Monthly Archives: October 2017

A protocol for ‘should’ thoughts

By Brandon S. Ballantyne October 31, 2017

As a licensed professional counselor, I believe that cognitive behavior therapy (CBT) offers clients a natural platform to gain insight into the relationship between thoughts and emotions. Using cognitive behavioral techniques, I invite clients to explore the specific nature and content of their thoughts and examine the ways in which these thoughts influence emotional distress.

Through CBT-oriented trial and error, thought records and behavioral experiments, clients can develop a comprehensive tool belt for responding to stressful events in a self-structured and practical manner. The active identification and disputation of negative thinking leads to improved emotional states and healthier behavioral reactions. I often introduce this concept as an enhanced version of the common treatment goal of learning how to “think prior to reacting.”

Framework

Before an individual forms an emotion, that individual needs to observe an event. This event can be a person, place, thing or activity. The important criteria here is not what the individual observes but simply the fact that an event has been noticed.

Once an event is observed by the individual, the brain produces a thought. A thought is very different from an emotion. A thought is a statement that is verbalized or experienced silently. A thought has sentence structure. Every thought has punctuation. Some thoughts end in a period. Some thoughts end in a question mark. Some thoughts end in an exclamation mark. It is important for the counselor to offer this education to the client. To experience success with CBT coping tools, it is essential for the client to be able to differentiate between thoughts and emotions.

Once a thought is produced and experienced by the individual, an emotion is formed. I tell my clients that in some cases, it feels as if the emotion occurs before the thought, but CBT tells us this is not exactly true.

Individuals experience emotions as an internal continuum of distress. This means that emotions can fluctuate from low distress to moderate distress to high distress. Most of the time, individuals will experience emotions consistent with mad, sad, glad or fearful. The continuum of emotional distress is often experienced parallel to physical symptoms. In other words, certain emotional states will produce certain physical symptoms. Counselors can assist clients in recognizing which physical symptoms are most typically associated with each emotional state.

For example, the emotional state of mad often occurs parallel to a headache or clenched fists. The emotional state of sad often occurs with tearfulness and internal weight between the stomach and lungs. The emotional state of glad most often occurs with smiling or laughter. The emotional state of fear most often occurs with a rush of adrenaline, quickening heart rate and sweaty palms. Of course, individuals can experience many other emotional labels and physical symptoms, but acquiring this basic education about emotion-body response can enhance our clients’ abilities to more clearly identify what they are feeling at any given time. This also provides clients with another important layer in understanding the difference between thoughts and emotions.

Once an emotional state is experienced, a behavioral reaction will be provoked. A behavioral reaction is simply something that the individual says or does that leads to a desirable or undesirable environmental/social outcome. Behavioral reactions that lead to undesirable outcomes typically create more barriers and perpetuate the cycle of life problems. Positive behavioral reactions lead to desirable outcomes and ignite a cycle of positive change.

The key to all of this is for individuals to identify where they can initiate intervention in their cognitive behavioral processes. Intervention can occur immediately after thoughts or immediately after the formation of the emotion. As long as intervention is implemented prior to the behavioral reaction, then positive change can take place.

Counselors can assist clients in building cognitive behavioral skills through the examination of self-talk. Self-talk is another term used for thought. Because thoughts have sentence structure to them, the sentence content in our thoughts is directly responsible for the formation of emotion.

Certain “words” increase emotional distress when they are experienced within our self-talk. One of the biggest culprits is the word “should.” When individuals experience “should” in their thoughts, it produces an emotional state associated with a demand to achieve extreme standards or ideals. The emotional consequence is likely to be guilt, frustration or depression. When directing their “should” thoughts toward others, individuals are likely to feel anger and resentment.

Protocol/intervention

I have developed the following intervention as a tool that counselors can use with clients consumed with persistent “should” thoughts and who identify unpleasant emotional responses that have led to patterns of undesirable behavioral reactions and environmental/social consequences. The intervention’s goal is to offer a protocol for effective identification, practice, application and implementation of cognitive restructuring, specifically in the context of problematic “should” thoughts.

S-H-O-U-L-D

Say: It is important to encourage the client to verbalize the “should” thought out loud. This brings life to the negative thought process and makes the negative self-talk a concrete, tangible item to work on in the counseling process. It also creates a safe opportunity for the counselor and client to work at restructuring negative internal dialogue within the realm of trust and rapport that they have developed.

Counselor: “Help me understand these should thoughts. I would like to invite you to verbalize them out loud to me.”

Client: “I should not feel depressed. I have no reason to be depressed.”

Hold: It is important for the client to learn to tolerate the distress created from the negative self-talk. The counselor encourages the client to practice tolerating the emotional discomfort through a pause and delay. This creates an opportunity to enhance distress tolerance ability, while engaging in safe examination of the negative self-talk.

Counselor: “There is pressure to react to these emotions. Try not to react. Let’s slow things down so we can address this rationally. I would like you to try and sit with these emotions, in the presence of my support, for as long as you can tolerate. Let’s try to pause and delay a reaction for one to two minutes.”

Client: “I will try my best.”

Offer: The counselor and client engage in a discussion of possible alternative ways of thinking that could potentially lead to more desirable emotional states and healthier behavioral reactions. This is a brief trial-and-error component within the intervention. The counselor will engage with the client in a balanced, rotational practice of coping thoughts.

Counselor: “If we were to remove the word should from your negative self-talk, what can we replace it with that might reduce the emotional pressure that you feel? Let’s discuss all the possibilities together.”

Undo: It is important to identify one coping thought that the client can continue to practice within his or her routine internal dialogue. For example, the counselor might ask the client to write one coping thought on an index card that can be kept in a safe, visual space. This encourages proactive, routine practice of healthier self-talk. It also makes the coping thought a concrete, tangible tool that can be used both in the present and in the future, as needed, in the context of counseling goals.

Counselor: “Which one of the coping thoughts that we discussed today do you feel you could continue to utilize as positive self-talk during future episodes of distress?”

Client: “I have experienced depression for a reason. I have permission to feel how I feel. I am always working on finding ways to cope with my life stressors, and I am doing the best that I can.”

Learn: The counselor and the client identify a homework assignment or task for the client to complete that encourages ongoing utilization of this tool. For example, the counselor might invite the client to begin a thought log, in which the client actively records dates and times when the tool is utilized and how effective it was in reducing emotional distress or contributing to healthier behavioral reactions. This provides opportunities for the client to begin constructing a cognitive behavioral blueprint for effective thought substitution.

Counselor: “I would like to introduce you to an exercise called a thought log. This will provide you with a platform to practice replacing ‘should’ thoughts with more positive self-talk this coming week. Remember, the most effective change takes place when you can take the skills learned in counseling and apply them to situations outside of these office walls.”

Do: Follow-up is essential to the counseling process. If the counselor and client agree on homework assignments or behavioral experiments, it is important for the counselor to follow up with the client to examine the client’s beliefs about what is effective versus ineffective. This holds both the counselor and the client accountable for maintaining diligence and dedication in their roles within the counseling relationship.

Counselor: “In the prior session, we discussed problematic ‘should’ thoughts, and I offered you the assignment of a thought log. How did you do with that?”

Conclusion

As a professional counselor, I am always looking for ways to enhance my practice and also share my interpretation of theories and treatment approaches. I hope that this piece will help you reflect on ways in which you may be able to use a tool such as the one I described with the clients you serve. Through continued consultation, collaboration and publication, mental health professionals can become unified in our mission to initiate genuine counseling processes that contribute to the enhanced well-being of our clients. I would love to hear your feedback on how this CBT tool is working for you and the individuals you serve.

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Brandon S. Ballantyne is a licensed professional counselor and national certified counselor who has been practicing clinically since 2007. He currently practices at Reading Health System in Reading, Pennsylvania, and Advanced Counseling and Research Services in Lancaster. He has a specialized interest in using cognitive theory to help his clients recognize problematic thought patterns and achieve more desirable emotions and healthier behavioral responses. Contact him at Brandon.Ballantyne@readinghealth.org.

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Other articles by Brandon S. Ballantyne, from the Counseling Today archives:

“Assessing ‘ideal’ versus ‘real’ family characteristics with adolescents” https://wp.me/p2BxKN-3Uo
“Where’s Waldo? A creative tool to introduce CBT skills” https://wp.me/p2BxKN-45K
“Helping clients realize their daily potential” https://wp.me/p2BxKN-4lw
“The Social Adventures and Experiments of Tommy Joe Peterson” https://wp.me/p2BxKN-4Bo

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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.

A light in the darkness

By Bethany Bray October 30, 2017

Erin Wiley, a licensed professional clinical counselor in northwestern Ohio, once had a client tell her that seasonal depression was like diving into a deep, dark pond each fall. Wiley understands the comparison. With seasonal depression, “you have to prepare to hold your breath for a long time until you get across the pond, reach the other side and can breathe again,” she says.

Wiley routinely sees the effects of seasonal depression in her clients — and in herself — as summer wanes, with the days getting shorter and the weather getting colder. Ohio can be a hard place to live when daylight saving time takes effect and the sun starts setting just after 4 p.m., she says.

Seasonal depression “feels like a darkness that’s chasing you. You know it’s coming, but you don’t know when it’s going to pin you down,” says Wiley, a member of the American Counseling Association. “[It’s like] getting pinned down by a wet blanket that you just can’t shake, emotionally and physically. … For those who get it every year, you can have anxiety because you know it’s coming. There is a fear, an apprehension that it’s coming. [You need] coping skills to have the belief that you have the power to control it.”

For Wiley, the owner of a group practice with several practitioners in Maumee, Ohio, this means being vigilant about getting enough sleep and being intentional about planning get-togethers with friends throughout the winter months. Keeping her body in motion also helps, she says, so she does pushups and lunges or walks a flight of stairs in between clients and leaves the building for lunch. If a client happens to cancel, “I will sit at a sunny window for an hour, feel the sun on my face, meditate and be mindful,” she adds.

Seasonal depression, or its official diagnosis, seasonal affective disorder (SAD), can affect people for a large portion of the calendar year, Wiley notes. Although there is growing awareness that some people routinely struggle through the coldest, darkest months of the year, it’s less well-known that it can take time for these individuals to start feeling better, even once warmer weather returns in the spring. According to Wiley, seasonal depression can linger through June for her hardest-hit clients.

“It takes that long to bounce back,” she says. “They’re either sinking into the darkness or coming out of it for half the year.”

Symptoms and identifiers

SAD is classified as a type of depression, major depressive disorder with seasonal pattern, in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. According to the American Psychiatric Association, roughly 5 percent of adults in the U.S. experience SAD, and it is more common in women than in men. The disorder is linked to chemical imbalances in the brain caused by the shorter hours of daylight through the winter, which disrupt a person’s circadian rhythm.

People can also experience SAD in the reverse and struggle through the summer, although this condition is much rarer. Wiley says she has had clients who find summers tough — especially individuals who spend long hours inside climate-controlled, air-conditioned office environments with artificial lighting.

Regardless, a diagnostic label of SAD isn’t necessary for clients to be affected by seasonal depression, say Wiley and Marcy Adams Sznewajs, a licensed professional counselor (LPC) in Michigan. Sznewajs says that SAD isn’t a primary diagnosis that she sees often in her clients, but seasonal depression is quite common where she lives, which is less than 100 miles from the 45th parallel.

“I live in a climate where it is prevalent. I encounter it quite a bit and, surprisingly, people are like ‘Really? This makes a difference [with mental health]?’” says Sznewajs, an ACA member who owns a private practice in Beverly Hills, Michigan, and specializes in working with teenagers and emerging adults. “We change the clocks in November, and it’s drastic. It gets dark here at 4:30 in the evening, so kids and adults literally go to school and go to work in the dark and come home in the dark.”

Likewise, Wiley says that she frequently sees seasonal depression in clients who don’t have a diagnosis of SAD. “I notice it with my depressive clients,” she says. “I have been seeing them once a month [at other times of the year], and they ask to come in more often during February, March and April, or they need to do more intensive work in those months. It’s rare for someone to be healthy the rest of the year and struggle only in the winter. It’s [prevalent in] people who struggle already, and winter is the final straw. They need extra help in the winter and reach out [to a mental health professional] in the winter.”

In other instances, new clients begin to seek therapy because life events such as the loss of a job or the death of a loved one push them to a breaking point during a time of the year — typically winter — when they already feel at their lowest, Wiley notes.

Cindy Gullo, a licensed clinical professional counselor in O’Fallon, Illinois, says that she doesn’t encounter clients who have the SAD diagnosis very often. However, she says that roughly 2 out of every 10 of her clients who have preexisting depression experience worsening mood and exacerbated depression throughout the fall and winter months.

The symptoms of SAD mimic those of depression, including loss of interest in activities previously enjoyed, oversleeping and difficulty getting out of bed, physical aches and pains, and feeling tired all of the time. What sets seasonal depression apart is the cyclical pattern of symptoms in clients, which can sometimes be difficult to see, Sznewajs says. If a client presents with worsening depressive symptoms in the fall, counselors shouldn’t automatically assume that seasonal depression is the culprit, she cautions. Instead, she suggests supporting the client through the winter, spring and summer and then monitoring to see if the person’s symptoms worsen again in the fall.

“If they show improvement [in the spring/summer], and then I see them in October and they start to slide again, that’s when I have to say it could be the season. And certainly if they point it out themselves — [if] they say, ‘I’m OK in the summer, but I really struggle in the winter.’ It’s really when you start to notice a pattern of worsening mood changes in November and December [that alleviate] in the summer.”

Sznewajs recalls a female client she first worked with when the client was 13. She saw the client from October through the end of the school year, and the young woman showed significant improvement. The client checked in with Sznewajs a few times during the summer, but Sznewajs didn’t hear from her much after that. Then, when the client was 16, she suddenly returned to Sznewajs for counseling — in the wintertime. In recounting the prior few years, the young woman noted that her struggles usually seemed to dissipate around April each year, even though the pressures of the school year were still present at that point.

“‘I don’t know what’s going on with me,’” Sznewajs remembers the client remarking. “‘I’m a mess right now.’ It was very evident that there was a pattern [of seasonal depression] with her.”

Wiley notes that clients with seasonal depression often describe a “heaviness” or feelings of being weighed down. Or they’ll make statements such as, “It’s just so dark,” referring both to the lack of sunlight during the season and the emotional darkness they are enduring, Wiley says.

Gullo, an ACA member and private practitioner who specializes in working with teenagers, keeps an eye out for clients who become “very flat” and engage less in therapy sessions in the fall and winter. Other typical warning signs of seasonal depression include slipping grades (especially among clients who normally complete assignments and are high achievers at school), changes in appetite, sluggishness, weepy or irritable mood, and withdrawal from friends and family. For teens, the irritability that comes with seasonal depression can manifest in anger or frustration, Gullo says. For example, young clients may have an outburst or become agitated over small things that wouldn’t bother them as much during other times of the year, such as a parent telling them to clean their room, Gullo says.

John Ballew, an LPC with a solo private practice in Atlanta, estimates that up to one-third of his clients express feeling “more grim,” irritable or unhappy as winter approaches. He contends that the winter holidays “are a setup to make things worse” for clients who are affected by the seasons.

Overeating and overconsumption of alcohol are often the norm during the holidays, and this is typically coupled with the magnification of family issues through get-togethers, gift giving and other pressures, notes Ballew, a member of ACA. In addition, many coping mechanisms that clients typically use, such as getting outside for exercise, may be more difficult to follow in the winter. And although many people travel around the holidays, that travel is often high stress — the exact opposite of the getaways that individuals and families try to book for themselves at other times of the year.

“It’s a perfect storm for taking the ordinary things that get in the way of being happy and exacerbating them,” Ballew says. “People feel heavily obligated during the holidays, more so than in other seasons. It means that we’re not treating ourselves as well, and that can be a problem.”

[For more on helping clients through the pressures and stresses of the holiday season, see Counseling Today‘s online exclusive, “The most wonderful time of the year?“]

In the bleak midwinter

The first step in combating seasonal depression might be normalizing it for clients by educating them on how common it is and explaining that they can take measures to prepare for the condition and manage their feelings.

“Educating [the client] can give them control,” Sznewajs says. “People often feel shame about depression. Explain that you can take steps to treat yourself, just like you would for strep throat. You can’t will yourself to get better, but you can do things to help yourself get better. When you know what’s causing your depression, it gives you power to take those steps.”

Ballew notes that many of his clients express feeling like a weight has been lifted after he talks to them about SAD. “Many of them won’t think they have [SAD], but they will say, ‘Winter is a hard time for me’ or ‘I get blue around the holidays.’ They’re caught off guard by this unhappiness that seems to come from nowhere. People seem to feel a certain amount of relief to find that it’s something they will deal with regularly but that they can plan for and be cognizant of. It doesn’t mean that they’re defective or broken. It’s just that this is a stressful time. That helps us take a more strategic and problem-solving approach.”

Many counselors find cognitive behavior therapy (CBT) helpful in addressing seasonal depression because it combats the constant negative self-talk, catastrophizing and rumination that can plague these clients. CBT can assist clients in turning around self-defeating statements, finding ways to get through tough days and taking things one step at a time, Sznewajs says.

Gullo gives her teenage clients journaling homework (she recommends several journaling smartphone apps that teenagers typically respond well to). She also encourages them to maintain self-care routines and social connections. For instance, she might request that they make one phone call to a friend between counseling sessions.

Wiley guides her clients with seasonal depression in writing a plan of management and coping mechanisms (or reviewing and updating their prior year’s plan) before the weather turns cold and dark. She types out the plan in session while she and the client talk it over. Then she emails it so that the client will have it on his or her smartphone for easy access. The plans often include straightforward interventions — such as being intentional about going outside and getting exposure to natural light every day — that clients may not think about when dealing with the worst of their symptoms midwinter.

“It sounds simple, but those [individuals] who are down may not realize that the sun is shining and they better get outside to feel it on their face,” Wiley says. “We list exercises that are feasible. You might not join the gym, but what can you do? Can you walk the staircase at your house five times a day? Or, what’s one [healthy] thing you can add to your diet and one thing you can take away, such as cutting down to having dessert once per week, cutting out your afternoon caffeine or drinking more water. And what’s one thing you can do for your sleep routine? [Perhaps] take a hot shower before bed [to relax] and go to bed at the same time every night.”

Wiley also reminds clients to simply “be around people who make you feel happy.” She suggests that clients identify those friends and family members whom they enjoy being with and include those names on their therapeutic action plans for the winter.

All of the practitioners interviewed for this article emphasized the importance of healthy sleep habits, nutrition and physical activity for clients with seasonal depression. “All of these things are really hard to do when you feel lousy, so that’s why the education [and planning] piece is so important,” Sznewajs says. “Let them know that this [the change in seasons] is why you feel lousy, and it’s not your fault. But there are ways to feel better.”

Sznewajs typically begins talking with clients about their seasonal action plans in early fall and always before the change to daylight saving time. One aspect of the discussions is brainstorming how clients can modify the physical activities they have enjoyed throughout spring and summer for the winter months.

One of the cues Wiley uses to tell if clients might be struggling with seasonal depression is if they mention cravings for simple carbohydrates (crackers, pasta, etc.), sugars or alcohol when the days are dark and cold. They don’t necessarily realize that they are self-medicating in
an attempt to boost their dopamine, Wiley says.

Of course, exercise is a much healthier way of boosting dopamine levels. “Exercise is important, but it’s really hard to get depressed people to exercise,” Wiley acknowledges. “Telling them to join the gym won’t work when they just want to cry and lay in bed. So, turn the conversation: What is something you can do? If you already walk your dogs out to the corner, can you walk one more block? Take the stairs at work instead of the elevator, or park farther away from the grocery store.”

Effectively combating seasonal depression might also include counselor-client discussions about proper management of antidepressants and other psychiatric medications. Gullo recommends that her clients who are on medications and are affected by seasonal depression set up appointments with their prescribers as winter approaches. Sznewajs and Wiley also work with their clients’ prescribers, when appropriate, to make sure that these clients are getting the dosages they need through the winter.

Wiley will also diagnose clients with SAD if the diagnosis fits. “For someone who is really struggling and could benefit from [psychiatric] medication, the prescriber is often thankful for a second opinion. It adds weight and clarity to what the client is saying and what the doctor is hearing,” Wiley says. “It also helps the client to have a diagnosis so they don’t just wonder, ‘What’s wrong with me?’ It removes the blame and shame for people who are really struggling.”

Seeking the light

Many factors contribute to seasonal depression, but a main trigger is the reduced amount of daylight in the winter. It is vitally important for clients with seasonal depression to be disciplined about getting outdoors to feel natural light on their faces and in their eyes, Wiley says. She coaches clients to be disciplined about making themselves bundle up and get outside on sunny days or, at the very least, sit in their car or near a window for extra light exposure.

Wiley cautions clients against using tanning beds as a source of warmth and bright light to fend off seasonal depression. However, she acknowledges that she has seen positive results with tanning beds in severe cases of seasonal depression in which individuals were verging on becoming suicidal. In those extreme cases, counselors must weigh the long-term risks of using a tanning bed versus the more immediate risks to the client’s safety, Wiley says.

In addition to encouraging those with seasonal depression to get outdoors, Gullo and Sznewajs have introduced their clients to phototherapy, or the use of light boxes. Roughly the size of an iPad, these boxes have a very bright light (more than 10,000 lumens is recommended for people with seasonal depression) that clients can use at home.

Sznewajs recommends that clients use a light box first thing in the morning for at least 30 minutes to “reset their body,” increase serotonin and boost mood. If a client responds positively to phototherapy, it also serves as an indicator that he or she has SAD (instead of, or in addition to, nonseasonal depression), she notes.

Neither Gullo nor Sznewajs require clients to purchase light boxes. Instead, they simply introduce the idea in session and suggest it as something that clients might want to try. Insurance doesn’t typically cover light boxes, but they can be purchased online or at medical supply stores.

Gullo does keep a light box in her office so she can show clients how it works. She also recommends “sunrise” alarm clocks, which feature a light that illuminates 30 minutes before the alarm sounds. The light gradually becomes brighter and brighter, mimicking the sunrise. Gullo uses this type of alarm clock at home and finds it helpful.

The light box and sunrise alarm clock “are game changers,” Gullo says, “and a lot of people don’t know they exist.”

Powering through

In The Lion, the Witch and the Wardrobe, the second book in C.S. Lewis’ The Chronicles of Narnia series, characters struggle through never-ending cold that is “always winter but never Christmas.” Grappling with seasonal depression can feel much the same way: an uphill battle in a prolonged darkness in which occasions of joy have been snuffed out.

The key to making it through is crafting and sticking to a plan. Sznewajs says she talks with clients in the early fall to help them prepare: Yes, winter is coming, and you’re probably going to feel lousy, but it won’t last forever, and there are ways of getting through it.

“People need to understand that this is a totally predictable kind of concern,” Ballew concurs. “It’s not weak or self-indulgent [to feel depressed]. This is a hard time of year for many people, and you need to plan for it. … We [counselors] are in a great place to validate clients’ concerns, but also help them to strategize beyond them.”

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To contact the counselors interviewed for this article, email:

John Ballew: john.ballew@gmail.com
Cindy Gullo: cindy@cindygullo.com
Marcy Adams Sznewajs: marcy@thriveworks.com
Erin Wiley: erin@willow-center.com

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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

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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: Taking safety seriously: Common issues found in small practices

By “Doc Warren” Corson III October 26, 2017

As a writer, educator and counselor certified in two countries, I find myself consulting with folks all over the globe. I belong to various counseling-related groups and find much inspiration therein. I’ve also found many a post or question that made me cringe. Not because these professionals were less bright, energetic or talented than others, but because it would appear that their educational programs and real-world experiences have been lacking in some key areas that would help ensure not just the highest quality of care but also the highest level of safety for them, their staff members and their clients.

I’m often asked why I write for so many places pro bono, and my reply is simple: I’m trying to give back to the profession that has enabled me to help so many in need while also providing a good life for me and mine. If we fail to feed our profession, if we fail to fill the current training and experiential gaps that currently affect our programing, then the future of the counseling profession will begin to look bleak. Sharing knowledge freely is one of the best ways to make lasting change in our profession.

As you read over the following issues that I have found to be very common, think about how they may apply to you or to someone with whom you work. If they apply, consider ways you can move to improve the situation. We are all on the same team, and we will ALL make mistakes in our work. Let’s do what we can to ensure that when we do make errors, that we remain safe, both physically and from a liability standpoint.

Issue: Having only one staff member working in the office when it is open for business

Concerns: Being the only person in an office (other than clients) increases the risk to a clinician in many ways. It can pose a physical safety risk should a client become physically or sexually threatening. It can pose a health risk should a major health issue such as an injury, heart attack or other collapse occur. It also can make it much harder to defend yourself should a current or former client ever make an accusation against you. Having another staff member available to report that nothing out of the ordinary happened that day and that no signs of impropriety were present can make a difference.

Ways to avoid: Always make it a practice to have at least two people in the office area at all times. This doesn’t mean that you need two clinicians. The people present might be a receptionist, an assistant, interns, a biller or even volunteers. My offices have a system in place to ensure that two people are in every office every day (last-minute health issues notwithstanding). Sometimes the “extra” person is a staff member; other times it is a graduate, doctoral or undergraduate intern or volunteer.

Issue: Not having documentation for services provided, often because you do not work with third-party payers

Concerns: I’ve seen this happen many times over the years. A clinician, often in a small private practice, decides that he or she will not take insurance payments and thus will no longer keep therapeutic records of any kind. Instead, the clinician determines simply to keep a tally of billable hours. I’ve also seen cash-only practices that keep no records whatsoever.

This leaves so many issues that it could be an article unto itself. Treatment record are required regardless of insurance. They are part of the profession and are subject to ethical and legal requirements (see Standard A.1.b., Records and Documentation, of the 2014 ACA Code of Ethics, as well as state and national laws).

Ways to avoid: Avoid going by what another counselor tells you and instead consult the ACA Code of Ethics and applicable laws. Review and use online resources, and develop documentation and a system to keep all records secure. Some free resources can be found here at docwarren.org/images/Documentational_Requirements_for_Practice.pdf and docwarren.org/supervisionservices/resourcesforclinicians.html.

Issue: Little to no prescreening of clients

Concerns: Without proper screening, you risk accepting clients with needs that are beyond the scope of your practice, knowledge, experience and education. This lack of screening can lead to safety issues, such as in a case in which the client is potentially violent. It also can lead to wasted session times and time-consuming referral services and follow-up that could have been avoided with a simple screening.

Ways to avoid: Use a prescreening form and process at the time of first contact with potential clients to ensure that they are a good fit for your program. If they are, schedule them accordingly. Should they not be a good fit, have a list of more appropriate placements, complete with phone numbers and other contact information, at the ready to offer them. This will potentially save hours, both for you and for the prospective client.

Issue: Keeping a clear path between you and the exit

Concerns: In the case of client violence or client physical collapse, having a clear path between you and the office door can greatly increase your chances of a positive outcome. I have consulted with clinicians who were assaulted by clients and found that they had no system in place for keeping a clear path to the door. In addition, they lacked safety training (see below).

Ways to avoid: Furniture placement can do wonders to increase safety in an office environment. Place “your” chair or other furniture as close to the door as possible, while placing client seating a bit farther from the door (even a few extra inches can make a difference). When greeting or exiting the room with a client, try to be the one to open the door for them. Once the door is open, you can allow them to walk out before you because with the door open, there is less risk. Plus, chances are great that your office opens into a public space.

Issue: Lack of safety training/not knowing what to do if a problem arises

Concerns: In many instances I have consulted on after a clinician has been assaulted, the clinician lacked basic insights into or training for when a problem might arise. Don’t get me wrong — depending on the situation, an injury can result no matter the amount of training a clinician has received, but a lack of knowledge only increases the odds of injury.

Ways to avoid: Depending on the treatment setting, the use of body alarms, comprehensive safety training and awareness exercises can be beneficial. Body alarms may not be needed in the average program, but those who serve violent offenders or those with a history of violence can surely justify the expense. For the average counseling program, consider having someone conduct a safety assessment who is knowledgeable both about safety and your treatment setting. Conduct regular in-service trainings and exercises, and make basic skill training part of new employee orientation. The few hours and few dollars spent can make a huge difference.

Issue: No way to communicate to other staff should an emergency arise

Concerns: Some nonprofit counseling programs are small, with just a few offices that share common walls. Other programs have large campuses that utilize different buildings or are spread across multiple acres, making it difficult (if not impossible) to hear a staff member in distress and in need of assistance.

Ways to avoid: Have a means of communication in place for all employees based on the office or campus setup. In our programs, staff members use handheld walkie-talkies whenever they are out of range of the reception or other high-traffic areas. These radios are only used in the event of an emergency, so there is little worry of intrusion or distraction. Our reception staff always have one with them in their area so that they can call for assistance if needed. Systems can range from about $100 into the thousands, depending on the number of handsets needed and type of system.

Issue: No receptionist or other staff in the waiting area

Concerns: Often, treatment records, schedules, cash boxes and other vital information are stored at the reception desk. Failure to keep this station manned can lead to theft of charts, especially if a volatile legal case (such as a divorce or custody hearing) is going on that involves one of your clients. An unmanned reception area can also lead to the loss of valuable property, folks wondering around the building and interrupting sessions, and a host of other issues.

Years ago, two different local programs contacted me about potentially wanting to partner on a few projects with my program. Both had great credentials, and as the program director, I decided to explore the options. If nothing else, I figured they could be referral sources. One day, I had a last-minute cancellation and decided to visit the programs.

At the first one, I found the door unlocked and the reception area deserted. I was able to roam the halls and noticed no white noise machines or other means of ensuring privacy. I also found confidential mail in plain view next to a few office doors.

I was greeted by much of the same at the second program, in addition to unlocked chart cabinets and confidential information sitting on top of a desk. The desk was also unlocked, as evidenced by several partially open drawers. Needless to say, I passed on any possible partnerships or referrals.

Ways to avoid: Keep cabinets locked and valuables secured when not in use. Hire staff or take on interns and volunteers whenever needed and train them on privacy laws, safety and securing documentation.

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Although this article is far from comprehensive, it highlights some of the more commonly found safety issues in smaller programming. Do what you can to keep your nonprofit program running smoothly while addressing safety and liability concerns. With a bit of prevention and an eye toward being proactive, we can do much to lower our liability and keep ourselves (and our staff members and clients) safer. People are counting on us.

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Nonprofit News looks at issues that are of interest to counselor clinicians, with a focus on those who are working in nonprofit settings.

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.

Making the counseling profession more diverse

Compiled by Laurie Meyers October 25, 2017

For many years, white men were presented as the face of the counseling profession and largely dictated its focus and direction. The American Counseling Association (originally known as the American Personnel and Guidance Association) was founded in 1952. Nineteen of its first 20 presidents — many of whom went on to become giants in the field — were white men. Given American society during that period, the lack of diversity at the highest levels of leadership wasn’t unusual.

When Thelma Daley was elected in the mid-1970s, she became the association’s first African American president (and only its third female president). Although women began ascending to ACA’s top leadership position on a fairly regular basis over the next two decades, it wasn’t until 1993-1994 that the association elected its second person of color as president — Beverly O’Bryant.

From those modest roots, there is little argument that the profession has grown abundantly in the emphasis it places on multicultural understanding in the practice of counseling. Conference programming, book titles and journal articles, continuing education offerings and other resources regularly address issues of multiculturalism. Updated and comprehensive Multicultural Counseling and Social Justice Counseling Competencies provide professional counselors guidance on working with diverse populations. The Council for Accreditation of Counseling and Related Educational Programs (CACREP) has made social and cultural diversity a core curricular area in the counselor education programs it accredits.

Even as the profession stresses the need for counselors to continually strive for multicultural competence, however, there is a recognition by many that the profession remains challenged in its ability to diversify its professional ranks. Many feel that the counseling profession is still largely dominated by white culture. Others point out that in many areas of the country, clients struggle to find counselors with whom they can identify culturally.

Given these circumstances, Counseling Today asked a number of ACA members who study diversity to share their thoughts — in their own words — on a complex issue: What needs to happen to make the counseling profession more diverse?

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Thelma Daley

ACA fellow Thelma Daley, the first African American president of both the American Counseling Association and the American School Counselor Association

Historically, the counseling profession has not been multicultural. In fact, many are still trying to define multiculturalism. When I became the first African American president of the American School Counselor Association (ASCA) and, a few years later [1975-1976], the first African American president of the American Counseling Association, there were less than 50 persons of color at the conventions. Additionally, not many women were holding key leadership roles. It is amazing to think that the governing board during my presidential term consisted of one white woman, and the remainder were white men, mainly from Southern universities.

Peruse the growth of the many divisions [in ACA], and one gets a picture that counselors from many aspects of life have fought for and are given recognition in an inviting place for expression, growth and development. However, the struggle continues.

We have come a long way, but the door has only been cracked. Institutional prejudice has not gone away. In fact, it has been awakened from its soporific state. More than ever, the profession is needed, and all racial/ethnic groups should have access to high-level counseling professionals with whom they can relate freely.

There is a need to survey the hiring practices, the working conditions and the pay, which might be repelling forces for those who might want to consider the profession.

People gravitate to where they see others who are like them. A stumbling block might be finding the means to recruit cadres of underrepresented populations and offering them the training and work sites with supervision, similar to AmeriCorps. A bold, creative step is needed. As we seek new populations, remember that we add and do not discard. Build upon the progress we have made. Whatever is done should involve a broad spectrum of professionals and citizens. The concern is beyond just counselor educators. Even the terminology used by the helping professions may rebuff some cultures.

In spite of the perceived deficiency, the association and the overall profession have truly advanced in making commendable strides toward inclusion and diversity. A laudatory foundation is in place that should make the forward thrust possible and achievable. It is my belief that most active members are open and ready to move beyond the status quo and will seek to enjoy and be enhanced by the amalgamation of rich new cultures of this wonderful world. Let us take a giant step and never shy away from expanding the realms of diversity within this great profession.

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Selma de Leon-Yznaga

Selma de Leon-Yznaga, past president of Counselors for Social Justice, founder of Texas Counselors for Social Justice, associate professor of counselor education at the University of Texas Rio Grande Valley and an expert on ethnic identity development and student success, issues surrounding Latina/o immigration, acculturation distress and racial discrimination

Confirming the representation of diversity among counseling students and professionals continues to be a challenge, despite our professed commitment to multiculturalism. CACREP reports some demographics in its yearly Vital Statistics Report, although this data is collected inconsistently by counselor education programs, especially for applicants not accepted and students who don’t complete the program. In addition, ethnicity is the only attribute assessed systematically, with little data available on students with disabilities, sexual orientation or transgender identification. If we aren’t even asking about and reporting it, it can’t be a surprise that students and professionals of ethnic and cultural diversity continue to be underrepresented in our programs and profession.

CACREP reported a slight increase from 2012 to 2015 in master’s-level enrollment by aggregated non-Caucasian students (38.81 percent and 39.45 percent, respectively). However, the graduation rate for total students enrolled in CACREP master’s programs was only 30 percent in 2015. It’s not clear how many of the 70 percent who didn’t complete [their programs] were ethnic minorities.

Enrollment of doctoral students in our programs narrows the diversity gap further: 41 percent and 46 percent of students in 2012 and 2015 were non-Caucasian. Again, the completion rate is disappointing: 16 percent (2012) and 18 percent (2015). Unfortunately, CACREP doesn’t provide disaggregated data by ethnicity for graduates; we have no way of knowing which share of noncompleters ethnic minority students comprise.

Faculty diversity rates in counselor education programs suggest that ethnic minorities in doctoral programs are not graduating at the rate of enrollment. Only 25.6 percent of the [counselor education and supervision] faculty reporting to CACREP in 2015 were ethnic minorities. With only one quarter of our faculty members reflecting the demographics of almost half of our master’s and doctoral students, it might be that students of color don’t feel a sense of belongingness or acceptance.

The counseling profession was developed by and for the American dominant culture (male, white, heterosexual, cisgender, nondisabled). In our counselor education programs, we continue to disseminate theories written for and normed on the dominant culture, despite rapidly changing demographics. More contemporary constructivist and feminist theories tend to be covered in courses as ancillary, not major, theories.

Until we can make counseling meaningful and practical for clients of all demographics,
the marketability of counselors will be low, and we will continue to attract students who represent the dominant cultural group, who in turn will attract clients from the dominant cultural group.

Until we can make counseling a service that is accessible to and valuable for culturally diverse communities, I think we will continue to struggle to attract and graduate diverse students. Until we attract and graduate diverse students, we aren’t likely to develop counseling theory and practice that meet the needs of diverse community members, and so the cycle is perpetuated.

Few people of color have had personal experiences with counseling, other than school counseling. It’s a service that is out of reach for many people of color. Priorities for ethnic minorities who tend to be overrepresented in poverty rates do not include one-on-one mental health counseling. A relatively long-term investment in time and money, counseling does not have an immediate or discernible return for the family. Without the experience or valuing of counseling, it’s hard to attract or interest potential students.

Living and working in one of the nation’s poorest, majority Latinx communities has taught me that counseling services are of little value to those who cannot afford them. Counseling as we currently conceptualize and provide it is a luxury that most in my community can only take advantage of through free social or school-based services. I don’t think we’re that different from other communities with high concentrations of ethnic minorities.

Many of the students in our geographical area are first-generation Americans and college students, and making the significant investment in college requires a commensurate return, whether it be financial or prestigious. Most of our families want their students to major in a discipline that they recognize and value, and that will “pay off” in the long run. The unfamiliarity with counseling is a big obstacle for potential students who usually have to get buy-in from the whole family to make the sacrifices necessary in graduate school.

Socially, a large-scale destigmatization media campaign aimed at ethnic and cultural minorities would educate communities in the process and benefits of mental health counseling. I recall a commercial sponsored by Johnson & Johnson for the nursing profession that ran during prime time on television and gave the public a sense of the multifaceted role of nurses. Making the public aware of our emphasis on wellness, client strengths and a here-and-now orientation might increase our practical value and attractiveness. A rise in public demand and job opportunities in diverse communities would most likely increase interest in counseling program enrollment for students of color and cultural diversity.

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Carlos Hipolito-Delgado

Carlos Hipolito-Delgado, former president of the Association for Multicultural Counseling and Development and associate professor of counseling at UC Denver; his research focuses on the ethnic identity development of Chicanas/os and Latinas/os, the effects of internalized racism, improving the cultural competence of counselors, and the sociopolitical development of students of color

A colleague of mine at University of Colorado (CU) Denver, Diane Estrada, and I were talking about the lack of ethnic diversity in our graduate student body. At the time, we were a faculty of eight, and four of us identified as people of color. Counselor education at CU Denver prides itself on our focus on issues of diversity and social justice. Despite all of this, less than 15 percent of our students identified with a community of color. Dr. Estrada, our graduate assistant, Marina Garcia, and I ran a study [“Counselor education in technicolor: Recruiting graduate students of color,” published in the Interamerican Journal of Psychology] investigating factors that influenced graduate students of color to pursue counselor education.

Over the span of a year and a half, we were able to interview 19 graduate students of color from across the U.S. These students were enrolled in master’s-level and doctoral programs. They also represented private, public and for-profit universities.

There were two primary factors that seemed to influence our participants’ decisions to become counselors: exposure to the counseling profession and commitment to diversity and social justice. Graduate students of color who had been involved with counseling, had family who worked in the helping professions and who themselves worked in related fields described how these experiences pushed them to explore counseling as a career option. What is more, these students also mentioned how they benefited from encouragement from family members and professional mentors.

In terms of commitment to diversity and social justice, participants wanted to work in a career field that would allow them to serve marginalized communities. Further, they were attracted to counselor education programs that demonstrated a commitment to issues of multiculturalism and social justice.

If, as a profession, we are committed to diversifying our ranks, we must do a better job of reaching out to ethnic minority communities. We must educate these communities about the value of mental health, the role counselors play in promoting mental health and how counseling can be a tool for facilitating community empowerment. I would recommend that we target communities of color by creating career education programs to teach youth about counseling, encourage counselors to serve as mentors for youth of color, develop internship opportunities at the high school and college levels to give students of color experience in counseling settings and look to expand our undergraduate course offerings to attract more students of color.

Additionally, if we can continue to show how counselors promote social justice for ethnically diverse communities, we will attract more students. ACA has done a superb job of this this year by issuing statements supporting DACA (Deferred Action for Childhood Arrivals program) and denouncing religious and ethnic discrimination. However, it is also time for counselor education programs to demonstrate this commitment. This goes beyond a diversity statement. It entails having faculty of color in leadership positions, infusing diversity and social justice into all facets of their programs and providing internship experiences with ethnically diverse populations.

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Cirecie A. West-Olatunji

Cirecie A. West-Olatunji, past president of ACA and AMCD, associate professor at Xavier University of Louisiana and director of the Center for Traumatic Stress Research; she has initiated several clinical research projects that focus on culture-centered community collaborations designed to address issues rooted in systemic oppression, such as transgenerational trauma and traumatic stress

There are several possible explanations for this phenomenon [a lack of greater diversity in the counseling profession]. Scholars have documented the implicit bias in academia wherein entering faculty of color and women experience marginalization and bias related to their teaching styles and research agendas. Thus, even when individuals are chosen for faculty positions, they often do not get tenure and leave.

Even more concerning, many doctoral students of color are not groomed to enter the professoriate. As graduate students, they are not selected to participate in research projects with faculty mentors to gain opportunities to apply their classroom knowledge about research in grant writing, dissemination at conferences and in academic journals. Thus, they often do not have competitive CVs [curricula vitae] or noteworthy letters of recommendation from faculty when applying for academic positions.

At the master’s level, students of color are less likely to be mentored by faculty to prepare them for doctoral studies. They are frequently not regarded as doctoral material. Instead, they are considered to lack intellectual capacity or sufficient curiosity.

The Association for Multicultural Counseling and Development (AMCD) has been at the forefront of this issue since the late 1970s. After several heated Governing Council meetings, the Association for Non-White Concerns was formed to highlight the issues of non-white counselors in the association. Later, the name was changed to broaden the scope of the organization. However, this division within ACA has continually advanced discussion and social action regarding the marginalization of groups of individuals within the profession. Most notably, AMCD scholars drafted the Multicultural Counseling Competencies that are widely used today within and beyond mental health disciplines.

Even today, AMCD serves as a haven for ACA members who seek support, advice, validation and increased competence. Most recently, AMCD sponsored the Courageous Conversations panel series that allowed women and men to talk about their unique experiences in counselor education. This was such a successful endeavor that a national webinar series followed. In these sessions, panelists and attendees shared their stories of distress and resilience in the academy as graduate students took notes on what to do and what not to do.

Yes, progress has been made. Despite the need for increased multicultural and social justice competence among white faculty and administrators, in comparison with our sister organizations, ACA has been quite active in pursuing multicultural ideals. First, our CACREP Standards hold counseling programs accountable for providing multicultural training throughout the curriculum. This is not a suggestion as is the case with other disciplines; it is a requirement. Second, for NBCC (National Board for Certified Counselors) accreditation, individuals must demonstrate multicultural knowledge on certification examinations. NBCC has also funded a Minority Fellows Program that has a strong mentoring component to it. Third, [ACA CEO] Rich Yep has established a climate of multicultural acceptance within the culture of the organization. Thus, in the execution of the membership’s wishes, the staff is held accountable for multicultural considerations. This is key and vital to a living, dynamic commitment to multiculturalism. Most of the ACA membership may not be aware how diverse the ACA staff is.

Areas to work on are: 1) increasing the percentage of faculty of color, 2) augmenting the percentage of doctoral candidates prepared to assume faculty positions, 3) ensuring that graduate students and early career professionals of color are mentored appropriately to afford them the opportunity to engage in leadership and research experiences, and 4) connecting with minority-serving institutions (historically black colleges/universities, Hispanic-serving institutions and tribal colleges) to access larger populations of graduate students and faculty of color.

The major obstacle to increasing multiculturalism in counseling is structural bias. Until we are able to assist individuals in unpacking their implicit biases toward socially marginalized individuals, it will be difficult to make any significant headway in advancing multicultural competence or expanding opportunities for women and individuals of color in counselor education. This refers to ideological as well as interpersonal differences. Thus, even white faculty who advance critical concepts such as social justice in counseling are likely to be marginalized. In essence, our ideal goal is to flip the switch and establish diversity as the mainstream normative value and marginalize cultural hegemony (i.e., Eurocentrism, including white masculinity as dominant) within our profession. It’s a tall order but possible within what’s left of even my lifetime.

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Manivong Ratts

Manivong Ratts, past president of Counselors for Social Justice, chair of the committee that developed the Multicultural and Social Justice Counseling Competencies and associate professor of counseling at Seattle University, where he runs the Social Justice Research Lab

To understand the lack of diversity in the counseling profession, one must examine the root of the problem. Higher education, and counselor education by extension, has largely been a predominately white institution. As such, institutions and programs continue to use admission criteria that advantage applicants from privileged groups over applicants from marginalized groups.

For example, graduate programs continue to look favorably at applicants who have volunteer experience. However, being able to volunteer is a luxury that is not always available to applicants who live in poverty. Such applicants sometimes work multiple jobs and, therefore, may not have extra time to volunteer. Many graduate counseling programs continue to also use the Graduate Record Examination (GRE) as admission criteria. Yet, research has shown the cultural bias inherent in GRE scores. Most in the professoriate in counseling are also white. There is a tendency for people to admit applicants who look like them because such applicants make them feel comfortable.

Counselor education programs continue to use admission protocols that fail to reach communities of color. For example, many counselor education programs fail to recruit in communities where people of color reside. It is much easier for faculty to hold admissions fairs on university campuses instead of in the communities where applicants of color reside. In addition, counselor educators, many of whom are white, continue to lack understanding that recruiting applicants of color into their programs is just part of the challenge. Programs must focus on retention as much as they focus on recruitment. This requires programs to evaluate whether current structures that are in place favor white students over students of color. For example, teaching students of color who intend to return to their communities counseling theories that are individualistic in nature may lead such students to question the relevance of their training.

Many counselor education programs [also] fail to focus on the unique training needs of students of color. Programs must understand how being a member of a marginalized group shapes the counselor experience differently for counselors of color. Being able to address this issue will better prepare counselors of color for their work.

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Shabnam Etemadi Brady

Shabnam Etemadi Brady, a doctoral counseling psychology student at Tennessee State University in Nashville who studies and works with immigrants and is herself an immigrant to the United States

From a master’s program in clinical mental health counseling to a doctoral program in counseling psychology, I have been the token Middle Eastern, immigrant, ethnic minority woman surrounded by mostly Caucasian peers and colleagues. One of the greatest barriers I faced in applying to and considering graduate programs in counseling and psychology was that of the GRE. Here I was again post-ACT/SAT experiences, attempting to take another standardized exam that was not created for me; rather, it was standardized on a majority group unrepresentative of me and my background. Thankfully, my grade point average and work ethic supported my competency as a student. However, this process turned me away from considering many master’s and Ph.D. programs. This can be a point for programs to consider when desiring to recruit students of diverse backgrounds, especially bilingual immigrants. The GRE is not always a marker of our success. Inclusivity in application criteria is welcoming.

[Another barrier I] faced and continue to face is the lack of accessibility to the population that I am now specializing in — immigrant and refugee communities. I had to become self-driven in this regard with both graduate programs because they did not have partnerships with agencies serving such diverse populations. Programs can partner with local agencies to expand practicum experiences for students interested in working with diverse populations.

Both of my programs are very welcoming to diversity. They seemed open and excited about my experiences as early as the interview. Additionally, both programs have diverse faculty as part of the program, which aligns with this value and interest. One program had only one diverse faculty member, and she soon became my mentor. My current program has two diverse faculty members who are knowledgeable and in support of multicultural work in mental health.

The greatest support I have received in both programs has been constant encouragement when I have initiated practicum positions with agencies serving the population I am interested in helping. Both programs allowed for me to engage in this clinical work as well as in research concerning immigrants and refugees. They have allowed me to share my experiences in classes, workshops and conferences. Faculty at both programs have vocalized their satisfaction and delight with my work. Thus, their appreciation of work concerning immigrants and refugees in mental health has encouraged my continued efforts in the field.

My cohort in my master’s program consisted mostly of Caucasian students [along] with myself and one African American student. The program has made efforts to increase both diversity in faculty and in students with recruitment strategies. My cohort in my doctoral program consists mostly of Caucasian students, me and three African American students.

I am often surprised to be the only immigrant and the only Middle Eastern student. When I learn about organizations in mental health for Middle Eastern students, I quickly run to join. I often feel isolated, with few people who understand my pursuit of higher education from a collectivist culture. I am a first-generation college and Ph.D. student. Most of my family is thrilled and in complete support of my graduate studies, but they do not always understand what the work entails. I find myself overwhelmed negotiating cultural values (collectivist and individualist) in achieving my dream.

For both of my programs, I have been the expert in immigrant and refugee topics because my programs have been cohort models and not adviser-advisee models (i.e., being matched to faculty who are experts on a student’s research interests). In classroom dialogues, I find myself “teaching” other students about mental health work with immigrants and refugees. Multicultural curriculum needs to be more inclusive of these groups for students and faculty to gain such critical training in mental health fields.

A fundamental resource that I receive as a first-generation college and Ph.D. student is financial support. Both of my programs have helped me secure a graduate assistant position that has partially funded my graduate education. Many immigrant students may endure hardships due to the socioeconomic implications of immigration. Graduate assistant funding can be a form of support and motivation for students from this group to enroll and to succeed in the field of counseling.

Individual counselors and programs can do the following in support and in encouragement of diversity for our field:

Model multicultural competency in your work and demeanor. Ask students/clients how to appropriately pronounce their name(s), what they prefer to be called, and pronounce these correctly. Ask them their preferred pronoun too.
Provide an inviting environment. Display culturally inviting photos of those from different cultures in mental health, a globe or greetings in different languages.
Hear students/clients and support them. I’ve been OK with being the token Middle Eastern, immigrant ethnic minority woman because both of my programs listened to me and supported me. They have shown me that they care about my success through interactions such as meetings, mentoring and resource initiatives for me.
Do not generalize; rather, individualize. Ask diverse students/clients about their experiences without exploiting them for your learning process. Get to know your students. Their stories have value and are often the reason that they are in mental health.
Similar to a therapeutic relationship, promote genuineness, authenticity and a safe space for diverse students to enroll in your program or to succeed. Often, students of diverse ethnic backgrounds feel that we have to blend in with the majority culture [and] that our differences are not appreciated by society in the U.S. Thus, an environment that supports our true selves, inclusive of our ethnicity or culture(s), is rare and appreciated.
Prioritize multicultural competency development and practices. It’s OK to not know how to help those from different backgrounds, but it’s not OK to avoid or isolate this disparity in mental health. Attend trainings, read and expand your learning to reach diverse groups.
Mentor students of diverse backgrounds. If it were not for my mentor, I would never have entered the field of clinical mental health counseling. I always knew I wanted to accomplish a Ph.D. in psychology or mental health, but as I neared the end of my undergraduate studies, I wasn’t sure which programs to consider. Meeting a faculty member from my master’s program who was willing to answer my questions and who believed in me enough to tell me to apply changed my life. From observing my volunteer work with at-risk youth, she said to me, “You are a counselor.” We as therapists and counselors know that words have power. Such encouraging words can be powerful for students who do not always feel welcome, who are first-generation graduate students and who are simply new to the field of mental health.

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Courtland Lee

Courtland Lee, past president of ACA, professor in the counselor educator program at the Chicago School of Professional Psychology’s Washington, D.C., campus and author of numerous books, including Multicultural Issues in Counseling: New Approaches to Diversity

If we are thinking about attracting more people of color to the counseling profession, counselor education programs and the profession in general need to consider a number of socioeconomic and cultural factors.

First, from a very pragmatic perspective, given significant socioeconomic gains for people of color in the last 50-plus years, talented students of color have greater access to financially lucrative careers. While counseling is a noble profession, it does not pay as much as other career paths. This is a real consideration for many potential counseling students of color as they think about their futures.

Second, counselor education programs must consider whether the culture of their program is relevant and welcoming to students of color. Do they feel welcomed at an institution? Do they perceive the counseling curriculum to be relevant to their cultural realities? Do they see people who look like them as successful counseling professionals?

People of color and other economically marginalized groups have historically been underrepresented at college, and especially [at] higher degree levels. Given that the practice-level degree in counseling is a master’s degree, that basic demographic impacts the number of folks from these groups that have had adequate financial and other access to successfully pursuing the degree.

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Lance Smith

Lance Smith, associate professor of counseling at the University of Vermont and author of numerous research papers analyzing diversity issues in the counseling profession

We should address the lack of scholarship that explores levels of diversity among counseling master’s programs, along with the absence of literature identifying effective recruitment and retention strategies for students from underrepresented groups. To the best of my knowledge, there are currently no published articles that have purposefully gathered representation
data for CACREP-accredited master’s degree programs.

A few years ago, my colleagues and I attempted to address this gap by looking at the extent to which CACREP-accredited master’s programs attend to representation of people of color, individuals with (dis)abilities [and] lesbian, gay, bisexual and transgender persons within admissions, enrollment and graduation data (“Attending to diversity representation among CACREP master’s programs: A pilot study” published in the June 2011 issue of The International Journal for the Advancement of Counseling). In a nutshell, we simply wanted to know if programs collect student admission, enrollment and graduation rate data regarding the social identity markers of race/ethnicity, gender identity, sexual orientation and ability status.

We reached out to all 238 CACREP programs at the time, of which 85 completed our entire survey. What we found was that just over half of the responding programs did not retain representative diversity data, and of the programs that did, emphasis was placed on enrollment data and not graduation data. Moreover, most of the data were associated with race/ethnicity only — a little bit being associated with (dis)ability and none of it associated
with sexual orientation or gender nonbinary identities.

So, is this lack of attention to representative diversity an expression of institutional prejudice within the field of counseling? Perhaps not overt, intentional prejudice, but I would suggest covert, complicit prejudice is at play. To quote Paulo Freire, “Washing one’s hands of the conflict between the powerful and the powerless means to side with the powerful, not to be neutral.” If we as counselor educators are not interested in gathering or keeping representative diversity data regarding enrollment, retention and graduation, then we are ignoring the white/straight/cis homogeneity within the profession and, thus, complicit in reinforcing the inequitable status quo.

The importance of retaining the demographic characteristics of accepted applicants who choose not to enroll is also very important when considering issues of recruitment. Counseling programs that maintain this information have access to data that can be very helpful in evaluating their strategies for recruiting diverse students. If such an evaluation reveals a consistent pattern of applicants from underrepresented groups choosing to go elsewhere, faculty need to sit together and discuss what they need to do differently.

In terms of attracting racially/ethnically diverse applicants, the materials that programs use to market their programs have been found to make a difference. There was a study … that found that professional psychology programs that provided materials emphasizing nondiscrimination policies, diversity-based financial aid, commitment to diversity training and recruitment, [and] multicultural minors and that had more racial/ethnic and LGBTQ-specific content attracted greater numbers of racially/ethnically diverse students.

Counselors who work in community counseling agencies can either become members of or form a diversity committee where their primary task is to address a representation of diversity in their agency to ascertain how diverse their staff is and then actively recruit more diverse staff members. This could happen at a community agency [or] it could happen at college centers, which are usually more active with this kind of recruiting. This could even happen in a private practice consortium, where a group of people in private practice are loosely connected. They can form a diversity committee there, and they can actively recruit counseling staff.

Counselors can also reach out to counselor education programs and actually request that they be an internship site for counseling students and specifically request that they would like to recruit and draw and mentor counseling interns who are from traditionally underrepresented groups. That would put a bug in the ear of local counseling programs that there are people who are specifically seeking to train, mentor and supervise counselors who come from traditionally underrepresented groups.

Counselors can advocate with state licensure boards and state legislatures to gather data about the diversity of counselors in their state. For example, here in Burlington [Vermont], we have one clinical mental health counselor of color [despite the fact that] we are also a refugee resettlement city — with a population of about 17 to 20 percent of residents who are refugees and people of color.

Practicing counselors can reach out to school counselors to offer to come to career fairs — specifically schools with diverse student bodies — and speak to students about the counseling profession and the need for a more diverse population of counselors.

Practicing counselors can also reach out to campus groups and clubs — African American Student Unions, LGBTQ groups, disability rights groups, etc., and offer to talk to undergraduates about the counseling profession and the need for counselors with more diverse stories
and backgrounds.

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Sylvia Nassar

Sylvia Nassar, member of the committee that developed the Multicultural and Social Justice Counseling Competencies, a professor and doctoral program coordinator of counselor education at North Carolina State University, and a researcher and author with a focus on Arab American issues

The counseling profession, like other master’s-level professions, has increased in terms of diversity as a simple parallel to increases in diversity at rates of graduate-degree acquisition. Moreover, the efforts of CACREP as well as individual educational institutions and other groups to systematically recruit and retain more students from marginalized groups has strengthened the profession generally and, in particular, the professional counseling associations and special interest groups with specific diversity foci, thus positively perpetuating diversity at multiple levels throughout the profession.

The historical trend of vulnerable groups within the overall population needing within-group representation in their counseling and advocacy services within their own communities [and] at national levels continues to drive the need for additional diversity. For example, refugees, veterans, individuals from marginalized sexual identity groups, along with many others, present growing needs for counseling and advocacy and, thus, need to be better represented by counselors and advocates from their own population groups.

These areas of diversity need to be intentionally and systematically addressed within broader diversity initiatives such as those promoted by CACREP, educational institutions, etc.

The Multicultural and Social Justice Counseling Competencies (MSJCCs), endorsed both by the Association for Multicultural Counseling and Development and the American Counseling Association in 2015, provide a promising perspective on recognizing and addressing diversity throughout the counseling profession. As the MSJCCs become operationalized for use by counselors and counselor educators and supervisors, professional counselors will ideally broaden their current thinking of diversity and challenge themselves to increase their inclusivity in conceptualizing diversity among their clients and students.

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To access the Multicultural and Social Justice Counseling Competencies, visit counseling.org, click on “Knowledge Center” and then click on “Competencies” in the drop-down menu.

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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.

The most wonderful time of the year?

By Bethany Bray October 23, 2017

Counselors can help clients prepare for the pressures that come during the holiday season, from a barrage of parties and social events to the temptation to compare themselves with the happy, near-perfect holiday scenes in movies, advertisements or friends’ social media posts.

For clients with seasonal depression, it can all be overwhelming — just at a time when people are expected to be happy and joyful, says John Ballew, a licensed professional counselor (LPC) with a private practice in Atlanta. Financial stresses, relationship concerns, grief over the loss of a loved one and other life challenges can feel more intense.

“This can be exactly the time that’s going to press on an old wound,” says Ballew, a member of the American Counseling Association.

Cindy Gullo, an ACA member and licensed clinical professional counselor in O’Fallon, Illinois, says she also notices an uptick in depression symptoms in her teen clients during the unstructured weeks of school break for the holidays, as well as anxiety over the return to school in the new year. She coaches clients to create and maintain structure over holiday breaks, including getting up at the same time in the morning and keeping up with the tasks they normally do while in school, such as completing reading assignments or practicing a musical instrument.

For Ballew’s adult clients, setting boundaries — from limiting their party RSVPs and holiday overeating to avoiding toxicity on social media — is often key to navigating the holidays. He also talks about the difference between self-care and self-indulgence with clients when preparing for the season.

“The adage that ‘No is a complete sentence’ is very applicable here,” Ballew says. “Especially if they have social anxiety, three hours at a party can feel totally overwhelming. Plan to go for 20 minutes, say hello to at least three people, then leave and admit you’ve done something difficult.”

On the flipside, clients who don’t receive any holiday invitations can sink into isolation or self-pity. Ballew says he works with clients to challenge themselves. Are they sitting at home waiting for the phone to ring? If so, they can be the one to call friends and initiate get-togethers. They can volunteer. They can choose to attend concerts and other local events on their own.

The holidays — from Thanksgiving to Valentine’s Day — can also be a struggle for clients who are single and unhappy about it. Again, Ballew says he challenges these thought patterns with clients. “For people who are alone, it’s learning to love being alone and make peace with it,” he says. “Reassess old patterns and beliefs and let go of things that aren’t working. What activities can you do alone? What beliefs do you have that keep you from enjoying things alone?”

Conversations with clients about setting boundaries can also be helpful in preparing for the family pressures and get-togethers that crop up during the holidays. For clients with particularly toxic or unhealthy family situations, this may mean limiting their involvement or staying away altogether, Ballew says. It may even be helpful to create their own new traditions during the holidays.

Sometimes, Ballew coaches clients to think of family visits as a trip to the zoo: What behavior might you see? What can you expect? What responses can you have ready for when family members make inappropriate or triggering comments?

When appropriate, he will create a “family bingo” board with clients, listing predictable patterns and negative behaviors that they can track in their minds. Although they wouldn’t bring the board to family gatherings, its creation is a way to prep for managing potentially challenging situations, Ballew explains.

“Approaching things with a sense that it doesn’t need to be that serious can be helpful,” he says. “With other folks, if the family is seriously dysfunctional, they just need to set boundaries. For example, if dad gets drunk, they don’t need to wait around to be berated. Have a [plan and] a place to go so you aren’t as vulnerable as when you were younger.”

Marcy Adams Sznewajs, an ACA member and LPC with a private practice in Beverly Hills, Michigan, specializes in working with teenagers and emerging adults. Like Ballew, she works with clients to prepare for family interactions over the holidays, with focus placed on empathy and listening skills.

“We do a lot of role-play in anticipation of family events,” she says. “What would happen if your uncle goes down this path and you respond in this way? How might that end? How would you like it to end? What are some different ways you can approach the situation? Teens don’t always have the ability to step back and say, ‘Just because someone doesn’t understand me doesn’t mean that I need to spout off my opinion at all times or respond.’”

“We also talk about understanding other people’s perspectives and life experiences,” she continues. “If they can look at a [family member’s] actions and behaviors from a place of empathy, sometimes it’s easier to sit through a conversation. Or, sometimes, it’s so horrible that all they can do is take a deep breath and get through it. Then we talk about management, mindfulness and ‘this too shall pass.’

“I tell them, ‘I can’t always help fix this, but I can help you cope, and you are strong enough to deal with this.’”

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READ MORE about supporting clients through seasonal depression in the article, “A light in the darkness” in Counseling Today‘s November magazine: https://wp.me/p2BxKN-4V1

From the Counseling Today archives: “Unhappy holidays: Helping clients through the ‘holiday blues’”

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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 at facebook.com/CounselingToday.

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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.