Monthly Archives: June 2016

Recognizing and managing deception in the therapeutic relationship

By Gregory K. Moffatt June 27, 2016

I had been working with “Alex,” an 8-year-old boy diagnosed with attention-deficit/hyperactivity disorder, for longer than six months. His hyperactivity had become a major problem at school, and much of our clinical focus had been on managing behavior in the school environment. Each week, Mrs. T, his mother, who drove almost three hours to bring Alex to see me, confirmed that his behavior was improving. Then, one cold December afternoon, she appeared for our appointment without Alex.

“I’m sorry,” she said, “but I haven’t been honest with you. Alex’s behaviors haven’t improved at home or at school. I’ve lied about it all along, and I don’t know why. We are withdrawing from therapy, but I wanted to tell you to your face.”

Mrs. T was embarrassed. She apologized profusely, thanked me and then left. I never saw her or Alex again.

I was devastated. I had been in the field for more than 20 years and had never had anyone be so overtly dishonest with me. Mrs. T had paid me a lot of money and invested a substantial amount of time driving Alex to and from therapy. I couldn’t understand why she hadn’t simply told me the truth all along.

From this experience, I learned the valuable lesson that I can’t always take a client at his or her word. But how can we know when clients are not being truthful? What clients are most likely to deceive? How can we identify and manage deception? The answers aren’t simple ones.

Problems with research

Before I address the questions at hand, some caveats about the research on deception are necessary. The research on indicators of lying is so full of conflicting ideas that little sense can be made of it all. Even some of the best studies have serious problems.

For example, some studies have argued that agents from the former U.S. Customs Service are no better at detecting lies than the average person. But many of these laboratory studies have subjects lie about little things such as “I have the ace of spades in my pocket” when in fact they don’t. These are called “low-stakes lies.” Nobody goes to jail for lying about having a playing card in his or her pocket. But when it comes to high-stakes lies — lies that are meaningful — Customs agents are much better at detecting lies than most of us.

In fact, it is easy for people to lie about little things. Most of us do it regularly in daily life.

“Do you like my sweater?”

“Um, yeah …”

These little white lies are meaningless in the big picture of life. But the physiological response to lying about big things (“No, sir, there are no illegal drugs in my bag”) is much harder to suppress. These are lies that most of us don’t tell.

Among the beliefs that have been held in the past are that liars fidget more, don’t make eye contact and stutter more frequently. Although sometimes these things are true, sometimes they aren’t. These oversimplifications were based on problematic research methodology. Today we know much more about deception. But before we look at what people who tell lies do, let’s look at who lies and why they tell the lies they tell.

Who lies?

All of us lie. We just lie about different things. Unless we are pathological liars, we regularly evaluate the cost or benefit of telling the truth, which often involves determining the likelihood of delaying or avoiding a certain cost or increasing a particular benefit by using deception.

For example, if someone made a meal for you and asked if you liked it, you might lie to protect the person’s feelings if you didn’t really enjoy it. The cost of the truth — hurt feelings — is much higher than the cost of a little white lie. The cost of a child telling me (a counselor) the truth about his or her abuse is shame, embarrassment and humiliation. The lie often feels much safer to the child.

For that reason, over several decades of experience working with children who have been sexually and physically abused, I have found that almost all children attempt to deceive me at some level in the initial interview. My question of whether anyone has ever touched them in a way that hurt them or made them feel uncomfortable is nearly always met with a “no” response, even when I already know that the child has been sexually or physically abused. They don’t trust me enough to tell me that secret yet.

By recognizing those clients who might be motivated to lie because of what the truth might cost them, we can, as counselors, better predict the likelihood that a lie is being told.

Why it matters

Nearly all of our clients will lie to us at some point. Lying can take several forms. A person can lie by saying something that isn’t true (called falsification) or by denying something that is true (called concealment).

Lies can be blatant. Former President Bill Clinton displayed this form of deception when he told the media, “I did not have a relationship with that woman.” But many lies are not so blatant. Clients might deflect as a form of lying. Again, in the case of the former president, he drew a lot of attention for his statement, “It depends on what the meaning of the word is is.” This is a common method a person who is lying might attempt to use to save his or her reputation (cost) by parsing terms. The person rationalizes that his or her response wasn’t really a lie by deflecting and answering a different question.

Clients might also lie by diminishing their behavior: “Well, I didn’t really hit my husband. I lost my balance and my hand might have touched his face.”

All these forms of lying might be seen in nearly any counseling context — marriage counseling, alcohol and drug counseling, anger management, working with court-ordered clients and so on. The accuracy of the information we get from our clients matters to us as therapists because we structure our interventions and treatment plans and measure progress based on what our clients tell us. When they deceive us, as Mrs. T did to me, at the very least we waste therapeutic resources. But we might also miss important pieces of information that are critical to a client’s survival. For example, a client who is attempting to manage suicidal ideation might end up succeeding at suicide if we miss the intensity and frequency of the individual’s ideation due to deception.

All of us can expect our clients to deceive us at some point. I was taught early in my education that “the problem is never the problem.” My professors and clinical supervisors were trying to demonstrate the importance of rapport and trust in a therapeutic relationship. Part of that is expecting that, sometimes, the stated presenting problem isn’t really why the client came in. Clients have to learn that they can trust us before they will tell us what they really want to talk about.

Therefore, early on in the relationship, I am always listening for hints that there might be more to the story than I am being told. I have found that, oftentimes, my teachers were correct.

High-risk populations

Several client populations are at particularly high risk for lying, including incarcerated individuals, children in foster care, clients who are addicted, people involved in sexual assaults and clients who are suicidal.

Prisoners and juvenile detention: Kenneth Bianchi, also known in the 1970s as the Hillside Strangler, came very close to successfully duping several of the country’s most renowned experts on multiple personality disorder (as it was known then) by faking the disorder while supposedly under hypnosis.

These professionals made a critical mistake. They naïvely believed that Bianchi wouldn’t — and, more importantly, couldn’t — fool them. These experts had extensive experience working with clients who were motivated to tell the truth, but a person accused of serial crime is highly motivated to lie.

Any client or patient familiar with the “system” is at risk for manipulating it. One of the lead psychologists in the Bianchi case later served as a clinical director in a prison. He acknowledged that the experience of working with prisoners confirmed that he had been naïve in the Bianchi case.

Most therapists have the luxury of believing their clients will tell the truth, or at least near truths, much of the time. But when working with those who are incarcerated — either those in the juvenile justice system or adults in the prison system — one must verify all information by a second source because the motivation to lie is so high. We have done this with alcohol and drug treatment patients for years.

“I didn’t smoke anything this week.”

“OK, I believe you. Please pee in the cup.”

“But I haven’t smoked anything …”

“Fine. Please pee in the cup.”

Clients who are addicted could be telling the truth, but the information must be verified. Manipulating people for one’s own gain is inherent in the prison system, where inmates have very little power and must always look out for themselves. Nobody trusts anybody. Inside the prison block or juvenile hall, deception is an everyday part of life, giving people motive to lie and providing ample opportunity to practice. In other words, telling the truth doesn’t outweigh the benefits of the lie — more privileges, freedom or exoneration.

Accusations of sexual abuse: Generally, young children do not falsely accuse others of sexual or physical abuse. They have too much to lose. As noted earlier, the opposite is far more likely. I’ve seen hundreds of children who have been physically or sexually abused by caregivers, and most of these children still want to go home. They want the abuse to stop, but they don’t want to be elsewhere, even if it means returning to the homes of their abusers. Therefore, they are not motivated to make up abuse allegations but rather motivated to lie that it did not occur (concealment).

The exception to this general rule involves teenagers who know how to manipulate their parents or guardians with threats of intervention by child protective services and children who have been exposed to the “system” (see the preceding section on prisoners and juvenile detention.) Sadly, I’ve seen several cases in which adolescent children in foster care accused a foster parent of sexual misconduct or abuse simply to exact revenge on the foster parent for a perceived grievance. These teens knew how to work the system.

Sometimes, parents also have a motivation to lie about abuse. I have worked with dozens of parents who were divorcing. In some of these cases, one of the spouses has either accused the estranged spouse of abuse or proposed a “concern” about potential abuse simply to improve his or her own position in the custody hearing. People know that the mere accusation of abuse can have an effect on a judge’s decision for custody. In these cases, the benefit of the lie may outweigh the benefit of the truth.

Rape allegations: Unfortunately, I have been in the position several times of having to evaluate the truthfulness of a victim and her alleged rapist. This is a very sensitive process because a mistake in either direction has tragic consequences. If I wrongly suppose an accused rapist is telling the truth, I have provided data that might let him avoid charges. Even more serious, I have contributed to one of a victim’s greatest fears — that she won’t be believed. On the other hand, if I errantly believe an accuser, an innocent man may go to prison and be labeled a sexual offender for the rest of his life.

Generally, the accuser is least motivated to lie, but both parties can possess motives to lie. The accused, obviously, is motivated to lie to avoid prosecution. But in false allegations of rape, the accuser is motivated also. In two of my cases, it was discovered that the accusers had engaged in consensual sex and then, fearing pregnancy or disease, realized their indiscretion would eventually come to light. A false accusation of rape provided the accusers with the benefit of being “victims” rather than facing the cost to their reputations of promiscuous sexual liaisons. Please note, however, that the data is quite clear. Most victims of rape never even call the police. Therefore, the accused is far more likely than the accuser to lie.

Suicide risk: Perhaps the most common instance in which clinicians will encounter deception is with suicidal risk assessment. Early in my career, I was working with a 19-year-old woman who was exhibiting suicidal tendencies. We had been working together for several weeks, and our rapport was strong. In one session, she verbally consented to a safety contract, agreeing to contact me before the next session if she felt suicidal. She left my office, and within two hours, I received a call from her mother saying that my client had taken an overdose of medication.

Fortunately, she survived, but there was no doubt that I had missed something and that my client had lied to me. It was my responsibility to take into account all risk factors, and I had failed. Part of my suicide risk assessment now involves evaluating what stressors a client might have after leaving my office, even if I believe the client is telling me the truth. Clients have to convince me that they are not simply saying what they think I want to hear.

Detecting lies

So, how can we detect lying? This is a process with many variables, but here are some of the basics.

1) The first issue is for the counselor to ask himself or herself if the client has a motive to lie. Is the cost of the truth potentially higher than the cost of the lie? If so, be on guard. How much trust has been built in the therapeutic relationship? When little trust has been established (such as early in the relationship), this increases the cost of the truth to our clients.

2) When telling a lie, people often provide unnecessary detail, and their stories are often presented verbatim over several tellings. When someone is simply describing an event, the gist of the event is what matters, and sometimes small details vary because they are comparably unimportant. Someone who is lying, however, feels the need to “prove” that his or her story is genuine by providing minute, memorized detail that doesn’t change much from one telling to another.

3) The story of a person who is lying won’t match the known facts. In a complicated story, cross-referencing facts can often lead to an untruthful person’s downfall because there are simply too many details to keep in working memory while the lie is being constructed. Lying requires an immense amount of mental energy.

4) People who are lying may not look you in the eye, but they may be just as likely to stare if they are trying to concentrate on being believable. Staring is an example of a “countermeasure.” As described in a 2014 article for FBI Law Enforcement Bulletin by Brian D. Fitch, these are behaviors construed in an attempt to prevent the hearer from recognizing the lie. The person may believe that “people who lie don’t look you in the eye,” so he or she attempts to counterbalance that by staring. When telling the truth, a client is more natural in either situation, looking off into space at times and making occasional eye contact in the same way.

5) When people lie, they often ramble on and on. When I’m interrogating a suspect in a legal situation, I sit quietly and let the person talk. The person telling the truth will tell the story and then wait for instructions or a response from me. Uncomfortable with silence, the person telling a lie will continue to talk, adding flowery language and detail to the story.

6) People who are telling lies are more physically stiff, use fewer hand motions, are more negative and use fewer first-person pronouns, according to a 1997 article by Mark Frank and Paul Ekman in the Journal of Personality and Social Psychology.

7) People who are telling lies often exhibit microexpressions. As described in a 2011 FBI Law Enforcement Bulletin article by David Matsumoto, Hyi Sung Hwang, Lisa Skinner and Mark Frank, these are behaviors that communicate a feeling such as contempt or disgust. Microexpressions that communicate an emotion inconsistent with the words being spoken are important clues. For example, a client who should be feeling relief at the telling of a story but is instead exhibiting contempt should be considered potentially untruthful.

Four steps to managing deception

The first step in managing deception with clients is recognizing that deception has occurred. The second step is determining what form the deception has taken (blatant, deflecting, diminishing, falsification or concealment).

Third, the counselor must decide if the deception must be confronted. Early in a therapeutic relationship, I sometimes can tell that I’m not getting the whole story, but my client needs to trust me more deeply before confiding certain secrets. In these cases, I don’t confront the deception. Once trust has been established, however, or in cases in which I am confident that confrontation is the proper therapeutic tool, I address the deception head-on.

Finally, the counselor must evaluate the therapeutic relationship and decide why the client didn’t trust the counselor with the truth. In the case of Mrs. T, I suspect that her deception was more for her than for me. She wanted so desperately for her son to be “normal” that it was more costly to admit that he wasn’t normal than to admit that nothing was working. She trusted me but couldn’t face the fact of her disappointment in her son.

Conclusion

At some point, we have to trust our clients. Mrs. T betrayed my trust in her, and this came at the expense of her son. But looking back, she gave me hints that she wasn’t being honest.

Therapy went too easily. She confirmed that things were better each week almost before I asked. Her confirmation that things were going well were inconsistent with some of the behaviors I saw in therapy and in the child’s sand trays — so much so that at one point, I consulted with a colleague on these inconsistencies.

But Mrs. T provided multiple energetic and animated stories to prove to me that therapy was working. She was anxious and nervous when I asked about her son’s progress at school and often jumped ahead in the conversation at a pause or lull in our discussions. In hindsight, the most notable clue was that she looked me straight in the eye, almost staring at me, each week as she lied to me.

I still don’t know why Mrs. T was motivated to lie to me, but perhaps the most important lesson I learned from her is that clients will, indeed, deceive me if I’m not careful. In her case, I never even bothered to consider the possibility of deception. It was a mistake I haven’t made again.

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Gregory K. Moffatt, a licensed professional counselor, runs a private practice in which he specializes in working with children who have experienced physical or sexual abuse. He is also a professor of counseling and human services at Point University in Georgia and serves as a risk assessment and psychological consultant for businesses, schools and law enforcement agencies. Contact him at Greg.Moffatt@point.edu.

Letters to the editor: ct@counseling.org

Polyvagal theory in practice

By Dee Wagner

Picturing brain chemistry can be something like picturing a hurricane. Although we can imagine bad weather, it is difficult to imagine changing that weather. But Stephen Porges’ polyvagal theory gives counselors a useful picture of the nervous system that can guide us in our efforts to help clients.

Porges’ polyvagal theory developed out of his experiments with the vagus nerve. The vagus nerve serves the parasympathetic nervous system, which is the calming aspect of our nervous system mechanics. The parasympathetic part of the autonomic nervous system balances the sympathetic active part, but in much more nuanced ways than we understood before polyvagal theory.

Our three-part nervous system

Before polyvagal theory, our nervous system was pictured as a two-part antagonistic system, with more activation signaling less calming and more calming signaling less activation. Polyvagal theory identifies a third type of nervous system response that Porges calls the social engagement system, a playful mixture of activation and calming that operates out of unique nerve influence.

The social engagement system helps us navigate relationships. Helping our clients shift into use of their social engagement system allows them to become more flexible in their coping styles.

The two other parts of our nervous system function to help us manage life-threatening situations. Most counselors are already familiar with the two defense mechanisms triggered by these two parts of the nervous system: sympathetic fight-or-flight and parasympathetic shutdown, sometimes called freeze-or-faint. Use of our social engagement system, on the other hand, requires a sense of safety.

Polyvagal theory helps us understand that both branches of the vagus nerve calm the body, but they do so in different ways. Shutdown, or freeze-or-faint, occurs through the dorsal branch of the vagus nerve. This reaction can feel like the fatigued muscles and lightheadedness of a bad flu. When the dorsal vagal nerve shuts down the body, it can move us into immobility or dissociation. In addition to affecting the heart and lungs, the dorsal branch affects body functioning below the diaphragm and is involved in digestive issues.

The ventral branch of the vagal nerve affects body functioning above the diaphragm. This is the branch that serves the social engagement system. The ventral vagal nerve dampens the body’s regularly active state. Picture controlling a horse as you ride it back to the stable. You would continue to pull back on and release the reins in nuanced ways to ensure that the horse maintains an appropriate speed. Likewise, the ventral vagal nerve allows activation in a nuanced way, thus offering a different quality than sympathetic activation.

Ventral vagal release into activity takes milliseconds, whereas sympathetic activation takes seconds and involves various chemical reactions that are akin to losing the horse’s reins. In addition, once the fight-or-flight chemical reactions have begun, it can take our bodies 10–20 minutes to return to our pre-fight/pre-flight state. Ventral vagal release into activity does not involve these sorts of chemical reactions. Therefore, we can make quicker adjustments between activation and calming, similar to what we can do when we use the reins to control the horse.

If you go to a dog park, you will see certain dogs that are afraid. They exhibit fight-or-flight behaviors. Other dogs will signal a wish to play. This signaling often takes the form that we humans hijacked for the downward-facing-dog pose in yoga. When a dog gives this signal, it cues a level of arousal that can be intense. However, this playful energy has a very different spirit than the intensity of fight-or-flight behaviors. This playful spirit characterizes the social engagement system. When we experience our environment as safe, we operate from our social engagement system.

Trauma’s effect on nervous system response

If we have unresolved trauma in our past, we may live in a version of perpetual fight-or-flight. We may be able to channel this fight-or-flight anxiety into activities such as cleaning the house, raking the leaves or working out at the gym, but these activities will have a different feel than they would if they were done with social engagement biology (think “Whistle While You Work”).

For some trauma survivors, no activity successfully channels their fight-or-flight sensations. As a result, they feel trapped and their bodies shut down. These clients may live in a version of perpetual shutdown.

Peter Levine, a longtime friend and colleague of Porges, has studied the shutdown response through animal observations and bodywork with clients. In Waking the Tiger: Healing Trauma, he explains that emerging from shutdown requires a shudder or shake to discharge suspended fight-or-flight energy. In a life-threatening situation, if we have shutdown and an opportunity for active survival presents itself, we can wake ourselves up. As counselors, we might recognize this shift from shutdown to fight-or-flight in a client’s move from depression into anxiety.

But how can we help our clients move into their social engagement biology? If clients live in a more dissociative, depressed, shutdown manner, we must help them shift temporarily into fight-or-flight. As clients experience fight-or-flight intensity, we must then help them find a sense of safety. When they can sense that they are safe, they can shift into their social engagement system.

The body-awareness techniques that are part of cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT) can help clients move out of dissociative, shutdown responses by encouraging them to become more embodied. When clients are more present in their bodies and better able to attend to momentary muscular tension, they can wake up from a shutdown response. As clients activate out of shutdown and shift toward fight-or-flight sensations, the thought-restructuring techniques that are also part of CBT and DBT can teach clients to evaluate their safety more accurately. Reflective listening techniques can help clients feel a connection with their counselors. This makes it possible for these clients to feel safe enough to shift into social engagement biology.

Specific aspects of ventral vagal nerve functioning

Porges chose the name social engagement system because the ventral vagal nerve affects the middle ear, which filters out background noises to make it easier to hear the human voice. It also affects facial muscles and thus the ability to make communicative facial expressions. Finally, it affects the larynx and thus vocal tone and vocal patterning, helping humans create sounds that soothe one another.

Since publishing The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication and Self-Regulation in 2011, Porges has studied the use of sound modulation to train middle-ear muscles. Clients with poor social engagement system functioning may have inner ear difficulties that make it hard for them to receive soothing from others’ voices. As counselors, we can be conscious of our vocal patterns and facial expressions and curious about the effects those aspects of our communication have on our clients.

Based on his understanding of the effects of the vagus nerve, Porges notes that extending exhales longer than inhales for a period of time activates the parasympathetic nervous system. Porges was a clarinet player in his youth and remembers the effect of the breath patterns required to play that instrument.

As a dance therapist, I am aware that extending exhales helps clients who are stuck in forms of fight-or-flight response to move into a sense of safety. For clients stuck in some form of shutdown, I have found that conscious breath work can stir the fight-or-flight response. When this occurs, the fight-or-flight energy needs to be discharged through movement for clients to find a sense of safety. For instance, these clients might need to run in place or punch a pillow. The hierarchy of defense system functioning explains these therapeutic techniques.

Respiratory sinus arrhythmia is a good index of ventral vagal functioning. This means we now have methods to study the effectiveness of body therapies and expressive arts therapies.

Polyvagal theory in my practice

What follows is an example of how I used polyvagal theory with a client who experienced medical trauma during her birth.

The client, whom I have been seeing for some time, described feeling very sleepy and acknowledged having difficulty getting to our session on this day. Her psychiatrist had prescribed her Zoloft as a way of treating anxiety stirred by the birth of her daughter’s first child. The client and I had previously normalized her anxiety as a trauma response.

During the years before coming to see me, this client had attempted suicide, which resulted in medical procedures that added to her trauma. Through our work, she has come to understand that the panic attacks she has when in contained situations are also trauma responses. She has lived much of her life in perpetual fight-or-flight response mode.

On this day, she was relieved to be less emotional, but she feared the tiredness that accompanied Zoloft’s help in calming her fight-or-flight sensations. I saw this fear of the tiredness as a fear of dorsal vagal shutdown. We discussed the possibility that this tiredness could allow her a new kind of activation. I asked if she would like to do some expressive art that would allow gentle, expressive movement. She shuddered, naming her preference for things that were less subjective.

We talked about the existence of a kind of aliveness that still feels safe. We talked about the possibility of existing in a playful place in which there is no right and wrong, only preference. We acknowledged that since her birth, she and her parents had feared that her health would fail again. This environment in which she had grown up had supported nervous system functioning designed for life-threatening situations. With the Zoloft calming her fight-or-flight activation, I suggested that perhaps she could explore some calmer, more playful kinds of subjective experiences.

“It feels like you are trying to create a different me,” she responded. I acknowledged that it might sound as if I were thinking she could be someone she wasn’t. But I explained that what I was actually suggesting was the possibility that she could be herself in a different way.

The client told me she had a new book on grandparenting that contained a chapter on play. She said she would consider reading it. At the same time, she said that she might not be able to tolerate the Zoloft and might have to get off of it. Regardless, the idea of this different, more playful way of being has been introduced to her and, for a moment or two, experienced.

Getting the picture

As counselors armed with polyvagal theory, we can picture defense mechanism hierarchy. We can recognize shifts from fight-or-flight to shutdown when clients feel trapped. We can also recognize the movement from shutdown into fight-or-flight that offers a possible shift into social engagement biology if and when the client can gain a sense of safety.

Before polyvagal theory, most counselors could probably recognize fight-or-flight and shutdown behaviors. They could probably sense a difference between defense responses designed for life-threatening situations and responses that characterize what Porges calls the social engagement system. Polyvagal theory deepens that awareness with the knowledge that playful arousal and restorative surrender have a unique nervous system influence.

Most counselors appreciate brain science but may find it difficult to picture how to use the information. Thanks to polyvagal theory’s clarification of the role of the ventral branch of the vagus nerve, we now have a map to guide us.

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Dee Wagner has worked as a licensed professional counselor and board-certified dance therapist at The Link Counseling Center in Atlanta for 22 years.
Her book/workbook Naked Online: A DoZen Ways to Grow From Internet Dating helps clients use their online dating experiences to shift from attachment trauma to social engagement system functioning. Contact her at mdeewag@gmail.com.

Letters to the editor: ct@counseling.org

Have you gone gray?

By Matthew Fullen

The United States is going through a rapid demographic shift unlike anything it has ever experienced. Approximately 10,000 Americans are turning 65 every day. Meanwhile, the average life span in the United States has increased to approximately 81 years for women and 76 years for men, with a significant number of people living well beyond those ages.

By 2030, demographers project that 70 million people, or about 20 percent of the U.S. population, will be 65 or older. Industries ranging from health care to technology to real estate have taken note of this emerging trend and are identifying how best to respond to the needs of an older population. Although a great deal has been written about how an aging population will affect the need for biomedical services, the story of how older people maintain optimal mental health throughout the life span has received far less attention.

First, the good news. Research indicates that older adults report the highest levels of life satisfaction when compared with young and middle-aged adults. Older adults are more likely to report a satisfying marriage, and they outperform younger individuals when it comes to remaining calm during times of stress. Subjective well-being is particularly high when older people perceive that they have adequate social support; have a sense of control and mastery, opportunities to derive meaning through paid or unpaid work and a positive perception of their age; and when they participate in spiritual or religious practices. Therefore, for many people, older adulthood can be a very fulfilling phase of life.

On the other hand, a large number of people 65 and older need mental health care but do not have adequate access to it. Approximately 20 percent of adults 65 and older meet the criteria for a mental disorder. Older adults with mental disorders experience higher rates of functional disability than those with a physical illness alone. They also experience poorer overall health outcomes and higher rates of hospitalization. Economically, these factors result in medical costs that are 47 percent to 200 percent higher for older adults with a mental disorder than for other older adults. Furthermore, older Americans are disproportionately likely to die by suicide, with older white males in particular having one of the highest rates of suicide.

Access to mental health services

Why is there such a discrepancy between the preponderance of older adults who experience increased life satisfaction in old age versus those who are at risk for depression, anxiety and suicide? One factor often cited in the research is older adults’ lack of access to mental health care.

In a recent study of older Americans, only 3 percent reported seeing a mental health professional, the smallest percentage of any age group. It is likely that stigma related to aging and mental health is at least partially to blame. For instance, previous cohorts of older adults came of age in an era when mental health services were far more stigmatized. Instead of seeking services from mental health professionals, older people are more likely to share their complaints with primary care providers, family members or friends. It is worth noting, however, that the current generation of individuals turning 65, known as the boomer generation, is likely to be more open to discussions about mental health.

Stigma also exists in the form of cultural myths about aging that create barriers to older adults seeking help for mental health concerns. For instance, despite the previously cited research about older adults’ high levels of life satisfaction, many people mistakenly believe that depression is a normal feature of growing older. A myth that may influence clinicians is the notion that certain problems associated with aging — including the increased likelihood of one or more chronic health conditions, the loss of a loved one and existential concerns related to meaning and life purpose — will not be responsive to counseling treatment.

Practical skills for counseling older adults

In reality, older adults are excellent candidates for counseling services. They respond to treatment as well as or better than members of other age groups. The counseling profession is particularly well-situated to provide effective services to older adults because of its emphasis on life span development, wellness and attention to diversity. Three practical strategies can promote the work of counselors with this population.

First, it is important for counselors to consider the developmental needs of older adults. Historically, human development theorists, including Sigmund Freud, suggested that development stopped around age 40. Although this seems laughable today, the assumption that most growth and change occurs early in life is still reflected in sayings such as “You can’t teach an old dog new tricks.”

In fact, in a 2000 study, Paula Danzinger and Elizabeth Welfel found that despite identical symptom profiles, mental health professionals rated older clients as having a more negative prognosis when compared with younger clients. Therefore, when working with older clients, it is imperative for counselors to challenge this myth, first in their own minds, but also potentially with clients who do not believe in their capacity to make changes at this point in their lives. For instance, recent findings in neuroplasticity suggest that humans are capable of making changes to their attitudes and behaviors across the life span. When counselors reflect this viewpoint in session, they provide hope to clients who may have otherwise resigned themselves to a particular problem or mindset.

Next, counselors should consider the use of a wellness perspective when assessing and treating older adults. Although the wellness paradigm is increasing in popularity, its use with older adults has lagged behind, both in research and clinical applications. However, older adults are prime candidates for the use of a wellness approach for multiple reasons.

First, a great deal of research indicates that a broad range of variables influence older adults’ longevity and quality of life. These variables include strong mental and emotional health, reciprocal social relationships that are perceived as supportive, participation in preferred spiritual or religious practices that provide meaning and purpose, a belief that one has at least some control over circumstances and a positive perception of aging. A recent example of the multidimensionality of older adults’ needs was demonstrated in a 2015 study by Kelley Strout and Elizabeth Howard. The researchers found that emotional wellness was the highest predictor of cognitive health, followed by physical and spiritual wellness as additional significant variables. Therefore, counseling interventions that bolster emotional wellness may influence brain health in later life.

Similarly, there is growing interest in the concept of resilience among older people. Given the wide range of challenges that may accompany older adulthood, some gerontologists suggest that resilience should be used as a primary measure of what it means to age well.

In research supported by the Association for Adult Development and Aging (AADA), a division of the American Counseling Association, Sean Gorby and I recently piloted a program in which older adults participated in a counseling group focused on how participants had demonstrated resilience in various domains over the course of their lives. Group members identified adversities they had experienced, including physical and functional setbacks, emotional distress, changes in social relationships and spiritual and existential hardships. Participants then shared personal stories about resilience, either in their own lives or in the lives of others, and discussed how this could be manifested once again with the current challenges they were facing.

At the conclusion of the group, we found that participants perceived themselves as more resilient. This indicates that counselors may be able to tap into the reserves of resilience that older clients possess, using discussions of resilience to help these clients restructure their self-concepts around adversity and their ability to bounce back.

Finally, in spite of cultural assumptions to the contrary, older adulthood is an extremely heterogeneous phase of life. Cultural diversity and vast individual differences related to the aging process shape how older adulthood is experienced. For instance, a person’s chronological age, by itself, does not communicate a great deal of information about how one perceives life, nor does it directly correlate with overall health and wellness.

Most broad definitions of older adulthood use age 65 and up; however, there have been efforts within gerontological research to subdivide older adulthood into two segments, with the “young-old” representing individuals 65–80, and the “old-old” reflecting those who are older than 80. Although some research supports differing health and life experiences for individuals in these two groups, the division is still limited by the assumption that chronological age is a helpful descriptor. For instance, one’s health, holistic wellness and functional status may provide better information about what life is like than simply stating how many years one has lived. For this reason, some have argued for the use of biological or functional age as a more descriptive demographic than chronological age.

How one perceives his or her age can also be a telling indicator for quality of life and longevity. In fact, research by Becca Levy shows that older people with a positive age perception live significantly longer than those older adults who have a negative perception of their age, even after controlling for other health and demographic variables.

The older adult population is also rapidly becoming more diverse. In fact, ethnic minorities, particularly Latino and Asian/Pacific Islander elders, make up the fastest-growing subset of the older adult population. Furthermore, more than 2 million American older adults currently identify as lesbian, gay or bisexual.

In terms of socioeconomic diversity, a wide gap exists between older adults who have accumulated sufficient financial resources and the vast number of older adults who have either experienced poverty throughout their lifetimes or who are now on the edge of poverty because of recent changes to their health, relationships or work status. Therefore, counselors interested in working with older adults should anticipate that their clients will possess a diverse range of backgrounds and perspectives, and differing levels of health, wellness and functional abilities. Some counselors may encounter older adult clients who can afford to pay out of pocket for mental health services, whereas other counselors are likely to interact with older adults whose low income levels qualify them for subsidized housing or health care.

Counselors should recognize that growing older in America is not a monolithic experience. In fact, the diversity of perspectives related to the aging process is one of the most compelling features of working with older adults. Rather than older adults all being alike and resistant to change — as the cultural myth might suggest — older people possess a diversity of backgrounds and life experiences that can make the counseling experience particularly invigorating for client and counselor alike.

Strategies for including older adults in your practice

Counselors interested in working with older adults should be proactive about seeking opportunities to market their services to these clients. Counselors cannot currently bill Medicare. However, there are other ways to make a difference in the lives of older adults.

For instance, a 2012 report by the Institute of Medicine (now the Health and Medicine Division of the National Academies of Sciences, Engineering and Medicine) found that 47.5 percent of older adults’ mental health services were not paid for through Medicare. Non-Medicare payment sources included paying out of pocket (18.3 percent), supplemental private insurance (11.7 percent), Medicaid (11.4 percent) and other state and community programs (6.1 percent). Therefore, in addition to offering services directly to older clients, counselors can also market their services to local agencies on aging, community and neighborhood clinics with local service grants and capitated health service providers.

For some older people, seeking mental health treatment within a private practice or standalone mental health clinic may be appealing. However, I have found that linking mental health services to older adults’ housing, medical care and social services is an excellent strategy for providing integrated care and making mental health services more accessible to older clients. For instance, forming partnerships with primary care providers who view mental health treatment as a necessary and value-added component of integrated treatment can be an effective strategy for connecting with older clients. Counselors accustomed to the use of a wellness paradigm are familiar with the challenges of providing prevention and holistic wellness services to clients in a world of managed care and disjointed services. Therefore, instead of focusing solely on the need for Medicare reimbursement, entrepreneurial counselors may wish to consider how to extend the integrated wellness work that is already being done with younger clients to an older population.

Ongoing education and training are helpful to ensure that your counseling services are well-suited for older clients. Members of the counseling profession should look for continuing education or postgraduate training opportunities that will expand their understanding of the impacts that adult development and aging have on their clients. This could include:

Attending educational sessions at state or national counseling conferences
Joining AADA
Networking with other professionals in the aging sector by getting involved with a local area agency on aging
Seeking formal education in the form of a certificate program in gerontology at a local university

Counselor advocacy

Given the rapid growth of the older adult population in the United States, there is a need for more mental health professionals who are both willing and able to work effectively with these clients. Although it is not the only means of access for mental health services, Medicare covers the majority of these services (52.5 percent) for older adults. Recently, there have been several critiques of the Medicare program for not doing more to address the growing number of older adults who need mental health treatment. According to the 2012 Institute of Medicine report, only 1 percent of the total Medicare budget was spent on mental health services (with a total budget estimated at $505 billion in 2014).

Advocacy for Medicare reimbursement of counselors is vital to expanding the mental health workforce. Two bills were introduced in Congress in 2015 calling for mental health counselors to be included as recognized Medicare providers: the Seniors Mental Health Access Improvement Act of 2015 (S. 1830) and the Mental Health Access Improvement Act of 2015 (H.R. 2759). Both bills have received bipartisan support in the past. However, it is common for legislative efforts to go through many iterations before becoming law.

Due in large part to the advocacy efforts of the counseling profession, there are currently numerous bipartisan co-sponsors for both of these bills. Recently, counselor advocacy efforts resulted in AARP writing a letter that supported passage of congressional bills calling for inclusion of counselors as Medicare providers.

To continue this momentum, it is imperative for all members of the counseling profession to raise awareness of Medicare’s lack of attention to mental health and the current restrictions that deny older adults the freedom to choose their mental health providers. Counselors should consider contacting their congressional representatives to provide awareness about the counseling profession and how it is uniquely situated to provide mental health care to older adults that is grounded in wellness, life span development and awareness of the diversity of older adults. Please consider contacting your senators and representative with a brief statement that advocates for S. 1830 and H.R. 2759. Contact information can be found at congress.gov/members, where you can sort by state to locate your senators or search by ZIP code to find your representative. (If you are interested in learning more about specific Medicare advocacy strategies, consider reading my April 2016 article in Adultspan Journal on this topic.)

Members of the counseling profession must also consider whether the current state of counselor training provides adequate exposure to the possibility of working with older adults. A 2009 study by Thomas Foster, Val Kreider and Jennifer Waugh found that counseling students had a high degree of interest in topics related to older adulthood, including the transition to retirement, helping families navigate the aging of a family member, providing support to caregivers and discussing issues such as dying and grief with clients. However, the authors suggest that counselors and counseling students lack opportunities to follow through with these interests.

At the programmatic level, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) specialization in gerontological counseling was discontinued in 2008 because of a lack of counselor training programs applying for accreditation in this area. Although the lack of Medicare reimbursement for counselors may influence the viability of a gerontology specialization, it is worth asking whether more could be done to promote work with older adults within counselor education programs. For instance, in reviewing the 2016 CACREP Standards, I found zero references to the words older, age or ageism, and only one reference to the word aging.

Anecdotally, I have had numerous conversations with counselors and students who express a great deal of interest in focusing more of their work on older adulthood but do not think they have adequate opportunities or knowledge to do so. Therefore, it is important for counselor training programs to assess their students’ interest level in working with older adults, identify practicum and internship sites that provide access to these individuals and participate in professional advocacy efforts to expand the role of counselors to meet the mental health needs of older adults. In addition, members of the counseling profession should work with their state counseling associations to coordinate state and local efforts to raise awareness within the community, as well as within the political arena, about the current state of older adults’ mental health access and the need for Medicare reform.

Conclusion

In summary, the “graying” of America is making its mark across a wide range of industries, including mental health. As more attention and public dollars shift toward the national challenge of promoting the health and wellness of an older population, members of the counseling profession will find themselves impacted in myriad ways.

Families will be affected by the growing number of older people living with chronic health conditions. Paid and unpaid caregivers will have greater responsibility for providing support to older adults. Topics such as retirement and lifelong vocation will be reconsidered as individuals work longer to make ends meet and spend their post-retirement years continuing to seek avenues for purpose and meaning.

In spite of the hurdles that remain, members of the counseling profession can support the growing number of older adults by providing mental health services that are developmentally appropriate, grounded in wellness and suited for a diverse range of older individuals. With that in mind, why don’t you go gray?

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

Matthew Fullen is a licensed professional clinical counselor in Ohio. He has worked with older adults in a variety of contexts since 2005. He currently serves on the board of the Association for Adult Development and Aging and is completing a doctorate in counselor education with a specialization in aging at Ohio State University. Contact him at fullen.33@osu.edu.

Letters to the editor: ct@counseling.org

Counseling in isolation

By Bethany Bray

Nebraska native and licensed mental health practitioner Tara Wilson grew up in a town so small that her high school graduating class comprised only 10 people. When her young niece was diagnosed with cancer a few years ago, Wilson’s family organized a pancake breakfast and benefit auction to cover the growing medical bills. People traveled from across the county to attend the fundraiser, and the family received cards and words of support from people they didn’t even know.

“People bend over backward for you in a rural community,” Wilson says. “Whenever a big life event happens … everyone just bands together. We had people from the surrounding communities that I had never even known or heard of or met [who] all came together. The outpouring of support from that was just remarkable. The entire community came together. I think that’s very unique to a rural area. I don’t know if you’d find that [elsewhere].”

Wilson can attest that working as a professional counselor in a rural area features its fair share of challenges. But the rewards — such as witnessing the impact of an entire county pulling together to support someone in need — make it all worthwhile, she says.

In addition to the “we’re in this together” character often in evidence in rural areas, the setting can afford counselors the chance to see young clients grow up, succeed and start families of their own.

“Living in a small town, I see [students] when they come to kindergarten and I see them when they graduate,” says Christi Jones, a school counselor and American Counseling Association member in rural Alabama. “I measure my success by the graduation invitations that come [in the mail] or the college students who come back to visit. You know they have overcome a lot of adversity to get there.”

A long and winding road

According to data from the most recent census, 19.3 percent of the U.S. population lived in rural areas in 2010. This reflected a slight decrease from the 2000 census, when 21 percent of the population resided in rural areas. (The U.S. Census Bureau defines “rural” as any population outside of an urban cluster or area with 50,000 residents.)

Counselors working in rural communities can face potential obstacles that practitioners in suburban and urban areas may never know. These challenges can include professional isolation, a culture where “everybody knows everybody” and long hours spent traveling to faraway or widespread professional commitments.

Stacey Meehl begins serving as president of the North Dakota Counseling Association (NDCA), a branch of ACA, in July. Most of the professionals in Meehl’s town, from the paramedics to the local parole officer, have her cell phone number on hand, and her phone is apt to ring at any time of day. “I could change [my number] and throw the whole town in a loop,” she jokes. “You do it all [as a rural counselor]. … I learned early on in my career not to specialize because you never know what you’re going to get walking through the door.”

Wilson, an ACA member and assistant professor at Wayne State College in Wayne, Nebraska, agrees. “If you start to specialize, I think everything else [besides what you specialize in] will walk through the door,” she says with a chuckle. “[Clients] are going to come at you with anything and everything.”

Meehl is a licensed professional clinical counselor who has a private practice in North Dakota and also works at a mental health center just across the border in South Dakota. She currently has clients — individuals, couples and families — ranging in age from 3 to 60-something. In private practice, she covers a four-county area. Last year, she put 15,000 miles on her car driving to meet clients at satellite offices, schools, homes, medical facilities, nursing homes and other locations.

Rural counseling is anything but the neat-and-tidy model in which a practitioner sees each individual client one hour per week in a single office, Meehl notes. “It’s what’s expected. It’s just part of where you live,” she says.

When working in rural areas, a professional counselor or school counselor may be the only mental health practitioner for miles around. Counselors considering moving to rural areas should be aware that the only option available to them may be opening their own private practice because other agencies or clinics in the area may be sparse or nonexistent, Wilson says.

At the same time, Meehl, Wilson and the other counselors interviewed for this article urge practitioners to consider working in rural areas because the needs — and the rewards — are great.

“There’s a shortage of [rural] practitioners,” says Wilson, who co-presented about the experience of rural mental health counselors at ACA’s 2016 Conference & Expo in Montréal. “But it’s not an opportunity someone should go into blindly. You need to be aware of the challenges. We’d always welcome more providers though. There’s such an opportunity.”

Meehl, an ACA member, concurs. “Consider giving your gifts and talents to work in this area,” she says. “There is an opportunity — a rewarding opportunity — to work with people. Yes, it is challenging. There is nothing in graduate school that will prepare you for this. But we deal with the same [clinical] issues as anyone in a larger town.”

Blooming where you’re planted

The practitioners interviewed for this article agree that working in a rural area has its challenges. But they say those challenges are nothing that can’t be lessened or overcome entirely with a little creativity and collaboration. Consider the following insights and words of guidance.

> Prepare for the inevitability of dual relationships. When you’re a counselor practicing in a small town or rural area, Wilson advises, “It’s not a question of whether you’ll see a client at Wal-Mart today; it’s how many clients you’ll see at Wal-Mart.”

Or in other real-life scenarios common in rural areas, a client and counselor might find themselves playing in the same softball league, singing together in the church choir or encountering each other regularly because their respective children are involved in Scouting. The key, Wilson says, is to be prepared, think ahead and talk such scenarios through with clients ahead of time.

Meehl has a conversation with each of her clients — children and adults — at the beginning of the therapy relationship. “I stress that we live in a small town. If you don’t want to say anything to me when we pass in the street, I won’t be offended,” Meehl says.

As the mother of an 11-year-old daughter and a 9-year-old son, Meehl also understands some additional complications that can arise. “In a small town, having kids, they become friends with your clients or their families. You might be sitting next to them at church or at your child’s ballgame. You may be fine, but [your clients] might feel uncomfortable,” she says.

Wilson has learned the value of asking her clients what their preference is ahead of time. In one instance, in trying to prepare ahead of time for any chance encounters, she told a female client that she wouldn’t acknowledge her in public unless the client said hello and initiated contact. The client took offense, interpreting this to mean that Wilson was embarrassed to be seen talking with her in public.

Wilson took the client’s reaction to heart. “The client felt fine about it, so why not?” she says. “What would have helped there is to approach it with ‘How would you want this to go?’ instead of saying, ‘This is what will happen.’ Be prepared [for client encounters outside of session], but let the client have a say in it. Ask them ‘How do you want to handle [meeting in public]?’”

Early in the therapeutic relationship, it is also helpful to have a discussion with clients about boundaries and what is — and isn’t — appropriate to talk about outside of session, Wilson adds.

Family members are also part of the equation, Meehl notes. “My kids learned the word confidentiality at a very early age,” she says. “They know that when mom gets a phone call and has to go to another room, it’s work and they understand. … They learn that boundary.”

> Be mindful of appearances. In a small town or rural area, the stigma of being seen going to therapy can weigh heavily on clients. “Not only does everybody know everybody, but everybody knows everybody’s car,” Wilson says.

Counselors should be mindful of this when choosing office space, Wilson advises. When she worked at a rural clinic in the panhandle of Nebraska, the facility shared space with a medical practice. This lessened the stigma for clients because passers-by wouldn’t know whether the person was there for a medical appointment or a therapy session, Wilson says.

In addition, if a counselor is aware that two different clients know each other — for instance because they’re neighbors or have children at the same school — it might be helpful to avoid scheduling their appointments back to back.

The “everybody knows everybody” rural culture can also affect how clients and potential clients reach out to the counselor, Meehl says, noting that people sometimes call her at home or pull her aside in social or public situations rather than calling her at the office.

“You have to make them feel comfortable. That’s the big thing — making them feel like there’s nothing that they can’t share with you or work with you on,” Meehl says. “Everything is case by case. What does [the client] need, and how do I put it together?”

> Carefully consider whether a little self-disclosure can help build trust. In rural areas, many clients will have spent their entire lives in the same town, growing up around the same neighbors and extended family members. For these clients, it can mean something for a counselor to share a few details about his or her background and family connections, Wilson says.

That might be particularly true when the counselor did not grow up in the immediate area where he or she is now practicing. “Name is huge — what family you belong to, who you’re connected to … Be prepared for [these clients’] curiosity of wanting to get to know you,” Wilson says. “They’re not being nosy or harmful. It’s a curiosity to help identify you.”

In Wilson’s case, she found that offering some limited self-disclosure — what part of town her family lived in, where she grew up — helped her forge relationships with certain clients, especially among the older generations.

Wilson also suggests that counselors practicing in rural areas — and especially those who are new to the area — build connections by getting involved in the community. This can be as simple as participating in an adult sports league or book club. Getting out and mingling in the community is the best way for counselors to get a better understanding of the local culture, while also letting people get to know them, she says.

Meehl says that counselors who move into rural areas should consider joining a professional organization such as the Rotary Club. This provides an outlet for these counselors to get ideas, network with other professionals and figure out whom they can call for referrals or support services for their clients.

At the same time, Wilson adds, counselors should keep in mind that word of mouth is a powerful tool in rural areas and small communities. Every client contributes to building the counselor’s reputation or could lead to a referral. “[Maintain] a very ethical practice, and keep boundaries with your professional and private life,” she says.

> Get creative. Rural counselors may have to think outside the box to find resources for clients, Meehl says. For example, she might connect a client who is a military veteran with services and support from a local American Legion or Veterans of Foreign Wars post because a Department of Veterans Affairs facility is too far away.

In another example, Meehl says the nearest psychiatrist or other practitioner who can prescribe medication is more than an hour away from her practice. If a client would have trouble making that trip, she sometimes works with the local senior center’s bus service to ensure that the client has transportation, even if the client is not a senior citizen.

“You get pretty creative to try and find the services you need,” Meehl says. “It just means you have to know your community very well. It becomes very collaborative. … You just have to get a little more creative in your treatment process.”

> Network and collaborate. In rural areas, counselors must learn to collaborate with professionals of all kinds, from those in social service agencies and law enforcement to schools and other medical professions. In turn, those professionals will routinely call on counselors for support, Meehl says.

With clients’ permission, Meehl has collaborated on client issues with domestic violence agencies, child services, local doctors and hospital personnel. On one occasion when a client was having back pain related to stress and anxiety, she even collaborated with the client’s chiropractor to set up a treatment plan.

“You learn to work with them all,” Meehl says. “The community of professionals becomes very tight-knit.”

Collaborating with those outside of the counseling profession is also a good way to learn about issues with which a counselor may be unfamiliar, Meehl adds. “I had several clients come in with eating disorders, and I hadn’t done too much with that in [graduate] school. I did any research I could, and I worked with other specialists in the area to figure out a treatment plan, simply because that’s a very specialized field. … You call people you may know and ask, ‘Where can I get training? How do I work with this?’ You learn to count on others to walk through things, or you figure it out on your own,” she says.

> Be flexible and navigate the learning curve. Jean Baird, NDCA president-elect and a school counselor in a very rural part of North Dakota, says much of what she does over the course of a typical workday falls under “other duties as assigned.” This may include helping to administer standardized tests, managing Section 504 plans for special education students or, in one instance, picking head lice out of students’ hair because her school does not have a nurse.

“We deal with whatever comes along,” says Baird, who is one of two school counselors at a high school with 500 students in the northern part of the state. “We are a jack-of-all-trades and do everything.”

Baird switched careers to school counseling after working as an elementary school music teacher. At the time she was hired, she was the only counselor at her high school, and she was in the midst of finishing graduate school. Within her first three weeks on the job, a student died by suicide outside of school. Baird also was the first to intervene in another student’s suicide attempt in a school bathroom.

Her on-the-job training was “baptism by fire,” she says. “It was a steep, steep learning curve — a very eye-opening experience.”

Many counselors in rural areas are isolated and may have few, if any, colleagues who do exactly what they do. In those situations, counselors must be disciplined about engaging in as much professional development as they can on their own, Baird says. Fortunately, webinars and other online continuing education opportunities are much more prevalent than they were even a few years ago.

“With every new thing that came up, I would consult with the social worker [in Baird’s school district] and read and read and read,” says Baird, a member of ACA. “I went to every conference and workshop that I could find. … The more basic information a [counselor] has, the better. You don’t know what you’re going to need. Prepare for anything and everything.”

> Use time spent in the car to your advantage. Rural counselors often spend many hours behind the wheel commuting and traveling between professional engagements. That time can be spent on the phone returning calls or consulting with colleagues, Wilson says. It can also be a chance to dictate notes into a recorder. Sometimes, it simply serves as much-needed time alone to decompress or engage in mindfulness or gratitude exercises.

Before Wilson was licensed, she did co-therapy training with another counselor. They rode together and used the 40-minute commute home after sessions to talk through the day’s experiences and discuss personal growth and self-care. Those car conversations proved particularly helpful and enhanced the learning experience, Wilson says.

> Stay connected. Meehl, Baird and Wilson agree that memberships in professional organizations, both at the national and state levels, are a good way for rural practitioners to stay connected to others in the profession. These memberships also open up opportunities to participate in conferences, trainings, workshops, webinars and other learning opportunities.

NDCA offers a monthly meeting via phone conference, which is much easier than meeting in person because its members are so spread out, Baird says.

Jones, an elementary school counselor in rural Alabama, meets periodically with a consortium of school counselors of all grade levels from across her district. The meetings offer not only a chance to share resources and ideas but also serve as an antidote to the isolation that can come with working in a rural area, Jones says.

The other school counselors in the group “know exactly what it’s like to walk in your shoes,” Jones says. “That support helps. It really is a form of self-care. It’s important to have someone you can reach out to and consult with. We all deal with similar issues.”

> Make time to be off the clock. Being the only mental health practitioner in a community can become all-consuming. You are not only constantly in demand but likely will also encounter clients around town when you’re not working, Meehl says. Before she scaled back her private practice, Meehl says she could put in a 12-hour day and still get work-related phone calls at night when she was home with her family.

On the flip side, Wilson points out that outdoor activities (her favorite is fishing) are often an easily accessible form of self-care in rural areas.

Meehl urges rural counselors to be deliberate about scheduling time off, whether it’s a date night with their spouse, attending their child’s sporting event or getting out of town for vacation. Provide clients with a number to call in an emergency, but otherwise, keep your cell phone turned off during personal time, she advises.

“One of the things I had to learn very quickly is to make sure I had time with my family,” Meehl says. “My son reminds me when I’m getting crabby. That’s my cue [to take a break],” she says. “You have to make sure to take some alone time, time to go out on a date with your husband. If you don’t, you will get consumed by [the work].”

Thinking outside the box

Collaboration is a watchword for rural and small-town counselors that can include everything from partnering with noncounselors in the community to participating in regular communications with mentors or colleagues in other parts of the state.

For Jones, collaboration comes in the form of an innovative program that brings a mental health counselor to her school, which is located in a very rural, high-poverty area, once a week. Jones is the only counselor in an elementary school of roughly 600 students in prekindergarten through fifth grade. The mental health counselor travels to a different school within the district each day.

The setup allows for intensive, long-term mental health care beyond what Jones can provide to students. The mental health counselor often works with students who have experienced abuse or trauma or who have ongoing issues such as difficulties with a blended family or a parent’s military deployment.

In many cases, the program provides treatment for children whose parents wouldn’t be able to provide transportation to regular counseling sessions outside of the school building. Jones’ school serves three communities, and many of its students are bused long distances to attend. In addition, a large number of parents in the area work two jobs and are already stretched to the limit, she explains.

Prior to the program, students wouldn’t always get the extra help they needed, Jones says. “This provides a way for students to get treatment. It’s a win-win,” says Jones, who has been a school counselor for 14 years. “I’m a school counselor with 600 students in my building. I try very hard to serve them and meet their needs, but that’s a lot of students for one school counselor. This [program] has provided extra, long-term support for students’ issues. To me, that’s an invaluable resource.”

The three-year-old program grew out of an idea from the school nurse in Jones’ district. After gaining support from the school board, the district set up a contract with the mental health counselor. Costs are covered by students’ insurance coverage through Medicaid. Eventually, Jones says, she’d like to see the program expand to accommodate students who aren’t under Medicaid. Jones co-presented a poster session about the program at ACA’s 2016 Conference & Expo.

A key factor in the program’s success is that all the involved providers established clearly defined roles for each participant before the program launched. The school counselors in Jones’ district refer students to the mental health counselor whenever a student presents with a mental health concern or other issue that would benefit from intensive, long-term therapy beyond what the school counselors can provide, Jones says. The mental health counselor is also able to meet with students and families year-round.

In return, Jones serves as a bridge between the mental health counselor and the teachers and students within her school, whom she knows very well. She also works with the mental health counselor to introduce families to resources in the community, such as charities that provide school supplies and clothing to those in need or support for families whose power has been cut off.

School counselors who serve students in rural areas often need to step outside of their basic, expected roles, Jones emphasizes. “The most important role of the school counselor is to be an advocate,” she says. “I feel like I give my students a voice when they have needs. A counselor cannot be successful if [students’] basic needs aren’t met, if they come to school and they’re hungry or cold. You have to deal with that first, and then you can sit down and have a counseling session.”

Jones is involved in organizing “wraparound” services for students at her school, which she says is a necessity in rural, high-poverty areas. For example, the school keeps a closet of extra clothes available for children who arrive at school with ill-fitting or worn-out clothing or who aren’t dressed appropriately for the season’s weather. Jones also helps with the school’s backpack program, in which a backpack full of snacks and easily prepared foods is sent home with children in need over weekends and school breaks.

“This is the hardest work and the best job I’ve ever had. When you come to a school and you see all this need, you can’t ignore it,” Jones says. “This job has changed me in ways that I thought weren’t even possible. To see what poverty really is … It’s hard work, but when you see students or a family turn a corner, it makes it worth it to come to work every day.”

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Guidance for rural counselors from the ACA Code of Ethics

Counselors in rural and small-town settings are often called on to play many roles and deal with multiple relationships with current, former and prospective clients. The more intimate settings common in rural areas present counselors with professional and personal challenges related to competence, effectiveness and self-care. The ACA Code of Ethics (counseling.org/ethics) provides some guidance to help address issues related to the following:

Understanding the diverse cultural backgrounds of clients (Section A, introduction)
Engaging in counseling relationships with friends or family members (Standard A.5.d.)
Risks and benefits of accepting clients with whom the counselor has had a previous relationship (Standard A.6.a.), extending current counseling relationships beyond conventional parameters (Standard A.6.b.) and entering into nonprofessional relationships with former clients or their family members (Standard A.6.e.)
Providing counseling services to two or more individuals who have a relationship (Standard A.8.)
Establishing means of payment for services and accepting gifts (Standards A.10.c., A.10.e., A.10.f.)
Working within the boundaries of competence (Standard C.2.a.)
Counselors monitoring their own effectiveness, maintaining self-care and preventing burnout and impairment (Standards C.2.d., C.2.g.)

— Source: Deborah H. Drew, Mikal Crawford and Cheryl Crabtree’s education session, “Multiple Roles in Rural and Small Settings: Personal Impact/Professional Response” at ACA’s 2016 Conference & Expo in Montréal

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

Letters to the editor: ct@counseling.org

License to deny services

By Laurie Meyers

In April, the Tennessee Legislature passed a bill, which the state’s governor then signed into law, allowing counselors to refuse to see any client if counseling that client involves “goals, outcomes or behaviors that conflict with the sincerely held principles of the counselor or therapist.”

The law, which is in direct opposition to the ACA Code of Ethics, was pushed through despite the concerted efforts of the American Counseling Association, the Tennessee Counseling Association (TCA) and other opponents. Even more alarming is that the legislation could represent only the beginning of efforts to pass similar laws in other states.

In response to the controversial law, the ACA Governing Council made the decision to move the 2017 ACA Conference & Expo out of Nashville and relocate it to San Francisco.

“We agreed it was important to move the conference because the Tennessee governor signed a bill into law that attacked our code of ethics and allowed counselors to refuse services to clients in the Tennessee communities based on their religious and personal beliefs,” explains Thelma Duffey, whose term as ACA president ends July 1. “We believed it was important that ACA take a public and powerful stance in opposition to this bill, and relocating provided us with this opportunity. We also believed it was important that we communicate our support to our members who voiced deep concerns about continuing to hold the conference in Tennessee in light of the new law. And, ultimately, we made the move based on our long-held belief of nondiscrimination and our commitment to advocacy for all people.”

The intent of Tennessee’s law is to allow counselors to discriminate against potential clients who identify as lesbian, gay, bisexual or transgender (LGBT), says ACA CEO Richard Yep. “This [is] a full-frontal attack on specific populations that some very conservative right-wing groups in the United States want to exclude from mental health services that they desperately need,” he says. “The new law will permit a counselor to reject an individual simply because of that provider’s beliefs and values. ACA and its code of ethics are very clear that counselors do not bring those beliefs and values into a counseling relationship.”

In addition to being unethical, the law is harmful to those looking for help, Yep emphasizes. “For someone seeking the services of a mental health provider to be told that because of who they are, a service provider will not work with them sends an incredibly negative message of exclusion, bigotry and discrimination,” he says.

Counseling in the crosshairs

When the Supreme Court ruled in June 2015 that states must recognize the validity of same-sex marriage, it marked a significant step forward in the fight for equal rights for LGBT individuals. At the same time, it also served as a clarion call to those determined to continue discriminatory policies and attitudes.

Currently, there are nearly 200 pieces of proposed anti-LGBT legislation in the United States. Like the Tennessee law, many of these proposed pieces of legislation — and other laws that have already been passed — were born partly in reaction to the Supreme Court’s decision, notes Perry Francis, who served as chair of the Ethics Revision Task Force for the 2014 ACA Code of Ethics. ACA believes that conservative politicians and lobbying groups focused on Tennessee and the counseling profession in large part because of a prior legal case, Ward v. Wilbanks.

In 2009, a counseling student named Julea Ward was dismissed from the counseling program at Eastern Michigan University (EMU) for refusing to counsel a gay client. Ward then filed suit against EMU in U.S. District Court, asserting that the university’s counseling program violated her rights to free speech and freedom of religion. In 2010, a U.S. District Court judge granted summary judgment in favor of EMU.

Ward was represented by the Alliance Defending Freedom (ADF), a nonprofit law firm that Art Terrazas, ACA’s director of government affairs, describes as the conservative equivalent of the American Civil Liberties Union. ADF is connected to the Family Research Council, a conservative lobbying organization. These organizations influence the Family Action Council of Tennessee, whose president, David Fowler, is a former Tennessee state senator who was a driving force behind Senate Bill (SB) 1556 and House Bill (HB) 1840. A group of conservative state legislators sponsored the bills, which eventually became the law signed by the governor.

The counseling profession also made an inviting target because the ACA Code of Ethics explicitly focuses on protecting clients by not imposing a counselor’s viewpoint, explains Lynn Linde, ACA’s senior director for the Center for Counseling Practice, Policy and Research. Linde, an ACA past president who also served on the Ethics Revision Task Force, notes that this focus on the client is unique to ACA. Although other organizations’ ethics codes implicitly prohibit mental health professionals from imposing their personal beliefs on clients, she says, the ACA Code of Ethics is explicit in this prohibition.

The legislation was introduced in the Tennessee Senate in January and passed with very little discussion, according to TCA President Kat Coy. It then moved on to the Tennessee House of Representatives. At that point, TCA rallied its members to contact their legislators to express their opinions on the bill, Coy says.

As the legislation was being debated in the Tennessee House, TCA and ACA worked together to provide expert testimony on the harmful nature of the bill and to educate individual legislators about the counseling profession, its code of ethics and the danger the legislation posed to those seeking mental health services in Tennessee. Although the law states that any counselor who turns away a client because of personal beliefs must give the client a referral, Linde notes that Tennessee has a critical shortage of mental health professionals. That raises questions about whom a counselor can refer to if he or she is the only mental health professional within 150 miles and, more important, where prospective clients are supposed to go to get the help they need, she says.

Linde and others testified about the harm this could do to potential clients. In the process, they also tried to clear up some mistaken beliefs that Tennessee legislators held. For example, Lisa Henderson, who chairs TCA’s public policy committee, says one of the first arguments she encountered was that because Tennessee is a sovereign state, it would not be dictated to by the federal government. Henderson had to explain that ACA is a professional organization that is not connected in any way to the federal government.

Linde and others testified that ACA’s opposition to the legislation was not about controlling individual counselors but rather concern for the harm that could be done to prospective clients. In addition, the law would be in direct opposition to the ACA Code of Ethics, which all member counselors are obliged to follow. Many states — including Tennessee — base their licensure standards of practice all or in part on the ACA ethics code.

An ethical dilemma

A common claim by those who support the law is that by asking counselors not to impose their beliefs on clients, the ACA Code of Ethics is actually demanding that counselors give up certain personal beliefs. That is an incorrect assumption, Linde says.

“Nobody is asking us to give up who we are the moment we walk into a counseling session,” she emphasizes. Counselors do not have to change their beliefs, but they must not impose those beliefs on clients, she continues.

“We, as professional counselors, seek to engage our clients in a genuine, thoughtful, caring relationship,” says Francis, a professor of counseling and coordinator of the counseling clinic in the College of Education Clinical Suite at EMU. “In order for me to connect to a client, I need to know who I am and what my personal values are so that I can be genuine in the room. At the same time, the profession is saying to counselors that you also enter the room with the values of the counseling profession, which are clearly delineated in the code of ethics.”

Francis says a counselor’s responsibility is spelled out in the ACA Code of Ethics in Standard A.4.b. (Personal Values): “Counselors are aware of — and avoid imposing — their own values, attitudes, beliefs and behaviors. Counselors respect the diversity of clients, trainees and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature.”

Many of those who supported Tennessee’s “sincerely held principles” legislation asserted that ACA changed its code of ethics regarding counselors’ personal values during the 2014 revision in response to Ward v. Wilbanks. Francis and Linde say that assertion is false.

“We clarified what has [long] been there,” Linde says. From the 1988 version onward, the ethics code has stated that counselors can refer clients only when a client is no longer progressing, when the counselor’s services are no longer required because the client has met his or her goals or when counseling no longer serves the client, Linde explains.

Anticipating that some might try to argue that a counselor who holds views diametrically opposed to what the client believes is not “competent” to counsel that client, the 2014 revision of the ethics code clarified the issue of referral, Linde and Francis explain. Standards A.11.a. and A.11.b. were added to further delineate what constitutes competency.

v A.11.a. (Competence Within Termination and Referral): “If counselors lack the competence to be of professional assistance to clients, they avoid entering or continuing counseling relationships. Counselors are knowledgeable about culturally and clinically appropriate referral resources and suggest these alternatives. If clients decline the suggested referrals, counselors discontinue the relationship.”

v A.11.b. (Values Within Termination and Referral): “Counselors refrain from referring prospective and current clients based solely on the counselor’s personally held values, attitudes, beliefs and behaviors. Counselors respect the diversity of clients and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature.”

In addition, Standard A.4.b. was expanded to include the necessity of obtaining training and multicultural competency, Francis says.

Linde says ACA’s official position is that although counselors in Tennessee are now legally able to refer clients on the basis of personal beliefs, that action still goes against the profession’s code of ethics. Accordingly, ACA will still sanction any member who engages in such behavior, Linde emphasizes. This also applies to counselors-in-training at university or college programs.

Linde testified in detail for legislators on the issue of competence. “Counselors can’t refer due to client characteristics,” she says. “It’s on [the counselor] if you come from another country and I don’t know anything about you or your culture. I have to educate myself on your culture.”

However, if a client comes to a counselor with a problem or issue that the counselor is not qualified to treat based on his or her individual scope of practice, then referral is appropriate. For example, Linde says, a client might present to a counselor for treatment of depression. In the course of therapy, the counselor might realize that the heavy drinking the client is engaging in is due to a chronic substance abuse problem, not just self-medication. Unless the counselor is specially credentialed to provide substance abuse counseling, the counselor would be operating outside of his or her scope of practice to offer those services. In this case, the counselor should instead refer the client to another counselor who is qualified to provide in-depth substance abuse services.

Values clash

Henderson, a private practitioner in the Nashville area, says that when she met with individual legislators about the “sincerely held principles” bills, it appeared that some of them already had their minds made up. When presented with the ethics testimony, she says, many of these legislators argued that it was impossible for counselors to separate themselves from their beliefs. They also rejected a primary counseling value of putting clients first, Henderson says.

“I kept reminding them that these are complex issues,” says Henderson. She points out that even though it takes years to become a professional counselor, the legislators were making decisions about the counseling profession based on a few hours’ worth of knowledge gleaned in hearings and meetings.

During efforts to defeat the legislation, Henderson acknowledges that she also encountered some counselors in Tennessee who supported it. The most common reason given was the counselors’ religious beliefs, she says. For example, one counselor told Henderson that he could not separate his religious beliefs from his counseling values. So, if a client came to him for treatment of alcoholism and wanted to use harm reduction, the counselor — who believes it is wrong to drink or take drugs — would only agree to treat using complete abstinence. Another counselor said she would not be able to counsel someone committing adultery unless that person pledged to end the adulterous relationship.

Francis says another common explanation or justification for values-based referrals is that a counselor who has a conflict with a client’s lifestyle or choices might not provide the best service or even cause harm. “This is a perfectly valid concern and is upheld in the ethics,” he says. “We don’t want to cause harm. We don’t want to put the client in any sort of jeopardy.”

However, Francis explains, the flaw in that reasoning is in assuming that the problem resides with the client. Instead, it is the counselor who needs to make adjustments and seek supervision, consult with trusted colleagues or get additional training to better serve the client.

Ultimately, it is those seeking mental health services who will be harmed by the passage of the legislation. “In rural Tennessee, or anywhere in the state that is listed as a mental health shortage area, there simply are not enough providers,” says Catherine B. Roland, who begins serving as ACA president July 1. “So, if a counselor is allowed to pick and choose who they will see simply due to a strongly held belief or value, those most in need of services will have nowhere to turn.”

The law is also written very broadly, which leaves it open to individual interpretation, Terrazas notes. “Initially the bill covered religious beliefs, but the wording was changed to ‘sincerely held principles,’ which could be broadened to include almost anything that a counselor disagrees with,” he says.

Duffey agrees. “People seeking mental health services can potentially be affected in any number of adverse ways as a result of this law,” she says. “For one, they are now aware that a law exists that protects counselors from working with them if the counselors’ beliefs conflict with who they are. That is profound. In a time where so much progress is being made with respect to equality and human rights, this bill may bring a painful resurgence of old feelings of rejection and discrimination and feelings of social exclusion.”

Current and future implications

Although those who defend the law often cite religious concerns for doing so, TCA leaders say many of their members who are Christian counselors have vowed not to use the law to discriminate.

In fact, other counselors have cited their religious beliefs as a reason not to discriminate. “[The Tennessee law] is an affront to the heart of Christianity,” says Ryan Thomas Neace, an ACA member and counselor practitioner in St. Louis. “The Scriptures reveal that those whom the religious folks said weren’t towing the line — not observing religious rituals or laws, not living up to sexual and moral purity codes by having sex too much or with the wrong people or drinking too much, etc. — those people were often far more hungry for genuine, transformative encounter than the religious folks themselves. This is why Jesus kept their company so much.”

Neace, who has been practicing for almost 14 years, cites his experience as an example of how harmful the law is to clients and to the counseling profession’s ideals. “By the time many of my LGBTQ+ clients show up at my office, they’ve already been hounded by unsupportive, and often abusive, friends, family, religious communities and sadly, professionals,” he says. “This law makes the sacred space that we offer as counselors less sacred and less spacious.”

There are already many barriers that discourage potential clients from reaching a counselor’s office, Neace says, and research suggests that LGBT individuals face even more obstacles. In Neace’s opinion, the obstacles the Tennessee legislation has erected for LGBT clients “are perhaps more akin to land mines.”

Unfortunately, Neace says, some counselors don’t seem to comprehend the precedent — and the slippery slope — that this law sets. “In a more long-term sense, it literally opens the door for clients to be denied therapy if they in some way represent an affront to anything counselors sincerely or principally believe,” he says. “This actually could, in my case, extend to me as a Christian. Someone could refuse to see me because of my religious beliefs. It’s hard to understand that religious folks who back this bill don’t see that it ushers in opportunities for the very persecution they hope to avoid.”

Keith Myers, a licensed professional counselor and ACA member, wrote an opinion piece for USA Today in May in which he highlighted some of the potential consequences of the law that its advocates might not have anticipated. “Imagine that Joe, a veteran who served our country faithfully, comes to counseling at a rural Tennessee practice,” Myers wrote. “He talks about his strong opinions concerning the Islamic State terrorist group and ways the military should be intervening. His male counselor happens to be a pacifist. This counselor has strong feelings against any kind of war or any type of military intervention against ISIL. Before the new law, he would have felt obligated to help Joe. Now, he refers Joe to another counselor 25 miles away from where Joe resides. Joe becomes angry and ultimately avoids getting help. The harm has been done.”

Henderson has already seen an effect. “After the news broke that the bill had been signed into law, one of my own clients asked if I would continue to see her now that I don’t have to,” Henderson recounts. “And this is a person who I already have an existing relationship with.”

One of Henderson’s counseling colleagues shared another story related to the passage of the law. During a client intake, the client asked questions about how the counseling process worked but also asked how long it would be before the counselor might decide not to work with the client any longer. The client wanted to know what he would do if that happened.

Counselors who practice in other states might question why they should be overly concerned about what is happening in Tennessee. “Quite simply, if it can happen in Tennessee, it can happen in any state in the union, making it an issue for all counselors,” Roland says. “One only needs to realize that the anti-LGBTQ legislation in so many states continues to grow. Those who believe in an anti-LGBTQ agenda are passionate and are using the legislatures and courts in this country to make their voices heard. ACA stands in support of the counseling profession and the consumers who seek our services — all consumers.”

The law could also contribute to misperceptions that go beyond what is happening in Tennessee. “This bill is problematic for counselors who hold religious beliefs and also support our code of ethics,” Duffey says. “The discussions around this issue can create misunderstandings and generalizations, with suggestions that faith-based counselors are, in principle, discriminatory. This is, of course, unfair and inaccurate, and runs the risk of creating division where it doesn’t exist.”

Terrazas says there is a danger that similar legislation could be proposed in other states and notes that ACA Government Affairs is maintaining a very watchful eye.

Seeking solutions

With the “sincerely held principles” legislation being signed into law in Tennessee, what happens next? ACA and TCA are taking a number of steps.

“We are certainly starting to pick up the pieces of what has transpired over the past several months and focusing on the future,” Coy says. “We are aware that there are varying opinions in Tennessee, and we will need to navigate through all of that in the coming months. Our ultimate goal shall remain meeting the needs of our membership and focusing on the needs of our clients.”

At July’s state leadership institute, TCA plans to focus on educating its members about what happened and encouraging them to in turn educate the public on the issues, Coy says. TCA’s annual conference in November will be devoted in part to additional education and training and to deciding what the association’s next steps should be.

When she was interviewed near the end of May, Coy said the rest of TCA’s plan of action was under development. “We will be sending out a survey to membership asking them what they want,” she said. “Our initial ideas will be training in the form of webinars, single-event training opportunities, podcasts, training bulletins and continued membership development.”

On the national level, Terrazas says that ACA Government Affairs is encouraging counselors in all states to get to know their legislators. The purpose is not only for counselors to be aware of what bills are being proposed in their states but also to educate legislators about counseling and what counselors do, he says.

The ACA leadership also wants counselors in Tennessee to know that even though the 2017 ACA Conference is being relocated from Nashville, the association is not abandoning the state’s practitioners. “ACA stands ready to assist with grassroots advocacy and to provide materials to Tennessee counselors who seek resources that will help the public policy officials understand the deleterious effects of this new law on the citizens of Tennessee,”
Yep says.

“We will continue to work with our colleagues in Tennessee in hopes that this law can be overturned,” Roland says. But she also offers a caution: “We cannot for a moment forget about the other 49 states where efforts like these can arise quickly and without notice.”

Despite the potential damage caused by the “sincerely held principles” law in Tennessee, Duffey believes the counseling profession will eventually emerge stronger than ever. “I absolutely believe we will ultimately be stronger as a result of our decision [to relocate the ACA Conference] and the unity we are experiencing through this advocacy,” she says. “I have been heartened by the outpouring of support for the Governing Council’s decision and by the appreciation of those members who courageously shared their stories and concerns. In fact, people who often vigorously debate other issues have come together on this one — in support, with clarity and with a sense of pride.”

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Does the ACA Code of Ethics trump discriminatory institutional policies? Read the July issue of the Journal of Counseling & Development, featuring three articles in the special Trends section that discuss the ethical issues raised by the practice of accrediting counseling programs at colleges and universities that use statements in their Codes of Conduct that are nonaffirming of LGBT individuals.

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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