Monthly Archives: July 2017

Observations from a licensing board

By Brian Carnahan and Tracey Hosom July 31, 2017

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In our respective positions with the Counselor, Social Worker and Marriage and Family Therapist Board for the state of Ohio, we have the unique opportunity to encounter many clinicians as they are starting their careers. (We use the term “clinician” to refer to the counselors, social workers and marriage and family therapists regulated by the Ohio Board who also provide direct services to clients.) This includes discussing the challenges and questions these new clinicians have as they embark on their career paths.

Clinician Jeffrey Kottler’s book, titled The Therapist in the Real World: What You Never Learn in Graduate School (But Really Need to Know), prompted some thinking from our perspective as a licensing board staff. What follows are some additional lessons that we believe fall under the category of “were never taught in graduate school but still need to know.”

One area in which newer clinicians often encounter difficulties is documentation. In our experience, issues with progress notes and other record-keeping concerns result in more complaints and employment issues for new licensees than most other possible violations. Proper documentation is critical for billing, quality control and transitioning clients to other providers, and when there are questions or concerns about a licensee. Case notes can form an integral part of a licensee’s defense if a concern or complaint is filed against the licensee.

In many settings, from community mental health to school-based settings, productivity demands can compound issues with record-keeping. Agencies must produce billable hours, and these demands fall upon clinicians. New clinicians are particularly susceptible to the pressures of productivity requirements. Our conversations with licensees suggest that productivity demands are occasionally a focus of training and education but that some of these associated skills, such as how to engage clients to show up for appointments, are generally learned on the job.

Understanding how important it is to meet client needs and agency goals and yet still remain ethical in record-keeping practices is critical for beginning licensees. Newly licensed clinicians may find themselves unable to keep up with these demands. This is where seeking proper supervision and practicing effective communication are key to the success of new clinicians.

Another important area concerns appropriate termination. We are now in an era when employees start and leave jobs more frequently than in the past. The world of mental health counseling is no different. For instance, better opportunities may emerge that licensees would like to pursue. New clinicians may wish to leave a job when they find the position is not satisfying or isn’t a good fit for them.

Unfortunately, licensees cannot simply walk out. No matter the reason, leaving a job must be done according to jurisdiction rules and agency/practice policies. New licensees should prepare to leave by reviewing termination requirements, offering written notice, ensuring that client documentation is complete and up to date, and helping to refer and transition clients.

The impact of mentors and supervisors on new licensees should not be understated. However, although these relationships are important for professional development, too often newer clinicians rely on others for answers without first doing their own research. New licensees need to develop their skills in reading and interpreting the laws, regulations and codes of conduct governing their profession. Although we coach licensees to rely on supervision, we realize that not every professional keeps up with developments in the field. Use good judgment when relying upon others to guide your career.

New licensees often confuse work supervision, or clinical supervision, with training supervision. Recognizing the difference between these two types of supervision is key to the success of new professionals. Having a supervisor to whom you report, and who is responsible for signing off on diagnoses and treatment records, is not the same as training supervision, which is supervision that is intentionally provided to develop the professional’s skills for possible independent licensure. Unfortunately, we encounter situations in which new clinicians mistake the work meetings they attend with training supervision that would qualify their hours toward independent licensure.

Many newer clinicians are savvy in their use of social media and technology. Their facility with these tools has both upsides and downsides. Make sure that you limit any personal accounts with privacy settings to protect yourself, and of course do not perpetuate multiple relationships by adding clients to your online accounts such as Facebook. Other tools such as texting can also be an issue. Be sure to limit texting and email to confirming appointments and similar administrative tasks, unless those tools are a planned part of therapy, for which proper notice is provided.

The last observation applies to everyone: A little humility goes a long way. The passion and excitement of starting a career can overwhelm good judgement or give one more confidence than is warranted. Use that passion and energy to serve clients well, while at the same time investing in growing your knowledge and understanding of the field.

 

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Brian Carnahan is executive director of the Ohio Counselor, Social Worker and Marriage and Family Therapist Board. Contact him at brian.carnahan@cswb.ohio.gov.

 

Tracey Hosom is an Investigator with the Ohio Counselor, Social Worker and Marriage and Family Therapist Board. Contact Tracey at tracey.hosom@cswb.ohio.gov.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Healthy conversations to have

By Kathleen Smith July 26, 2017

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In the United States, 1 in 6 adults has a prescription for a psychiatric drug. That ratio only increases among individuals who walk into counselors’ offices, leaving many counselors feeling that they must perform a special type of tightrope act to talk about medications with their clients. Given that licensed professional counselors don’t possess prescription privileges, some counselors feel that they lack the training to carry on such discussions. Other counselors fear letting their own beliefs and biases show. Regardless of the reason, some counselors are quick to refer clients back to their doctors or psychiatrists rather than engaging clients in a thorough conversation about medication management themselves.

Because primary care physicians write almost 70 percent of antidepressant prescriptions, counselors may find that new counseling clients who are on medication have yet to have an extended conversation about medication management and their overall mental health. These clients may not have given much consideration to how long they want to stay on medication, or they may be uninformed about the possible risk of growing dependent on sedatives, anxiolytics and other medications.

Several counselor educators are taking up the charge of encouraging more informed and comfortable conversations in the counseling room about client medications. American Counseling Association member Dixie Meyer presented with colleagues at the association’s 2016 conference in Montréal on adjunctive antidepressant pharmacotherapy in counseling. Meyer dedicated her dissertation research to the sexual side effects of antidepressants and their effects on romantic couples. As her research expanded, she grew more and more fascinated with exploring the relationship between psychopharmacology and counseling.

Today, as an associate professor in the Department of Family and Community Medicine at St. Louis University, Meyer educates many primary care physician residents, and she notes that counselors sometimes forget that they have a unique ability to conceptualize clients. “Primary care physicians are expected to be able to know pretty much anything, but they do not have the same level of depth in their mental health training,” she says. “Counselors need to really think about what kind of information they can share with a primary care physician, and the answer is, a lot.”

Meyer explains that counselors may have a greater understanding of the impetus for the client’s condition, the specific symptoms the client has experienced, which of a medication’s potential side effects might be more of a challenge for the client and what additional resources the client may need to maintain medication adherence.

Biases and fears

Professional counselors carry their own biases and values related to psychiatric medications, often based on their individual experiences and training. It is easy to see how the counseling profession as a whole might feel threatened by the statistics, however. For example, nearly $5 billion is spent every year on TV ads for prescription drugs. Then there is the fact that more than half of all outpatient mental health visits involve medication only and no psychotherapy.

A physician assistant with a second master’s degree in counseling, ACA member Deanna Bridge Najera is frequently invited to talk to counselors about improving dialogue between medication prescribers and counseling professionals. She gave a presentation at the ACA 2017 Conference in San Francisco titled, “Medicine Is From Mars and Counseling Is From Venus: How to Make It Work for Everyone.”

Najera has heard skeptical counselors make many statements about psychopharmacology, including that such medications turn people into “zombies,” alter their personalities or simply produce placebo responses. As a master’s counseling student, she also heard many comments from fellow students about their negative relationship with medication or their family members’ negative experiences.

“We have to make sure that we have these conversations out loud,” Najera says. “We have to ask counselors what their concerns are. The way I explain it, the medicine is supposed to allow you to be who you’re supposed to be. It doesn’t change who you are; it just makes it more manageable to learn and grow.”

Although there is still no clear winner in the medication versus therapy debate, researchers are learning more about who might respond to one treatment better than the other. For example, a 2013 study in JAMA Psychiatry found that patients with major depression with low activity in a part of the brain known as the anterior insula responded well to cognitive behavior therapy and poorly to Lexapro. Those patients with high activity in the same region did better with medication and poorly with the therapy. Researchers have also concluded that patients who are depressed and have a history of childhood trauma do better with combined therapy and medication than with either treatment alone.

“We chose our profession because we believe in our profession,” Meyer says, “but the research is going to report no differences between counseling and medication. I do see a lot of bias, and one of my concerns is that our No. 1 goal should be to help the client. So whatever the client’s perspective is, whatever the client thinks is going to help them is probably what will help. They are the experts on their own life.”

Erika Cameron, an associate professor of counseling at the University of San Diego and an ACA member, presented with Meyer in Montréal. When they were enrolled in the same doctoral program, Cameron found herself sharing Meyer’s interest in psychopharmacology and considering how she could respond to the general wariness of school counselors around the topic of medication.

“There can be a bias that that’s not part of their role. They are not diagnosing or prescribing, so they don’t need to know about medication,” says Cameron, who once worked as a school counselor. “But by not talking about it, we might be harming the client. Or if you don’t know that a student is on a medication, then you don’t know what behavior sitting in front of you is normal or atypical for that particular student.”

Another common trepidation among counselors is the fear of stepping outside their lane when it comes to talking about psychiatric medication. Clients often ask for advice about certain medications or when starting any type of drug, but there is a temptation among some counselors to avoid the subject or simply to refer all questions in that vein to a psychiatrist or doctor.

Franc Hudspeth, associate dean of the counseling program at Southern New Hampshire University and also a licensed pharmacist, says that counselors should serve as educators and advocates when it comes to client medications. “We should never cross that line of telling a client what to do with that medication,” he says. “We have to refer back to the foundation of our profession. We help individuals overcome problems, and we don’t give them the solutions. It’s saying to the client, ‘If you have concerns, we can present this to your prescribing physician, and I will support you in any way, but I’m not going to tell you how to do it or what to do with the medication.’ I wouldn’t even do that as a pharmacist. We have to help people make the best decisions based on the best information.”

Hudspeth also says that he observes more of a general hesitancy at work than a fear of liability among counselors. “If someone advocates for their client and their voice gets squashed by a physician or a psychiatrist, there may be some hesitancy to get involved. But it never hurts to voice concerns and to be the advocate for your client,” he says. “[Still], I do think that some counselors fear the repercussions of helping a client speak up.”

Having the conversation

How exactly should counselors respond when clients want to talk about psychiatric medications? In an effort to provide effective psychoeducation, Meyer says, counselors shouldn’t be shy about asking thorough questions upfront concerning clients’ beliefs and ideas related to medication. She suggests asking questions such as, “How do you know that you want to be on a medication?” and “Are you likely to have another depressive episode?” Questions such as these can provide valuable insight into the client’s knowledge (and knowledge deficits) about medication. For example, a client who wants to take an antidepressant might not realize that half of all individuals with depression will not experience another episode.Most frequently prescribed psychiatric medications in the U.S.

Najera also encourages counselors to ask clients where they obtained their knowledge about particular medications. “Many people have the idea that newer is always better, which study after study has shown is not true,” she says. “A client might see a commercial for a new medication and ask if it will work. I’d rather them not break the bank for a new medication when there’s a $4 medication at the local pharmacy that’s just as effective.”

Hudspeth suggests that counselors do a medication check-in with clients at every session. He says the best question counselors can ask clients who are already on medication is, “How is your medication treating you?” This kind of general question can help counselors gather information without overeducating clients in a way that predisposes them to having side effects, Hudspeth explains.

Cameron agrees that the simplest approach is often the most empowering for clients. “Sometimes [it’s simply] asking, ‘Did you read the really long paper that came in the bag with your pills? What is the medication really treating? What are its side effects? What would be considered not normal for you?’ [It’s] educating clients to be critical consumers of their medication,” she says.

Cameron also encourages counselors to role-play conversations that clients could have with their prescribing doctors. Counselors can assist their clients with compiling a list of questions to ask and also encourage them to track their symptoms, thoughts and feelings while on a particular medication. Data can be a powerful tool for holding doctors accountable for connecting clients with the best medication options, but sometimes clients need to learn what to observe while on their medications, Cameron says.

Counselors may also need to have conversations with clients about the impact that their physical health can have on their mental status. Meyer encourages counselors to take time to consider how nutrition, physical illnesses, medications and other substances could potentially influence the mental health of their clients. Anything from high blood pressure medication to birth control pills to low iron could be a culprit, and Meyer worries that individuals who don’t provide their doctors with detailed information about their health are at risk of being prescribed medications that don’t fit their particular symptoms.

“If a client has not had a physical in a long time, then you do not know if there are cardiovascular concerns, hormonal concerns, cancer symptoms or one of the many other disorders that can have depressive side effects or present as depression,” Meyer points out.

Counselors are also charged to have open and honest conversations with parents who are worried about putting their children on psychiatric medications. When Hudspeth worked as a pharmacist in the early 1990s, he began noticing that many children were being medicated without solid reasoning to back it up. Thinking there might be a better approach, he went back to school to become a counselor and later a counselor educator. In his counseling work with children, he has fielded many questions from parents about whether their child should be evaluated for the need to take psychiatric medication.

“My perspective is that the evaluation isn’t going to hurt anything,” Hudspeth says. “I tell parents that they don’t have to make the decision to choose medication, but if the child is medicated, he or she will also do better if they’re in therapy. The two treatments are synergistic, and our goal as a team is to find the [right] balance of different components.”

Cameron adds that school counselors are presented with the complex task of advocating for developing kids who are on medication. “Because there’s so much hormonal change and physical growth, medication may need to be adjusted more frequently,” she says. “School counselors have the ability to see these students on a daily basis, and if we’re not paying attention to these changes, there could be a downward spiral before something
is corrected.”

Psychopharmacology in counseling classrooms

Counselor educators are tasked with preparing their students for the increased use of psychiatric medication among their clients. The 2016 CACREP Standards require clinical mental health counseling students to be educated about the “classifications, indications and contraindications of commonly prescribed psychopharmacological medications for appropriate medical referral and consultation.” Similarly, the CACREP Standards say that counselor education programs with a specialty area in school counseling should cover “common medications that affect learning, behavior and mood in children and adolescents.”

Hudspeth is of the belief that every master’s program in counseling should require a psychopharmacology course. “When 50 percent of our clients are on medication, we should have a basic foundation for understanding psychopharmacology,” he says. “New practitioners need to be better prepared for what they’re going to face in internship or post-master’s work, so they should be familiar with what medications are used for what disorders and what kind of side effects pop up.”

A 2015 article in the Journal of Creativity in Mental Health by Cassandra A. Storlie and others explored the practice of infusing ethical considerations into a psychopharmacology course for future counselors. The authors argue that counselor educators should engage students in talking about how their own values and perceptions about medication use could potentially affect the quality of counseling service they provide. The authors tracked the success of one psychopharmacology course that asked students to complete a variety of creative assignments, including reporting on a legal or ethical issue in the field of psychopharmacology, interviewing an individual who takes a psychotropic medication and discussing fictional client scenarios. At the end of the course, students reported greater confidence in how they understood their role related to discussing medication with clients.

Cameron agrees with the benefits of offering a psychopharmacology course to counseling students. She also sees value in inserting medication conversations into her supervision work with students. When her students bring in case conceptualizations during their internship work, she asks them to list what medications the client is taking. She then asks them to educate their peers about what each medication is treating, what the dosage is and any typical side effects.

“I have to model being comfortable bringing up the topic of medication so that my students get more comfortable,” Cameron says. “Often they don’t talk about medication because they feel that they don’t know it all. They don’t want to give bad information. But they can learn to take a proactive role by sitting with a client and saying, ‘Hey, let’s look this up. Let me get this resource guide or a consult on this.’ There’s this fear, especially with student counselors, that you have to know everything to be able to be helpful.”

Areas for growth

Of course the work of medication education doesn’t end with graduate school. New medications are steadily being introduced, and over time researchers will learn more about the long-term effects of popular ones. Cameron recommends that counselors keep a copy of the Physicians’ Desk Reference, a compilation of information on prescription drugs, in their office. “They update it pretty regularly, so when you have clients come in, you can open the book and figure out what’s going on,” she says.

Hudspeth says counselors should stay informed but also avoid the subtle ways in which they might give advice about any medication, including over-the-counter ones. “A client may come in and say, ‘I’m having difficulty sleeping,’ and a counselor says, ‘Have you tried melatonin?’ They just stepped over that line,” Hudspeth says. “Just because you can buy it at Target or Walmart doesn’t mean you should be asking those questions.”

Meyer suggests that counselors who feel overwhelmed with the breadth of information on medications begin with the client population they serve most frequently. “What information can help your particular clients?” she asks. “Start there and seek out information, depending on who’s coming in and how you can treat them to the best of your ability.”

Above all, Meyer recommends that counselors never forget to take the topic of medication seriously in their work and training. “When you are choosing to take a medication, you may be choosing to have potential side effects. You are choosing that you will alter your neurochemistry. That is not a decision that should be taken lightly. It is not an easy decision,” she says. “When a client makes a choice about whether to take a medication, they need to make it from a place where they are well-informed.”

 

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Kathleen Smith is a licensed professional counselor and writer in Washington, D.C. She is the author of The Fangirl Life: A Guide to All the Feels and Learning How to Deal. Contact her at kathleensmithwrites@gmail.com.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Lending a helping hand in disaster’s wake

By Laurie Meyers July 25, 2017

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Sept. 11, Hurricane Katrina, Virginia Tech, Newtown, Superstorm Sandy, Pulse nightclub … It is only a partial list, but this roll call of places and events seared into public memory makes it obvious: The 21st century has provided counselors with many unfortunate opportunities to exercise disaster mental health counseling skills.

Post-9/11, the practice of disaster mental health has been shifting and evolving as practitioners have continued to gain a better understanding of how people recover from traumatic events. Disasters, whether natural or human-caused, can be life-altering and psychologically scarring, but counselors and other experts say that most survivors will recover without major psychological trauma. And it is now widely recognized that in most cases, brief targeted treatments work better with survivors of disasters than does extended therapy.

Historically, counselors would show up in the wake of a disaster and engage in talk therapy, says Gerard Lawson, president of the American Counseling Association. Today there is an understanding that the immediate aftermath of a disaster is not the time to engage people in traditional psychotherapy. Survivors need something much more immediate — psychological first aid, which Lawson describes as a kind of mental health version of medical first aid. Responders try to “stop the bleeding” in a sense by treating survivors’ immediate stress and assessing who might be a threat to themselves or others, he says.

“One of the foundations of psychological first aid is that we assume not everybody [who experiences a disaster] is going to develop severe mental health problems,” Lawson says. He notes that research has shown that a fairly low percentage of disaster survivors — approximately 10 percent — will go on to develop posttraumatic stress disorder. Although in a different context the psychological distress that many survivors experience might seem indicative of mental health problems, in the wake of a disaster, this emotional (and sometimes physical) dysregulation is normal, he explains.

“These are people having normal reactions to abnormal events,” says ACA member J. Barry Mascari, an associate professor in the Department of Counselor Education at Kean University, where he teaches, studies and writes about trauma and disasters. “Therefore you cannot look at their reactions through a traditional mental health lens. The reactions are often situation specific and transient.”

In fact, says Mascari, who is certified in New Jersey in disaster response crisis counseling, the practices used in the past — engaging in talk therapy and focusing on the details of the disaster — can cause survivors to “relive” the event, which can be retraumatizing.

Indeed, the help that survivors need most is often practical as much as psychological, notes Laura Shannonhouse, an ACA member and a licensed professional counselor who has worked with survivors of multiple disasters. She says that psychological first aid is designed to provide information, comfort and practical support, all tailored to the individual needs of each survivor in a structured manner.

This support consists of eight core actions: contact and engage, provide safety and comfort, stabilize, gather information, offer practical assistance, connect individuals to social supports, give coping information and provide links to needed services, says Shannonhouse, an assistant professor in the clinical mental health school and the counselor education and practice doctoral programs  at Georgia State University.

Disaster survivors are grappling with a substantial number of difficulties, notes ACA member Karin Jordan, who has worked directly with disaster survivors and is the coordinator of ACA’s Traumatology Interest Network. “Immediately after and in the wake of the disaster event, emotions tend to be very strong,” she says. “People are often put in a position in which they need to act in a heroic way to save their own or others’ lives and get themselves and others to safety. So safety of self and others is very important. This would include safety from the disaster and aftereffects.”

Safety concerns can involve anything from downed power lines to a disconnected gas line to earthquake aftershocks, notes Jordan, professor and director of the University of Akron School of Counseling. “Returning to damaged homes might be unsafe, which might mean that people will spend some time in a shelter or tent. Being displaced might also mean that some families are scattered across different camps.”

Counselors should keep all of this in mind when engaging with survivors, says Lawson, whose areas of expertise include disaster mental health and response and resilience. He explains that after introducing themselves to and establishing a basic rapport with survivors, counselors should assess for safety and comfort. For instance, if the person is having a panic attack or hyperventilating, the goal is to try to stabilize them, he says. Counselors should then gather information about survivors’ needs and concerns, such as whether they know the location of their loved ones, have a place to stay and have or know where to get items such as clothing and other supplies. Helping survivors identify resources to meet their needs can help them feel more in charge, Lawson notes.

Counselors also play a very important role in normalizing what survivors are feeling and how they are reacting to tragedy, Lawson points out. “We want to help them feel competence so they are not waiting for someone to come in and rescue them. We want to move them toward being in charge of what comes next,” says Lawson, who previously chaired an ACA Task Force on Crisis Response Planning.

“We hope for them [survivors] to be able to return to something like pre-trauma functioning,” Lawson says. “It won’t be the same, but similar. We talk about a ‘new normal.’ Your life isn’t going to be exactly the same as before, but you can get to a new normal.”

Healing connections

It is also crucial to get survivors reconnected with social supports such as family members, friends, their spiritual communities and the community in general, Lawson says. These natural support networks are particularly important to the long-term well-being of those who experience disasters, he adds. “As helpful as it is to have counselors there, they are ultimately going to go away,” Lawson points out.

ACA member Laura Captari, who has a background in community mental health and has counseled survivors of disasters in the United States and internationally, agrees. “Disasters often uproot social networks just like they do trees,” she says. “Isolation is a strong predictor of negative mental health outcomes. … Responders should listen for signs of isolation, loss of relationships and/or disconnection from community resources, and be looking for ways to facilitate reconnection with neighbors, family members and faith communities.”

“For survivors, acting on and celebrating interdependence on others can ease feelings of loneliness and isolation,” continues Captari, who is earning her doctorate in counseling psychology at the University of North Texas, where she works in the Family Attachment Lab studying the role that spirituality and attachment play in facilitating posttraumatic growth and resilience.

When survivors of disasters come together to support one another, in many cases they gain not only practical assistance and the comfort of being with people who understand what they have endured, but also a variety of emotional benefits, Captari says. She notes that research has associated altruism with increased gratitude and well-being among those who practice it.

Although most survivors will not need long-term treatment, counselors should be alert to certain signs and symptoms. “Disaster can lead to feeling hopeless and desperate,” Captari says. “Responders should listen for any indication of harm to self or others, as well as impulsive or risky behaviors. It is important to recognize when a survivor may need additional follow-up services from another professional, agency or organization, and [then to] provide this referral.”

Lawson adds that signs such as hypervigilance and difficulty sleeping can indicate trouble if they are present for weeks or months at a time.

Calling on a higher power

The Humanitarian Disaster Institute at Wheaton College in Illinois is a research center that studies the role that faith plays in helping people cope with disasters. Shannonhouse is a fellow at the institute, where she is part of a team that is developing a program of spiritual first aid.

“Survivors [of disasters] often turn to their faith to make sense of suffering, and there is more than 40 years of scholarship on religious and spiritual variables in coping and making sense of suffering,” Shannonhouse says. “Unfortunately, most of this knowledge is left out of disaster mental health programming.”

Captari is also working with Shannonhouse and others at the Humanitarian Disaster Institute to develop general spiritual first aid practices. “In working with professionals of diverse cultural backgrounds, I have learned so much about resilience in the wake of systemic trauma … and have seen, time and again, that for many individuals, their personal faith and spiritual community buffer against negative psychological outcomes,” Captari says.

Captari points out that multiple studies have indicated that the majority of Americans (an estimated 89 percent, according to the Pew Research Center) express a belief in God or some other higher power. In part for this reason, Captari contends that counselors have an obligation to understand and integrate survivors’ cultural, religious and spiritual values into treatment.

Shannonhouse, who also works at Georgia State University’s Center for the Study of Stress, Trauma and Resilience, notes that although spiritual beliefs can be a source of strength for survivors, disasters can also cause feelings of spiritual distress, such as feeling abandoned or punished by God. These feelings can lead to a loss of hope. Spiritual first aid is intended to help promote positive spiritual coping, Shannonhouse says.

“SFA [spiritual first aid] is an evidence-informed, early disaster, spiritual- and emotional-care intervention that promotes fortitude and resilience through spiritually oriented support, resources and interventions,” she explains. “[It] is designed to help triage survivors immediately following a disaster by reducing spiritual distress, fostering spiritual support [and] improving access to spiritual resources.”

Some of the aspects of spiritual first aid are based on general coping behaviors, such as practicing self-care and understanding common stress reactions. In addition, spiritual first aid involves working with survivors to help them identify what rituals or beliefs connected to their religious or spiritual traditions might bring them comfort. Disaster mental health workers then encourage survivors to turn to these practices as a way of coping, Shannonhouse explains.

Says Captari, “This could include attending religious services, vigils [or] support groups; meeting with spiritual leaders; yoga, meditation and mindfulness practices; reading sacred texts; listening to religious or spiritual music; prayer; journaling — the possibilities are endless, but they should be guided by the client.”

“SFA is not a step-by-step manualized intervention,” she continues, “but rather provides a simple, flexible model to help facilitate therapeutic interactions with survivors in a variety of short-term contexts through empathic listening and support.” She explains that when talking with survivors, counselors and community responders can hold in mind the acronym S.O.U.L.S. to assess how the individual or family has been affected and what the survivor’s greatest needs are:

S: Stress

O: Other support

U: Ultimate concerns

L: Loss of resources

S: Self-harm and harm to others

 

Another acronym, C.H.A.T, describes the helping process taught in spiritual first aid:

C: Connect through presence

H: Help with humility

A: Assess by observing and questioning

T: Triage with spiritually oriented interventions

 

S.O.U.L.S. and C.H.A.T. will be featured in a spiritual first aid manual currently being written by Shannonhouse, Jamie Aten (founder and director of the Humanitarian Disaster Institute) and Don Davis, an assistant professor at Georgia State.

Both Shannonhouse and Captari caution that no one-size-fits-all approach exists for spiritual first aid. Like any counseling method, it must be practiced with cultural humility.

“Be curious and seek to understand the survivor’s unique experience and needs,” Captari says. “Some survivors may be reticent to talk about spiritual issues due to fear of judgment or criticism. Counselors can use SFA to ask about, encourage and validate the importance of existential questions and struggles that may be present rather than shying away [from them].”

Captari also emphasizes the importance of counselors maintaining an open, interested and accepting attitude toward the beliefs and faith tradition of survivors. “For example, if the survivor identifies as religious or spiritual, explore how the disaster has impacted their relationship with the sacred or their connection with their faith community,” she advises. “Spirituality for many people is a profoundly physical and emotional experience, and people who have lived through disaster are likely experiencing acute stress reactions. It is often difficult to connect with the divine when one is in a state of hyperarousal. Normalize feelings of anger or confusion toward their higher power. Do not minimize, trivialize or pass over the very real negative impact of the disaster, and do not try and correct, challenge or ‘fix’ survivors’ theology, assumptions or beliefs.”

Counselors can help disaster survivors who identify as religious or spiritual in a number of ways, Captari says. These include:

  • Helping them to draw on their sacred texts to normalize their feelings
  • Exploring themes of mercy and protection with them
  • Facilitating gratitude
  • Encouraging the practice of daily spiritual routines such as prayer, yoga or meditation
  • Encouraging them to identify and reflect on hope-filled mantras, positive imagery and stories of overcoming adversity

Says Shannonhouse, “Counselors don’t need to identify as religious or spiritual themselves in order to utilize the assessment [S.O.U.L.S.] and intervention [C.H.A.T.] strategies included in SFA. Nor do they need to be well-versed in the survivor’s faith tradition or spiritual beliefs. An attitude of humility, curiosity, empathy and acceptance is what is important, rather than coming in as the mental health expert who has all the answers.

“Joining with survivors and entering into their experience is the key to the therapeutic presence offered by SFA. This model provides a framework for talking about and exploring how the disaster has impacted a survivor’s sense of well-being and helps providers critically consider ways to connect survivors with spiritual resources that are in line with their faith tradition to help facilitate grief, adjustment and restoration of stability.”

Spiritual first aid isn’t just for counselors or other mental health professionals. Clergy and other professionals and volunteers such as emergency management professionals, humanitarian aid workers, first responders, and health and public health professionals may also find it helpful, Shannonhouse notes.

Resilience and growth

Helping people with the immediate negative aftermath of a disaster is important, but it is also crucial to note survivors’ capacity for resilience and growth, say Lawson and Mascari.

“Human resilience is amazing,” says Mascari, who studies disaster response and co-edited the third edition of the ACA book Terrorism, Trauma and Tragedies: A Counselor’s Guide to Preparing and Responding with Jane Webber. “People come out of disasters feeling stronger.”

Adds Lawson, “We focus an awful lot on posttraumatic stress, but there is also the potential for posttraumatic growth.”

Survivors of disasters often emerge with a new appreciation for life, value their relationships in a new way, feel a new sense of community or are strengthened spiritually, Lawson explains. In some instances, survivors even experience a renewed sense of power and purpose that they devote to a cause related to the disaster.

Lawson notes that the organization Mothers Against Drunk Driving emerged out of traumatic experiences. “They could have stayed in the victim stage, feeling helpless and distressed,” Lawson says, “but those people connected with others who had been through the same thing and resolved to do something about it.”

Shannonhouse points to the concept of spiritual fortitude. “Spiritual fortitude is … a process of facing adversity in which one intentionally engages redemptive narratives and the sacred in order to metabolize the difficulty of suffering and loss. Spiritual fortitude does not imply conquering adversity or returning to a state of previous functioning, nor is it simply enduring suffering. Rather, spiritual fortitude is about leaning into the suffering and undertaking virtuous action.”

Counselors can help encourage posttraumatic growth by assisting clients with the meaning-making process, say Shannonhouse and Captari.

“Invite them to view their present adversity from a transcendent perspective,” Captari suggests. “Ask them to think about how their life is part of something bigger.” Counselors can also help survivors create a “spiritual life map” or history to rediscover insights, strengths and resources that they have gained from their beliefs over the life span.

When people experience posttraumatic growth, it can allow them to say, “I’m not a victim. I didn’t just survive, I thrived,” Lawson concludes.

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

ACA Disaster Mental Health webpage (counseling.org/knowledge-center/trauma-disaster)

Includes information on the U.S. Substance Abuse and Mental Health Services Administration’s Disaster Distress Helpline and 15 fact sheets compiled by the ACA Traumatology Interest Network covering topics such as one-to-one crisis counseling, disaster and trauma responses of children and parents, helping survivors with stress management skills, grief reactions over the life span and intrusive memories.

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • Terrorism, Trauma and Tragedies: A Counselor’s Guide to Preparing and Responding, third edition, edited by Jane Webber & J. Barry Mascari

ACA Interest Networks

 

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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

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Nonprofit News: Would the Founding Fathers have supported nonprofits and nationalized health care?

By “Doc Warren” Corson III July 24, 2017

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I’ve heard a lot about the Founding Fathers the past few years, and given that we celebrate American independence in July, I thought it would be fitting to explore what they might have thought about this work of ours as counselors working in the nonprofit space.

There are many theories about what our Founding Fathers would say or do nowadays. Some of these theories are fascinating, while others appear to be little more than fiction, but at least they appear to attempt to look back at our nation’s founding to find guidance for our present and future.

I don’t claim to know what the founders wanted, especially as it relates to mental health care, which was poorly understood at the time. In fact, if poor mental health resulted in someone straying a little too far from the societal norms of the day, that person ran the risk of being accused of demonic possession. I mean, physical health care at the time promoted bloodletting and the use of leeches (which have seen a limited return in recent years), so in many ways, our Founding Fathers were living in primitive times. Still, they set about developing a living, breathing set of documents that they hoped would transcend time and grow with the needs of those they served.

One of the key phrases in the Declaration of Independence calls for the right to life, liberty and the pursuit of happiness. Could it not be argued then that the Founding Fathers would support any enterprise, public or private, that seeks to help ensure everyone’s right to a quality life and the ability to live freely and happily (so long as it does not legitimately impinge on another’s right)? Would health care not be a vital part of a right to life and liberty?

Think about this for a minute. If one has a right to life, one surely must have a right to health because, without health, life cannot sustain itself for long, not while also including liberty. One cannot be at liberty if he or she is needlessly allowed to become and remain infirm until death.

If we have a right to life, is that right confined only to those who possess an endless ability to pay for it? Should it be? As of 2009, 58 countries had some sort of national health care system in place, meaning that all of their citizens had access to health care regardless of income, status and so on. As wise as the Founding Fathers were, surely they would welcome such an endeavor, right?

This conclusion can of course be argued. In fact, unless we have some kind of message from at least one of the Founding Fathers related to this, it remains little more than conjecture. Thankfully, with just a small bit of research, I found several such messages. Although other founders may have spoken along the same lines, I decided to end my search after the first three attempts proved fruitful.

Thomas Jefferson dedicated at least part of his life to the improvement of health care. From 1784-1789, he worked on a committee to reform the public health care system in Paris. He was also a friend of the Marquis de Condorcet, who among other things proposed national health care. This in and of itself looks promising in the support of publically supported systems, although I could not find anything where Jefferson actually supported such a system in America (honestly, I spent very little time trying, however).

Thomas Paine, the author of Common Sense, was an inspirational figure in the United States’ move for independence from Britain. In another of his works titled Agrarian Justice, he wrote about what could be termed social security or a safety net. He proposed that men, starting at age 21, should be given 15 pounds sterling, whereas any man 50 or older would be given 10 pounds yearly. This would be paid for by what essentially would be a tax on land. This money would go to qualified individuals, regardless of income or health. He stated that he felt it was a right, not a charity.

Here we have one of the most influential figures in the founding of America talking about the need for a shared system of support for all male citizens. (In Paine’s time, women were seen as needing the support of men in order to live. Support to men would also support their families. Thankfully, we have progressed). This money was to go to support the needs of the man as he saw fit. It’s reasonable to assume that this would include such things as food, shelter, clothing and health care.

John Adams perhaps said it best in the Constitution of Massachusetts (article VII) in 1780:

“Government is instituted for the common good; for the protection, safety, prosperity and happiness of the people; and not for the profit, honor or private interest of any one man, family or class of men: Therefore the people alone have an incontestable, unalienable and indefeasible right to institute government; and to reform, alter or totally change the same, when their protection, safety, prosperity and happiness require it.”

Adams called for government to be concerned with all men of any class and for the need to alter or reform laws when required. As time moves forward, needs and priorities change. Hopefully, with these changes come increased insight and understanding. For instance, as we discovered the cause of certain illnesses, we started to learn how to treat them. Prevention and treatment went hand in hand in many ways. Soon a new school of thought emerged and with it, the modern idea of medicine (including mental health care).

Because of the space constraints of this column, I did not delve into other Founding Fathers, but I hope that someone else does and adds to this discussion. Based solely on my reading of the Declaration of Independence and other related documents, my bet is that the Founding Fathers would have supported the notion that this country was set up to be a commonwealth — one that shares its good fortune and prosperity with all within its borders — because they seemed to understand fully that the longevity of any endeavor is dependent on investment in its infrastructure.

 

I have a humble suggestion the next time that someone questions the importance of your, or any other, counseling nonprofit and its role in helping the citizens of this great country of ours. Simply say, “If Thomas Jefferson, Thomas Paine and John Adams felt it was important for the government and its people to help one another, who am I to argue?”

Nonprofits: Real people, real change.

 

The Thomas Jefferson Memorial in Washington D.C.

 

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Dr. Warren Corson III

“Doc Warren” Corson III is a counselor, educator, writer and the founder, developer, and clinical and executive director of Community Counseling Centers of Central CT Inc. (www.docwarren.org) and Pillwillop Therapeutic Farm (www.pillwillop.org). Contact him at docwarren@docwarren.org. Additional resources related to nonprofit design, documentation and related information can be found at docwarren.org/supervisionservices/resourcesforclinicians.html.

 

 

 

 

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

ACA advocates for Medicare bill on Capitol Hill

By Bethany Bray July 20, 2017

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ACA leaders gather for a day of advocacy on Capitol Hill on July 18. (Photo by Paul Sakuma)

A bill that would allow professional counselors to be reimbursed for the treatment of clients under Medicare has been introduced in the House of Representatives, and more than 100 counseling professionals added to its momentum by advocating in person on Capitol Hill earlier this week in an event organized by the American Counseling Association (ACA).

Currently, Medicare does not reimburse licensed professional counselors (LPCs) for the treatment they provide for older adults who carry this federal insurance coverage. However, ACA is advocating for a bill that would add LPCs to the list of providers who can be reimbursed under Medicare – a list that already includes clinical social workers and marriage and family therapists. H.R. 3032 was introduced last month by Rep. John Katko (R-N.Y.) in the House of Representatives, and a companion Senate bill is expected to be introduced shortly by Sen. John Barrasso (R-Wyo.) and co-sponsored by Sen. Debbie Stabenow (D-Mich.).

H.R. 3032 currently has three co-sponsors: Reps. Mike Thompson (D-Calif.), Elise Stefanik (R-N.Y.) and Zoe Lofgren (D-Calif.). If passed, the measure would add an estimated 165,000 mental health providers to the Medicare network, providing much-needed access to care for older adults in the United States.

On July 18, 125 ACA members from across the United States visited the Capitol Hill offices of their senators and House representatives to ask for support for the Medicare bill. The counselors were gathered in Washington, D.C., for ACA’s annual Institute for Leadership Training (ILT), a four-day conference of education sessions, trainings and business meetings for leaders in the counseling profession.

“In the United States, exercising our First Amendment rights under the Constitution is vitally important to ensure that we have a strong and responsive government,” said ACA Director of Government Affairs Art Terrazas. “I am so happy that we were able to help ACA leaders from across the country meet and speak with their federal lawmakers about the needs of the counseling profession.”

Amanda DeDiego, an ACA member from Casper, Wyoming, talks with Sen. John Barrasso (R-Wyo.) in his Capitol Hill office. (Photo by Bethany Bray)

Amanda DeDiego, an ACA member from Casper, Wyoming, met with Sen. Barrasso to thank him for his upcoming sponsorship of the Medicare bill. Barrasso expressed his support for the issue, saying “the needs are great” in Wyoming. For example, the average life expectancy on Native American reservations is 47 years – decades below that of Wyoming’s general population – and issues related to mental health are part of the cause, Barrasso said.

A delegation from the American Counseling Association of New York (ACA-NY) met with staff in the office of Sen. Kirsten Gillibrand (D-N.Y.) to ask for co-sponsorship of the bill that Barrasso soon will introduce in the Senate.

ACA-NY leaders Summer Reiner, Allison Parry-Gurak and Tiphanie Gonzalez (ACA-NY president) explained that LPCs have training and graduate coursework that is equal to or exceeding that of the social workers and other mental health practitioners currently covered under Medicare. In the rural parts of New York, a dearth of mental health providers already exists, and that number shrinks further for people who rely on Medicare coverage for treatment, Reiner explained.

“There’s a huge need,” said Reiner, an associate professor at the State University of New York (SUNY) in Brockport and ACA-NY past president. “There are more than enough clients to go around, and we all have a different perspective for a reason.”

“We’re very much cousins in the exact same family, with different specialties,” agreed Gonzalez, an assistant professor at SUNY Oswego.

ACA members who visited legislative offices on July 18 also advocated for full funding of the Title Four block grant as part of the Every Student Succeeds Act (ESSA). The grants, some of which goes to support school counseling programs, were funded at $400 million, or just 25 percent of the $1.6 billion that was authorized this year. President Trump’s proposed budget for 2018 recommends no funding for the block grant at all.

Terrazas, in a training session held prior to the Day on the Hill event, urged the assembled ACA leaders to follow up with their legislators, stay informed and continue pushing for issues that are vital to the counseling profession.

“Advocacy doesn’t start and end with just this day [on Capitol Hill] tomorrow; it is year-round,” said Terrazas.

 

ACA members from Louisiana speak with staff in the office of Congressman Steve Scalise (R-La.) on July 18. (Photo by Bethany Bray)

 

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By the numbers: ACA Day on the Hill 2017

125 ACA members from 37 states, plus the District of Columbia, U.S. Virgin Islands and Puerto Rico, visited 74 Senate offices and 95 House offices

ACA President Gerard Lawson also met with

  • James Paluskiewicz, staff, House Committee on Energy and Commerce
  • Nick Uehlecke, staff, House Committee on Ways and Means
  • Allison Steil, deputy chief of staff, U.S. House Speaker Paul Ryan (R-Wis.)
  • Wendell Primus, office of House Minority Leader Nancy Pelosi (D-Calif.)

 

Cynthia Goehring and Sarah Shortbull, ACA members from South Dakota, met with Sen. John Thune (R-S.D.) on July 18. (Photo by Paul Sakuma)

 

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ACA awards Murray, Lieu

ACA has recognized Rep. Ted Lieu (D-Calif.) and Sen. Patty Murray (D-Wash.) with an Illumination Award for their work against harmful conversion therapy. Lieu and Murray have introduced bills in the House and Senate, respectively, that would classify commercial conversion therapy and advertising that claims to change sexual orientation and gender identity as fraud.

An ACA delegation met Murray on July 18 to recognize her on Capitol Hill; Lieu was previously honored at last month’s Illuminate symposium, a three-day conference in Washington, D.C., focused on the intersection of counseling and lesbian, gay, bisexual, transgender, questioning or queer (LGBTQ) issues.

Sen. Patty Murray (center left, in grey suit) is given an ACA Illumination Award on July 18 by ACA Past President Catherine Roland, current ACA President Gerard Lawson and ACA President-elect Simone Lambert, along with ACA members from Washington state. (Photo by Paul Sakuma)

 

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To stay up-to-date on the Medicare bill and other current issues, sign up for updates from ACA Government Affairs at counseling.org/news/aca-blogs/aca-government-affairs-blog

 

Search for the hashtag #ACAILT2017 for social media posts from ILT and the Day on the Hill

 

See more photos on the ACA flickr page: flickr.com/photos/23682700@N04/albums/72157686345016025

 

A delegation from the American Counseling Association of New York (left to right) Tiphanie Gonzalez (ACA-NY president), Summer Reiner and Allison Parry-Gurak met with staff in the office of Sen. Kirsten Gillibrand (D-N.Y.) to ask for cosponsorship of the Medicare bill that Sen. Barrasso will soon introduce in the Senate. (Photo by Bethany Bray)

 

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

 

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