy of those in charge and standards for survivor care.

Yet something that can still complicate the response to a tragic event is the influx of what Mascari calls “SUVs,” or spontaneous uninvited volunteers. “It was very clear both after the hurricane [Katrina] in New Orleans and after 9/11 that mental health professionals showed up expecting to do therapy with people and, in many cases, could have done more harm than good,” he says.

Del Vecchio-Scully also witnessed this after the school shootings in Newtown. “Communities can be overwhelmed by well-meaning helpers in the aftermath of a mass violence event, just as they are after a natural disaster,” she says. “Out of the goodness of people’s hearts, they want to help, and communities get flooded by individuals who may not have the training. Newtown was flooded by many whose hearts were in the right places but [who] did not really have the expertise to be doing what they were attempting to do.”

“You never want to be an SUV,” Mascari advises his colleagues in the counseling profession. “If you’re not deployed through an organization, you shouldn’t be there, because what happens is that you contribute to the disaster rather than help mitigate it.”

Counselors who are interested in assisting after a tragedy should start by seeking training beforehand to become an American Red Cross disaster mental health volunteer, Del Vecchio-Scully says. Among other places, the training is offered each year at the ACA Conference & Expo.

Mascari agrees that counselors should first get trained as disaster mental health volunteers and never self-deploy. He advises connecting with one of the responding organizations, such as the respective state mental health organization or the American Red Cross, to help in the aftermath of a disaster.

According to Mascari, New Jersey was the first state — about a decade ago — to develop a disaster response crisis counselor program. It uses a formal certification process for the state’s disaster crisis response workforce. Other states have since followed suit, using New Jersey’s model to create similar programs, he says.

Finding a new normal

People are often resilient in the face of disaster, says Daniel Linnenberg, an assistant professor of counseling in the Warner School of Education at the University of Rochester. “However, it takes a long time for them to go from being a victim of an event to a survivor of an event to a ‘thriver’ of an event,” adds Linnenberg, an ACA member who teaches a course on crisis counseling and disaster mental health and is also a disaster mental health volunteer with the American Red Cross and in his home county in New York.

“There will always be that ‘hole’ of that event within them,” he continues. “But, generally, people go beyond that and sort of come to what they refer to as a new normal.” Still, Linnenberg says it’s important to “remember that the event may only take seconds, but the recovery time takes years.”

That process of building resilience can be aided by various factors, the most important of which is social support, Linnenberg says. For example, when people have loved ones around them to lean on, that can foster resilience. Possessing a sense of optimism, having meaning and purpose in life, and accepting that we don’t have control over the world can also foster resilience, he says.

One way that counselors can assist survivors in building social support is through peer groups, such as the one Linnenberg helped establish in the wake of a tragedy in Webster, New York. Linnenberg had been providing counseling in the aftermath of an ambush shooting of firefighters that took place in the Rochester suburb in December 2012. The peer group was set up for loved ones of the firefighter community because they didn’t naturally have a group of people to connect with who could understand what they were going through.

Although resiliency will look different for everyone in the aftermath of an event of mass violence, Del Vecchio-Scully says that counselors can foster resilience among clients by engaging in ego-strengthening exercises — namely, recognizing and honoring when they take a step forward in some way. Remind clients that simply getting up in the morning and completing a task such as attending a counseling appointment or going to work is evidence of resilience, she says.

Del Vecchio-Scully cautions, however, that when the immediate aftermath of an event of mass violence has passed, it will not be a “neat transition” from the psychological first aid stage to what survivors will need next. Counselors should be on the lookout for people who are struggling and might need mental health treatment, she says.

Trauma affects people on a number of different levels in a tragedy such as a mass shooting. The base level is personal trauma, or what the individual’s own experience in the tragedy was, Del Vecchio-Scully says. There is also vicarious trauma, which usually affects helpers who are repeatedly exposed to the traumatic stories of others, she says. Secondary trauma is experienced only where primary trauma has occurred and results from being exposed to others who have been traumatized by the same event, she explains. Shared trauma affects people at the community level — for example, a teacher who works at a different school in Newtown, she says.

Complicated reactions to events of mass violence and other disasters, including posttraumatic stress disorder (PTSD), complicated PTSD and traumatic grief, are sometimes missed or misdiagnosed, Del Vecchio-Scully says. Counselors working with people in the aftermath of disaster or violent tragedy need to understand that trauma is a neurobiological injury to the brain, she says. A traumatic event such as a mass shooting can affect the brain in such a way that fearful memories get stored and the fight-or-flight response gets frozen. A cascade of neurochemicals then leads to triggering, emotional flooding, avoidance and hypervigilant reactions, she says.

“The long-term impact of trauma on children is particularly concerning within the Sandy Hook community [because] the brains of those directly impacted are in their most formative stages, ages 5 to 18,” Del Vecchio-Scully says. “The dysregulation of the brain due to trauma may impact brain size, brain hemisphere integration — which is important for emotional regulation — and an ability to determine cause and effect. [There is also] the impact on academic learning and performance.”

Del Vecchio-Scully suggests that counselors work from a trauma-informed model, which “requires advanced training in the neuroscience of trauma and trauma-informed treatments that focus on whole-brain treatment.” She says the treatments include eye-movement desensitization and reprocessing therapy, brainspotting, the emotional freedom technique, trauma-focused cognitive behavior therapy, somatic experiencing and trauma-informed art therapy.

“Counselors must have a basic understanding of the brain’s reaction to trauma, avoid assessment/treatment that requires a client to ‘retell their story,’ utilize calming and soothing techniques to regulate the brain and then initiate a trauma-informed treatment approach,” Del Vecchio-Scully says.

Caring for the caregivers

Most recently in Newtown, Del Vecchio-Scully has been working to provide support for the mental health clinicians in the community. She says that two and a half years after the shootings, community members affected by the tragedy are still coming to see these clinicians for the first time, which means the impact hasn’t really lessened for these mental health professionals.

On top of that, the community’s mental health clinicians are likely navigating multiple layers of exposure to the tragedy. For example, a counselor might be hearing clients’ stories of trauma while simultaneously feeling personally connected to the trauma because their children go to school in Newtown.

Del Vecchio-Scully’s team has been working to create peer support groups for the mental health clinicians working in the community. The helping professionals, who are from in and around the Newtown area, have a deep commitment to helping their community, Del Vecchio-Scully says. But clinicians in these kinds of situations can struggle to identify when they become impaired.

“If you enter into this work with an open heart, it isn’t a matter of if you’ll be impacted by the work but when this will occur,” she says. “Self-care when responding following a mass violence or natural disaster tragedy requires the basics of adequate rest; food and drink; time off and away from the situation; good, solid support from others; [and] methods of decompressing from what has been witnessed, including supervision, which for licensed people often lapses.”

In her role in Newtown, Del Vecchio-Scully participates in two peer supervision groups. It is an experience that she terms “invaluable.”

“Our team has worked with nearly 400 Newtown residents since its inception in July 2014,” she says. “I have worked very closely with a group of families whose children survived the shooting and were in the classrooms where the shooting took place. Bob [Schmidt, a fellow leader in the Connecticut Counseling Association] and I run a monthly group with these parents, and I have worked individually with some of the parents and kids. I have also worked in the Sandy Hook School providing support to the staff.”

Linnenberg emphasizes that supervision or peer support is a must for counselors who provide services in the aftermath of mass tragedy, no matter their level of experience. Self-care is also about knowing when to take a break, he says. “It’s more than drinking water. It’s more than getting exercise,” he asserts. “All those things are important, but it is really … forcing yourself to take time off even though you know you’re needed.”

Prevention on campus

One of Meggen Sixbey’s roles as a counselor is to try to prevent instances of violence before they happen. As the associate director for crisis and emergency resources at the University of Florida’s counseling and wellness center, Sixbey serves as a member of the university’s multidisciplinary threat assessment team.

Multidisciplinary threat assessment teams, which can be convened in a variety of communities, such as college campuses, typically bring together representatives from that community to address individuals who have raised a level of concern. On a college campus, the team might include representatives from the university administration, law enforcement, the campus counseling center and other sectors of the campus, says Sixbey, a member of ACA.

At the University of Florida, Sixbey says the team is called a behavioral consultation team, and its purpose is to bring a holistic perspective to individuals of concern. That individual might be someone who is threatening harm to others, Sixbey says, but it’s also possible that the person is a victim in some way, such as someone who survived a car accident or is being stalked.

All students, faculty and staff at the university have access to a phone number and email address that allow them to report a person of concern, Sixbey says. That information first goes to the office of the dean of students, which vets the reports and forwards the situations that need to be addressed to the multidisciplinary threat assessment team.

A counselor’s role on teams such as these is to act as a consultant and assess the situation with others on the team, Sixbey says. Although other team members might want a counselor to predict the likelihood of violence or pathologize behaviors, Sixbey says her role is to help cultivate a holistic perspective by looking at the whole of the person and the whole of the systems around the person. She often finds herself asking questions about what else could be done or what else is in play in the situation to help move the team forward in its assessment. “I don’t really come in with a diagnostic lens,” she says.

The ethical considerations surrounding a counselor’s participation on teams such as these can be complex. For example, Sixbey says if she is currently working with or has previously worked with a client at the university counseling center who subsequently comes up as a person of concern, she doesn’t typically consult with the team on that assessment because it would be a conflict of interest. But each situation must be considered on a case-by-case basis, she says. For instance, it may not be helpful to the person of concern if Sixbey recuses herself because that action may confirm to the rest of the team that the person is seeking counseling services or has sought them in the past.

In other situations, Sixbey might possess confidential knowledge about the person of concern that she can’t share with the team even though she is participating in the assessment. For example, during the course of the team’s assessment, a student could be asked to meet with Sixbey. That student could confidentially share with Sixbey that she is willfully stalking a faculty member, despite claiming publicly that it was a cultural misunderstanding. “A lot of that ethical piece is having this firsthandish knowledge that we can’t share,” Sixbey says.

In such situations, Sixbey has to consider how she can consult with the team in a helpful way while still honoring the legal and ethical guidelines of confidentiality. In this example, she might suggest to the team that if the student is to see the faculty member in person, a third person should be present. That way, Sixbey could protect the confidentiality of the student but also protect the safety of the faculty member.

The most helpful thing counselors can do to navigate ethical dilemmas associated with participation on multidisciplinary threat assessment teams is to consult with other mental health professionals, Sixbey says. “Consultation is key, and if we don’t do that, we’re doing ourselves a disservice.”

Some counselors might worry that a multidisciplinary threat assessment team is essentially a “profiling team,” Sixbey says. “That’s far from what these sorts of teams do if they’re doing it right.” In fact, teams such as the one Sixbey serves on focus mainly on ways they can help a person of concern be successful — “as opposed,” she says, “to cleaning up something that happens later because we didn’t do any kind of prevention.”

“I’d like to think our team is preventing crimes and homicides and suicides and depression, just frankly, on a daily basis,” Sixbey says. The hard part is that the team members will rarely know just how effective their intervention and prevention efforts have been at heading off crises. “We know when a school shooting happens, for example, but we don’t know when a school shooting has been prevented,” she says.

Since the mass shootings at Virginia Tech in 2007 and Northern Illinois University in 2008, more college campuses have initiated multidisciplinary threat assessment teams, Sixbey says. In addition to defusing potential situations of mass violence, she says these teams allow counselors to feel they are part of a larger, more collaborative effort to help people.

“If it’s just us with that person behind closed doors, we’re going to have a really limited view,” Sixbey says. “We may have a tenth of the pie, and there’s 90 percent more that we just don’t know.”

Sixbey offers an example. Perhaps getting a family member involved in a situation might help a person of concern — and perhaps the dean’s office would be better positioned than the counseling office to get that family member involved. “Counselors [can] get caught in a role of [thinking], ‘It’s just me trying to help this person,’” Sixbey says, “and that can feel really daunting.”

‘It can happen here’

Although a community may be flooded with outside resources and supports in the immediate aftermath of a tragedy, many of those supports, such as the American Red Cross, will eventually leave. At that point, Linnenberg says, the community itself needs to be prepared to take over.

For that to happen, Linnenberg contends that the community must be ready before a tragedy takes place. That includes mental health counselors and school counselors in the community preparing ahead of time for what they would need to do should an event of mass violence affect their community, he says. It also means counselors should prepare others in the community as well. For example, school counselors might help students understand what actions they should take if an event of mass violence were to happen at their school.

Counselors should also get more involved in public policy, Mascari says. “We tend not to think that we should be active in public policy, but public policy drives almost everything we do,” he says. Mascari tells his students to listen to what is being said in the public arena and then respond so that fewer public policy decisions will be made based on fear and misinformation.

The supposed connection between mass violence and mental illness is a perfect example, Mascari says. “There is a constant tagline in the media about mentally ill people performing violent acts,” he says. But Mascari points to a New York Times article written by Richard A. Friedman in the wake of the Newtown, Connecticut, shooting that said “only about 4 percent of violence in the United States can be attributed to people with mental illness.”

“While it is true that policy should consider closer screening of people with violent histories or mental illness who want to obtain guns, people should not stigmatize the majority of [individuals who are] mentally ill as violent, because they are not,” Mascari says.

Regardless of who the perpetrators of mass violence are or where these traumatic events take place, counselors need to be ready to respond, Del Vecchio-Scully says. “Following mass trauma, the community looks to counselors for support,” she says. “Therefore, counselors must have a minimum, base knowledge of trauma assessment and crisis intervention to assist immediately following the event before referring to a colleague with the advanced skills needed to engage in treatment,” which could mean another counselor or a different clinician with appropriate training.

“Nobody expects these things to happen, but they are happening with an ever-increasing amount of frequency,” Linnenberg says. “You hear about them almost every day. … We cannot necessarily prevent them from happening,” he says, “but we need to be prepared for them happening.”

Even in the class he teaches on crisis counseling and disaster mental health, Linnenberg says he has students who don’t understand why the door to the classroom should be locked.

“We do not have that mindset that this could happen to us at any time,” Linnenberg says. “The likelihood is very, very, very extremely low. But there is always that possibility. And, in a sense, as a counselor, you never want to be the one thinking, ‘I didn’t think it could have happened here.’ Yes, it can happen here.”

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To contact the individuals interviewed for this article, email:

Deb Del Vecchio-Scully at deborahscully@ymail.com
Daniel Linnenberg at dlinnenberg@warner.rochester.edu
J. Barry Mascari at jmascari@kean.edu
Meggen Sixbey at sixbey@ufl.edu

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Harm to Others

Earlier this year, the American Counseling Association published Harm to Others: The Assessment and Treatment of Dangerousness by Brian Van Brunt. The book offers students and clinicians an effective way to increase their knowledge of and training in violence risk and threat assessment, and it also provides a comprehensive examination of current treatment approaches. Van Brunt offers numerous examples from recent mass shootings and rampage violence to help explain the motivations and risk factors of those who make threats.

See Counseling Today‘s Q+A with Van Brunt here: ct.counseling.org/2015/06/behind-the-book-harm-to-others-the-assessment-and-treatment-of-dangerousness/

For more information on the book, visit ACA’s Online Bookstore at counseling.org/bookstore or call 800.422.2648 ext. 222.

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Lynne Shallcross is a contributing writer to Counseling Today. She recently graduated with a master’s degree in journalism from the University of California, Berkeley. Contact her at lshallcross@berkeley.edu.

Letters to the editor: ct@counseling.org

Treating depression and anxiety

By Laurie Meyers July 22, 2015

According to the National Institute of Mental Health (NIMH), approximately 25 percent of U.S. adults struggle with depression, anxiety or some combination of both. In any given year, approximately 6.9 percent of American adults — about 16 million people — live with depression. Approximately 18.1 percent — about 42 million — live with anxiety.

NIMH estimates that an even greater percentage of adolescents ages 12-18 struggle with depression and anxiety — approximately 9.1 percent and 25.1 percent, respectively. The precise incidence in children is unclear.

These numbers are staggering but perhaps not as eye-opening as another number. According to NIMH, 50 to 60 percent of those living with anxiety and depression receive no mental health services.

But what about those who do seek help? What works? Which treatments should counselors know about? Counseling Today asked several practitioners to discuss the steps they’re taking to help clients who are engaged in struggles with anxiety and depression.

Letting go

Beth Patterson, a licensed professional counselor (LPC) with a private practice in Denver, uses an eclectic mix of mindfulness practices, epigenetics and, in some cases, eye-movement desensitization and reprocessing (EMDR) to help clients with depression and anxiety. “I see a mix of depression and anxiety. They’re really closely related. The same brain chemicals are involved,” she says.

Depression and anxiety also share an essential psychological component — namely, pushing people away from living in the present moment. Individuals with anxiety are continuously worried about the future, while people with depression are often focused on what has happened in the past, explains Patterson, a member of the American Counseling Association.

Although she uses the same basic methods to treat both depression and anxiety, Patterson says it is essential to discern what clients are saying to themselves to help them address their negative self-talk. For example, she says that people dealing with depression ask a lot of “why” questions of themselves, such as “Why did I … ?” People struggling with anxiety, on the other hand, tend to use statements indicative of fear of future events, such as “I’m really worried about what’s going to happen with …”

Patterson helps her clients recognize when they’re having negative or anxious thoughts. She also gives them homework, instructing them to focus on noticing their self-talk. Patterson says she also teaches visualization as a tool to “bring them back down to their bodies” and out of the constant cycle of negative thoughts. Clients learn methods such as the “tree meditation,” in which they imagine themselves as a tree that is growing from the ground and sprouting branches. Another technique she uses is to have clients breathe in and out while visualizing that they are drawing breath through their feet. Patterson also meditates with her clients, teaching them to focus on their breathing and center their bodies instead of always living in their heads.

Another mindfulness technique is known as the driving meditation. “When you are in the car, drive,” Patterson tells her clients. “Turn off the radio [and] your cell phone and feel the road. When you get to a stop sign, stop and notice whether you’re driving or making a shopping list.” Over time, Patterson explains, these tools help clients become more aware of their thoughts and recognize when they are ruminating or engaging in negative self-talk. Once clients start recognizing negative thought patterns, they can then use visualization or other mindfulness practices to break the cycle, she says.

Clients often feel ashamed of having anxiety or depression and tell themselves that they must be weak to be susceptible to the condition, Patterson says. One of the ways she helps her clients see the fallacy behind this thinking is by asking them to build a family tree to find out whether depression, anxiety or trauma runs in the family. She talks with them about epigenetics, or chemical changes that alter a person’s genome and affect whether certain genes are expressed. Some researchers believe that life experiences can cause these changes and that the alterations can be passed from generation to generation.

For instance, Patterson says that depression runs in her family. She believes that a great trauma — her grandmother’s flight from the Russian pogroms at the turn of the 20th century — caused a change in DNA that was handed down in the form of depression.

Patterson also probes for trauma in the backgrounds of her clients because she believes it is common in people with depression and anxiety. “There are all kinds of trauma,” she says. “There is large ‘T’ trauma and small traumas.” Sometimes, the accumulation of small traumas can also cause psychological damage, she asserts.

Patterson often sees clients with trauma-related depression. For those cases, she uses EMDR as part of the treatment. She sometimes also uses EMDR for anxious thoughts. Developed by psychologist Francine Shapiro, EMDR uses bilateral stimulation, or stimulation on each side of the body, to help alleviate the emotional distress caused by traumatic memories. The most common method of EMDR uses eye movement, but it can also be performed through physical stimuli, such as buzzers or tapping, explains Patterson, who uses hand-held buzzers with her clients.

Patterson’s overall strategy in treating depression and anxiety is to use self-awareness techniques to help clients escape the thoughts and feelings that are holding them back. After clients learn to recognize their negative self-talk, she says, they can use the other tools she has given them, such as meditation and visualization, to ultimately banish their negative thoughts and the anxiety or depression that accompanies them.

Balancing the brain

Lori Russell-Chapin believes that neurocounseling — which combines traditional counseling with an understanding of how the structure and functions of the brain affect behavior and emotion — can deliver the most effective treatment for depression and anxiety.

In neurocounseling, clients are taught about the brain’s structure and chemical processes and how they influence a person’s emotions, she explains. Clients then learn that they can change some of these processes through neurotherapy.

“Neurotherapy is anything that changes or neuromodulates any of our neurons. That could be counseling, it could be neuro- or biofeedback, or it could be exercise,” says Russell-Chapin, a licensed clinical professional counselor (LCPC) at Chapin and Russell Associates in Peoria, Illinois.

Russell-Chapin, an ACA member, begins counseling with a complete assessment of the client. Because she is probing for neurological and physiological factors, her assessments cover elements such as a client’s medical history all the way back to birth. For example, Russell-Chapin wants to know whether there was any trauma during the client’s birth, such as oxygen deprivation or the use of forceps. These details help reveal potential sources of brain dysregulation, or an unhealthy alteration of the brain’s activity, explains Russell-Chapin, who is also a professor of counselor education at Bradley University in Peoria and co-director of the university’s Center for Collaborative Brain Research. This dysregulation is at the heart of clients’ mental health problems, she asserts.

For instance, she says, depression is related to frontal asymmetry — a condition in which the left frontal lobe, which is associated with positive affect and memory, is underactivated. In cases of anxiety, she adds, the right frontal lobe usually has excessive activity.

This dysregulation shows up in clients’ brain waves and can be treated through neurofeedback, Russell-Chapin says. The process begins with an initial electroencephalogram (EEG), which will reveal where the brain is dysregulated and the corresponding imbalance of brain waves.

Neurofeedback sessions are designed to change specific brain wave activity, Russell-Chapin says. “During the session, an [electroencephalograph] tracks the client’s brain waves. The neurotherapist sets a clinically needed threshold, and when the EEG indicates the desired brain wave activity, the brain is ‘rewarded’ with music or video activity,” she explains. “For example, a client with depression may have an underactivated left frontal area —not enough alpha — and an overactivated right frontal area — too much beta. Over time, the principles of learning win over, with the reward system ‘training’ the client’s brain. The sessions continue until the client’s EEG is consistently showing the desired — or properly regulated — wave activity and the symptoms of depression begin to dissipate.” The process usually takes 20 to 40 sessions, according to Russell-Chapin.

To make neurocounseling more effective, Russell-Chapin usually begins by teaching clients basic biofeedback skills such as controlling their breathing, heart rate and skin temperature. “I think [this] gives people great freedom and power,” she says. “[They think], ‘If I can control this, I can control anything.’”

Russell-Chapin also emphasizes to clients the importance of diet, exercise and sleep because they all have a significant effect on brain regulation.

“I had a client in my office who was drinking eight cups of caffeinated coffee a day. So we’re going to have to withdraw some of that caffeine,” she says. “I had another client who drinks maybe six or seven Cokes a day. Do you know how much sugar is in them?”

Russell-Chapin firmly believes that all counselors should take a similarly holistic approach with their clients. “What I am trying to do in my private practice and teach my students is that we now more than ever need to teach clients this holistic approach and that they can impact their physiology and brain and corresponding behaviors,” she says. “There’s really this underpinning of physiology underneath most of our mental health problems. We can do so much to help with this dysregulation.”

Brain-based psychoeducation

Humans are hard wired to have negative thoughts, says Vanessa McLean, and that is something she emphasizes to clients with depression and anxiety. McLean, an LPC with The Westwood Group, a group practice in Richmond, Virginia, that offers a wide variety of therapies, has found that teaching people about the physiology of their emotions with intense brain-based psychoeducation can be very effective for treating depression and anxiety. Learning that the tendency to react with fear or sadness is in part biologically driven helps to lessen the shame that often accompanies depression and stress, she says.

“That initial emotional response, we often can’t control, but it’s what we do with it. Do we feed it?” asks McLean, whose areas of specialization include anxiety and mood disorders.

Although anxiety and depression involve overreactions or underreactions in different parts of the brain, McLean doesn’t base her counseling on a diagnosis. “I don’t really treat anxiety or depression — I treat people,” she says. “They [depression and anxiety] are the same kind of feelings, just manifested differently.”

McLean talks to clients about their personal histories and how they have traditionally reacted to and coped with negative emotional responses. She helps them understand that struggling with negative thoughts is normal, but they can learn to reinterpret or not dwell on these emotions.

“A lot of times, people spend all day living in their heads,” McLean observes. She urges clients who might be struggling with depression or anxiety to distract themselves with exercise and other activities that they find enjoyable or that give them a sense of meaning and purpose.

She also talks to clients — particularly those with anxiety — about how the body and brain can create a kind of tension loop. “If the body is tense, the brain thinks something is wrong,” McLean explains. “A lot of people with anxiety don’t know what it feels like to be relaxed.”

To short-circuit this loop, she teaches clients deep breathing techniques and progressive muscle relaxation. She also asks them about other activities that have helped calm them in the past.

When clients are open to it, McLean may also discuss spirituality with them and get them to talk about what gives them meaning and purpose. As one element of her practitioner profile, McLean identifies herself as a Christian counselor, so sometimes people seek her out because of that. However, she doesn’t limit herself to clients of a particular religion. She believes that everyone is a spiritual being in one way or another, and she helps clients explore their beliefs — whatever they may be — to impart a sense of hope.

Something that McLean doesn’t embrace is the medical model — the view that mental health issues are illnesses. She believes that calling depression or anxiety an illness encourages people to think that they can’t do anything about their symptoms.

Lisa Jackson-Cherry has a counseling practice in a medical setting — the Chester Regional Medical Center in Chester, Maryland — and often receives referrals from physicians. She doesn’t reject the concept of mental health problems as illnesses, but she believes that psychotropic drugs are rarely the answer to treating those issues.

“I believe that the majority of individuals can overcome their anxiety and depression with counseling,” says Jackson-Cherry, an LCPC and a member of ACA. “I have found people want a quick fix [through medication] because they do not want to feel the uncomfortable feelings.”

Although the process may take longer, Jackson-Cherry thinks that the tools clients acquire through counseling will bring longer lasting relief and will also help individuals cope should symptoms of depression or anxiety later resurface.

Although she often uses cognitive strategies to help clients, Jackson-Cherry, who is also an associate professor of psychology at Marymount University in Arlington, Virginia, doesn’t use a predetermined script. She believes that depression and anxiety are inextricably linked to a client’s life experiences.

“My experience is that anxiety and depression often interfere with life goals, sense of purpose and meaning issues,” Jackson-Cherry says. “I believe many individuals have irrational beliefs or cognitive distortions. However, some of those ineffective cognitions are so enmeshed into their lives [that] listening to their … struggles and stories is an important aspect [of treatment].”

Talking to clients about their experiences helps Jackson-Cherry to individualize their therapy, she says. For example, talking about the root of a client’s anxiety may reveal that it comes from not feeling protected or safe in the wake of a sexual assault, she explains. In that case, Jackson-Cherry might use not just cognitive therapies but also behavioral therapy, such as talking about how the client can feel safer and more in control.

The gender gap

Research has shown that women are two to three times more likely than men to experience depression. Approximately 1 out of every 5 women in the United States will experience depression at some point in her lifetime. This is largely, though not entirely, due to hormonal factors, according to ACA member Laura Hensley Choate, an associate professor at Louisiana State University in Baton Rouge. She adds that this stark gender gap does not appear until puberty and then disappears after menopause.

“There are no gender differences between boys and girls until about age 12,” she explains. “Then, at the onset of puberty, it [depression] spikes in girls. Puberty is a particularly vulnerable time.”

In fact, between the ages of 12 and 15, the depression rate in girls triples, growing from about 5 percent to 15 percent of all girls, says Choate, who has written extensively about girls’ and women’s mental health, including two books published by ACA (Girls’ and Women’s Wellness: Contemporary Counseling Issues and Interventions and Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment). This rapid increase in depression incidence is related not only to a surge in hormones but also to factors that accompany the onset of puberty, she explains.

“Girls are more likely to experience multiple stressors at once,” Choate continues. “They’re going through puberty, they’re changing schools [going from elementary to middle school], they’re having to deal with romantic relationships … so everything’s hitting them all at once.”

Girls who go through puberty early are at even greater risk for depression, Choate says, in part because their emerging physical maturity often pushes them into situations that they are not emotionally ready to handle, such as older boys becoming interested in them sexually. These girls may also find themselves pulled in socially by older students and encouraged to experiment with drugs and alcohol, which further sets them up for depression, she explains.

Boys, on the other hand, go through puberty about three years later, which gives them time to become settled in school and adjust to the challenges of adolescence, Choate says. In essence, they have more life experience before they face the hormonal surge of puberty.

Another factor in the early gender gap with depression is that girls place more importance on relationships than boys do, Choate notes. “That’s another big issue [as puberty hits],” she says. “They’re more sensitive to disruptions in their relationships, like fights with friends or fights with romantic partners.”

And then there is the monthly hormonal shift that girls and women face with their menstrual period, Choate points out. Counselors should be aware that not only can PMS exacerbate depression symptoms, but in some cases, she continues, what looks like major depression may actually be premenstrual dysphoric disorder (PMDD), a condition that was added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

If depressive symptoms seem to appear for only part of the month, a counselor should screen for PMDD by helping the client track her moods over time, Choate says. If PMDD is present, making dietary changes such as decreasing alcohol, fat, salt and caffeine and increasing complex carbohydrates may help. If antidepressants are needed, they may be necessary for only part of the month, Choate notes. Counselors can also help clients evaluate their options for lessening the symptoms of PMDD. For example, if a client decides she wants to consult her gynecologist or primary care physician, the counselor can help her come up with questions to ask to be fully informed about her options, Choate says.

It is also important for counselors to encourage female clients to focus on self-care during their symptomatic days, she emphasizes. Women need to be told that it is OK to slow down, plan a less hectic schedule and take care of themselves when they are feeling bad. “We know through CBT [cognitive behavior therapy] that just decreasing [self-] expectations can help,” Choate says.

In fact, CBT is often regarded as the “go-to” treatment for depression by mental health professionals, but counselors should also consider interpersonal psychotherapy (IPT), especially if CBT doesn’t work, Choate says.

IPT can be very effective for women and, in particular, girls, Choate asserts. “It works not just on depression but also on social skills, building up relationships and self-esteem,” she says.

IPT assumes that regardless of depression’s cause, it is intertwined with personal relationships, Choate explains. In IPT, counselors start by taking an interpersonal inventory of the client’s life: Whom can she count on? Who supports her emotionally? Is she dealing with any relationship issues, including unresolved grief?

Role transitions, such as from childhood to adolescence or the transition into motherhood, are also important because they raise questions about loss, Choate says. For example, when she becomes a mother, a woman is gaining a child, but she may also question what she is losing, such as a degree of personal freedom. The uncertainty that accompanies transitions can trigger depression.

Because women are more likely to view relationships as central to their emotional well-being, supportive interpersonal relationships can help them cope with the emotional aspects of transitions. Conversely, interpersonal conflict may exacerbate feelings of anxiety or depression, Choate explains. Therefore, identifying negative and positive interpersonal factors in a woman’s life can be essential to treating depression, she says.

Pregnancy and depression

The childbearing years are also a prime time for depression in women, Choate says. Part of that involves issues such as deciding whether to become a mother or becoming a mother and learning to juggle family, work and life.

However, pregnancy itself poses a depression risk that counselors may not be aware of, Choate cautions. Postpartum depression has become a familiar concept, but women can also become depressed during pregnancy, she explains. Women who have a history of depression are at very high risk for developing pregnancy-related depression. But prepartum depression can mimic normal pregnancy symptoms such as fatigue, loss of appetite and not wanting to participate in previously pleasurable activities, Choate explains. To help distinguish between normal pregnancy symptoms and depression, Choate advises counselors to ask their clients who are pregnant whether they would want to go out and do what they used to do if their physical symptoms such as nausea and fatigue disappeared. Most pregnant women would say yes, but those who are depressed would generally answer no, she explains.

Depression during pregnancy — whether it is preexisting or prepartum — can also raise the particularly difficult question of whether to take antidepressants, she says. The answer is not simple. Untreated depression is bad for the mother, and research indicates that once the child is born, a mother’s state of mind can have a significant impact on the child.

But the other side of the argument is also valid. “In the past, doctors have prescribed [antidepressants] without considering the risk, and the research really is mixed,” Choate says. “So counselors can help [pregnant clients] weigh the risks of untreated depression versus an antidepressant. … This is an emotionally charged issue, so counselors need to help the client and also check their own biases.”

Although not conclusive, some research has indicated that antidepressants are associated with low birth weight, preterm delivery and pulmonary hypertension in newborns. Antidepressants may also be associated with spontaneous abortions and preeclampsia. However, many of these complications have also been associated with depression itself.

After the child is born, a mother experiencing depression will have to make another related decision: whether to take antidepressants and nurse, to nurse without taking antidepressants or to continue drug therapy and rely on formula to feed the child. Again, says Choate, the research on the implications of these choices is mixed.

There is also significant medical and social pressure for mothers to breastfeed, so female clients who are dealing with depression will need support gathering and considering all the variables to make a decision. Counselors can play a valuable role in helping clients formulate the right questions, Choate says.

As women leave their childbearing years behind, they also face increased risk of depression. “Women are more vulnerable to depression during the years leading up to menopause,” Choate says.

Then there are the issues that women face related to aging in today’s society, she continues. Women are valued for their youth, beauty and fertility, and as they grow older and no longer reproduce, they lose societal status, Choate says. These changes are especially difficult if a woman’s self-identity is closely tied to her looks, she says.

So, Choate concludes, although hormonal factors are certainly a contributing factor, counselors should be aware of all the sociocultural influences that make women and girls more vulnerable to depression.

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To contact the individuals interviewed for this article, email:

Lori Russell-Chapin at lar@fsmail.bradley.edu
Laura Hensley Choate at lchoate@lsu.edu
Lisa Jackson-Cherry at ljackson@marymount.edu
Beth Patterson at bethpatt@mac.com

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Additional guidance

The American Mental Health Counselors Association, a division of the American Counseling Association, was chartered in 1978. It represents mental health counselors and advocates for client access to quality services within the health care industry. Visit its website at amhca.org.

For more information on treating depression and anxiety, counselors can also access the following webinars and podcasts on the ACA website:

Webinars (counseling.org/continuing-education/webinars)

Depression: New and Emerging Treatment Strategies
Neuroscience: The Cutting Edge of Counseling’s Future

Podcasts (counseling.org/knowledge-center/podcasts)

Assessing and Treating Perinatal Mood and Anxiety Disorders
Suicide Assessment: Sharpen Your Clinical Skills

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

State licensing boards asked to adopt uniform scope of practice, licensure title

By Bethany Bray July 20, 2015

This summer, state licensing boards across the United States are being asked to accept both a uniform scope of practice and a common licensure title for professional counselors as part of an effort to improve license portability for counselors.

Letters, cowritten and signed by the leadership of the American Counseling Association (ACA) and the American Association of State Counseling Boards (AASCB), were finalized and sent last month.

The two organizations are requesting that state licensing boards adopt a uniform professional title – licensed professional counselor (LPC) — and scope of practice, a five-paragraph job description that defines the work of professional counselors.

More than 35 different license titles are currently in use by professional counselors across the country. Scopes of practice for professional counselors also vary state to state.

This summer’s letter is the culmination of the Building Blocks to Portability Project, which was part of 20/20: A Vision for the Future of Counseling, a yearslong strategic planning initiative that ACA and AASCB co-sponsored.

For more background on the profession’s license portability issues, read Counseling Today’s April feature, “Addressing counseling’s portability crisis.”

See a sample of the letter being sent to each state licensure board here.

See ACA’s announcement about the letter, including the full scope of practice for counselors, here.

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Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday

Preparing counselors for America’s multiracial population boom

By Bethany Bray July 15, 2015

The U.S. Census Bureau estimates that the nation’s multiracial population will triple by 2060.

That prognostication only heightens the long-standing need for counselors to better understand this population, say Kelley and Mark Kenney. The husband-and-wife counselor educators spearheaded development of the Competencies for Counseling the Multiracial Population, which were endorsed by the American Counseling Association Governing Council this past spring.

The new multiracial competencies, which offer guidance for working with individuals, couples and families who have backgrounds from more than one racial heritage, were developed by a task force made up of members of the ACA Multiracial/Multiethnic Counseling Concerns Interest Network, co-chaired by the Kenneys.

Counselors are going to have multiracial clients walking through their doors more and more frequently, says Mark Kenney, a licensed professional counselor (LPC) who is a professor and coordinator of the master’s program in psychology at Chestnut Hill College at DeSales University in Pennsylvania. That client might be a multiracial teenager who is struggling in school, a same-sex couple that has adopted a child of a different heritage or many other scenarios.

The ACA Code of Ethics’ call for counselors to be competent and ethical practitioners applies here, Mark says. Understanding and being sensitive to the multiracial experience “isn’t an option anymore,” he says. “This is an expectation with this population.”

“Historically, there has not been a good relationship between this community and the helping professions,” he adds. “Only within the last 20 years has there been better research and understanding of this population.”

Much of the talk leading up to the 2008 election of President Barack Obama – a man with a white mother and a black father – suggested that Americans still harbor significant misunderstandings about the biracial population, says Kelley Kenney, a full professor and program coordinator of student affairs in higher education at Kutztown University.

“There was a lot of discussion about [multiracial] couples and families, brought on by the fact that we had a man who was running for president who, oh by the way, just happened to be of multiple heritages,” Kelley says. “As recent as 2008, there was still a lot of bias and stereotyping going on.

President Barack Obama and First Lady Michelle Obama in September 2014. (Official White House photo by Pete Souza/via Flickr)

And we still hear it now. … We [counselors] hold the same biases, stereotypes and assumptions as the general public, based on misinformation we’ve gotten growing up.”

There is good news, however, Kelley says. The United States has come a long way since Loving v. Virginia, the landmark U.S. Supreme Court case that invalidated state laws prohibiting interracial marriage. The case, which made its way to the Supreme Court from Virginia, involved Mildred Loving, a black woman, and Richard Loving, a white man, who had been sentenced to a year in prison for marrying each other in 1958.

Kelley noted that it was significant that she and her husband – an interracial couple – were interviewed by CT Online on June 12, the anniversary of the court decision, a day that is also referred to as Loving Day.

“We definitely know this is an ever-growing population,” she says. “We’ve seen a dramatic increase in the number of multiracial couples since 1967 when the Supreme Court decision was made. That alone speaks to and is the most compelling reason why these competencies are important. This population is here, they’re everywhere. … They have become a large segment of the U.S. population.”

Bridging the gap

The multiracial counseling competencies were developed by ACA’s Multiracial/Multiethnic Counseling Concerns Interest Network, of which the Kenneys are co-founders and facilitators. They started the interest network two decades ago with Bea Wehrly, author of the 1996 book Counseling Interracial Individuals and Families.

“As we’ve been working as a core group for the last 19 years, it’s really been our aim to promote and raise awareness and knowledge about this emerging and growing population,” says Kelley, a past member of ACA’s Governing Council. “That’s really how the idea for the competencies came about.”

In the nearly two decades since Wehrly’s 1996 book, Kelley notes, only two other titles have been published within the counseling profession about working with interracial clients, one of which the Kenneys co-wrote with Wehrly (Counseling Multiracial Families).

The competencies were written to help fill that void, she says, and to create a complete, accessible and up-to-date resource for counselors.

“We felt there was a need,” Kelley says. “In putting together a competencies document to be approved by the ACA Governing Council, we are able to provide a document that would be much more far-reaching than books. We are the only, as of this point, helping profession that has developed a set of competencies for working with this population. … Having Governing Council approval further elevates this population in the minds of the profession.”

The multiracial competencies, posted on the ACA website and available to the public, are the eighth set of competencies endorsed by ACA.

The Kenneys were part of a team of 14 people who developed, wrote and edited the multiracial counseling competencies over the past two years. Members of the Multiracial/Multiethnic Counseling Concerns Interest Network contributed to sections they specialize in, such as adoptive families, couples and so on (see sidebar, below).

The competencies are divided into sections focused on segments of the multiracial population: interracial couples, multiracial families and individuals, transracial adoptees and families. In addition to competencies specific to each segment of the population, the sections include information on the contextual framework used to inform and create the population’s competencies, language and definitions specific to the population and current issues and needs. The competencies’ bulleted points of information are further divided into subcategories for different aspects of the profession: research, group work, career development, assessment, ethical practice and so on.

The competencies are dedicated to Wehrly, who passed away in 2014.

A growing need

Americans were first allowed to select more than one race on census forms in 2000. Since that time, it has been found that the country’s multiracial population is growing three times as fast as the population as a whole.

In June, the Pew Research Center released a study that estimated multiracial adults currently make up 6.9 percent of the adult American population.

At the same time, the amount of research and data available to counselors about this population is behind the curve, the Kenneys agree.

There is very little on this topic in counseling journals, says Mark, and only recently have counseling textbooks begun to include chapters on working with multiracial clients. The Kenneys know this because they have been involved in writing for several counseling textbooks recently.

In years past, counselors searching for information on working with interracial couples would find research only on couples in therapy in which one spouse was white and the other was black, Mark says.

“It was all pathology [and] the assumption that the offspring of multiracial couples will never find their identity in society,” he says. “We as a profession did not do a very good job – just as with the monoracial experience of race – in our society. We still have a problem of misdiagnosis and overdiagnosis.”

Although there is still a long way to go, there are signs of progress in some areas.

“This is not a group that is one size fits all. There might be over-research with one group [within the multiracial population], or under-research with another,” Mark says. “There is still a dearth of information to prepare counselors for counseling families after a transracial adoption. Most graduate programs don’t even go there, [but] there will be an increase going forward. A lot of [doctoral] dissertations are being written. Young professionals are the driving force.”

Becoming part of the solution

Above all, the Kenneys stress that counselors should be aware of their own biases when it comes to working with multiracial clients. Self-monitor and hold yourself accountable, Kelley advises.

“If you do happen to realize you’re working from a place of bias, now you have a resource” — the ACA competencies — “for gaining knowledge and skills for working with this population,” Kelley says. “This becomes a way to hold our profession accountable. … There is importance in the intentionality around, if you don’t know, acknowledging that you don’t know and taking the time to read up and consult research. For me, that’s the important piece. I’ve seen the impact of the harm that’s done, and I don’t want to continue to see that go on.”

“It’s the awareness piece,” Mark agrees, “making sure professionals are working from the most recent and complete research, not misunderstanding or holding assumptions.”

Additionally, counselors should understand that no two multiracial clients will have the same needs and sensitivities. For example, geography and social history may play a role. Some areas of the United States, such as the West Coast, have high numbers of multiracial families, while other regions have very few.

“As I’ve lived and learned and experienced this population, the takeaway for me is being aware of the diversity within the diversity in this community,” Mark says. “We’re not all having the same experience.”

It’s all contextual, he explains. For example, a person with a black/white identity will have different needs and experiences than a person with a white/Asian identity, and so on. Within this diversity, there will also be different needs for heterosexual couples versus LGBT couples, cisgender versus transgender individuals, etc.

“Therefore, you need to be open [and] truly empathically listening, allowing the story of the individual, couple or family to unfold in front of you,” Mark says. “Appreciate the strengths of the family or the individual couple. These individuals have strengths. Don’t forget to be listening for their strengths, in terms of how they journeyed to the point of coming to your office. Allow the individual, couple or family to come to their own determination of identity. [Their identity] is not for us to decide as counselors; it’s up to the individual or family, how they wish to come to their sense of who they are.”

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Find the full competencies on the ACA website.

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Contributors

The multiracial competencies were written by a team of 14 people, including:

Full document: Kelley R. Kenney and Mark E. Kenney
Editor: Carmen F. Salazar
Couples and families section: Mark E. Kenney, with team of Leah Brew, Mark L. Pope, Hank L. Harris, Cheryl L. Crippen and Stuart Chen-Hayes
Individuals section: Derrick A. Paladino, with Richard C. Henriksen Jr. and Anneliese A. Singh
Transracial adoptive families and individuals section: Amanda L. Baden, with Susan B. Alvarado and Krista M. Malott

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Related reading from the Pew Research Center:

“Today’s multiracial babies reflect America’s changing demographics”

“Multiracial in America: Proud, Diverse and Growing in Numbers”

Also, from the August 2014 issue of Counseling Today: “Counseling transracial adult adopted persons”

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday

Behind the book: Critical Incidents in Integrating Spirituality into Counseling

By Bethany Bray July 10, 2015

Professional counselors must consider the entirety of the human experience with clients, an experience that includes spirituality.

Leaving spirituality out of the counseling process does a disservice to the client, say Tracey Robert and Virginia Kelly, licensed professional counselors (LPCs) and co-editors of Critical Incidents in Integrating Spirituality into Counseling.

A separate concept from religion, Robert and Kelly define spirituality as “the pursuit of meaning and purpose in life, often individual to clients, including the influence of their belief system and worldview and their values as they face the challenges of life events.”

“Wellness, a foundational construct of the counseling profession, places spirituality at the person’s core. Ignoring this domain can result in a lack of understanding of the client’s worldview and an insensitivity to multicultural issues. Both can be detrimental to the counseling effort,” write Robert and Kelly in the book’s introduction. “In counseling, as in many disciplines, the only constant is change. The counseling field has evolved in recent years to accommodate clients’ changing needs and increasingly has recognized the important role the spiritual domain can play in meeting them.”

Robert and Kelly’s book, published this year by the American Counseling Association, provides cases and examples of ways to incorporate spirituality into counseling, from working through grief and loss to eating disorders and career counseling. The books final section delves into spiritual interventions that can be used in counseling, including meditation, group work and prayer.

Q+A: Critical Incidents in Integrating Spirituality into Counseling

Responses by co-editors Tracey E. Robert and Virginia A. Kelly

What do you hope counselors take away from the book about this topic?

With the growing recognition of the importance of the spiritual domain, there has been an increased need for training materials and strategies for integrating this topic into counseling. Our hope is that counselors will find this casebook a useful tool for a holistic approach to the counseling process and training future counselors.

The Association of Spiritual, Ethical and Religious Values in Counseling (ASERVIC) developed competencies on spirituality and counseling in the 1990s. What would you want an experienced, veteran counselor — one who may have completed grad school before the ‘90s — to know about this topic?

Our hope is that any professional counselor will be familiar with the most updated ASERVIC competencies. These competencies have been endorsed by ACA and serve as the standard for integration of spirituality and religion into professional practice.

An experienced, veteran counselor needs to adhere to the same ethical (code) that suggests recognition of the importance of the spiritual domain.

In your opinion, what makes professional counselors a “good fit” for integrating spirituality into therapy? What unique skills do they bring to the table?

Our (counselor’s) emphasis on a developmental perspective and a wellness model makes our profession a good fit for inclusion of spirituality into counseling. Jane Myers’ model of wellness has spirituality at its center.

The key skill would be the focus on the relationship that includes the whole person and examines the client’s worldview.

What advice would you give a counselor who is not spiritual or religious themselves about working with spiritual or religious clients — and vice-versa?

The same advice I would give a counselor to work with diverse clients whose worldview differs from their own: This is part of being multiculturally competent and constitutes professional ethical practice.

The Pew Research Center recently released data that shows a growing number of Americans, especially young adults, do not identify with any organized religion. Do you think this will affect the work counselors do? (If so, how?) Is there anything you would want counselors to keep in mind about this?

No I don’t think this will affect our work. We have distinguished spirituality from religion by defining them separately and then we focus on the client’s worldview. It requires that counselors are able to assess the client’s spiritual/religious values and to address them in counseling if they choose to.

But with more young adults not having an organized religious connection, we may see alternative connections to spiritual practices filling the need for community.

What makes you, personally, interested in this topic?

We have both been interested in this topic for a long time. Tracey’s interest was influenced by her work as a career counselor when clients were seeking meaning and purpose in life. Ginny’s scholarly interest emerged from her research in the treatment of substance abuse and addictions that has always incorporated a spiritual component.

What prompted you to collaborate to create this book? What made you want to include case studies?

Both of us have had a scholarly interest in spirituality and counseling. Ginny (Kelly) had edited Critical Incidents in Addictions Counseling (published by ACA in 2005) and suggested that this format has served as a valuable resource in several counseling arenas (e.g., school counseling, group counseling, addictions counseling). We decided to collaborate on a similar project related to spirituality. Tracey (Robert) then took the lead on the project.

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Critical Incidents in Integrating Spirituality into Counseling is available from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222

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About the editors

Tracey E. Robert is a licensed professional counselor (LPC) and associate professor and director of clinical training in the Counselor Education Department at Fairfield University in Connecticut. She is current president of the North Atlantic Regional Association for Counselor Education and Supervision and a past president of the Association of Spiritual, Ethical and Religious Values in Counseling (ASERVIC), a division of the American Counseling Association.

Virginia A. Kelly is also an LPC and associate professor in the Counselor Education Department at Fairfield University. She is past president of the International Association of Addictions and Offender Counseling (IAAOC), a division of the American Counseling Association, as well as the North Atlantic Regional Association for Counselor Education and Supervision.

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday