Monthly Archives: May 2018

Rate of youth suicide-related hospitalizations has nearly doubled

By Bethany Bray May 31, 2018

Recent research has revealed an alarming development: The number of youth admitted to the hospital for a suicide attempt or suicidal ideation nearly doubled between 2008 and 2015.

The findings, published in the May 2018 issue of the journal Pediatrics, analyzed seven years of billing data for emergency room and inpatient visits at children’s hospitals in the United States.

In 2008, the number of hospital visits for suicidal thoughts or suicide attempts in children and adolescents younger than 18 was 0.66 percent of total hospital visits. In 2015, that percentage nearly doubled to 1.82 percent.

The co-authors of the journal article note that “significant increases” were seen across all age groups, but the highest rise was seen in adolescents, specifically the 15 to 17 and 12 to 14 years-old groupings. The data also pointed to a seasonal curve, with the fewest suicide-related visits in the summer and the most in the spring and fall.

“These findings are deeply troubling and also not surprising,” says Catherine Tucker, president of the Association for Child and Adolescent Counseling, a division of the American Counseling Association.

Tucker points to several factors that were in play during the time of the Pediatrics study (2008 to 2015), including an economic collapse that contributed to stress in families — even forcing some in younger generations to change career or college plans.

Also, “during this same time period, many states drastically cut funding to schools and youth-serving programs,” adds Tucker, a licensed mental health counselor and research director at The Theraplay Institute in Evanston, Illinois. “It is highly likely that the positive resources that were keeping some youth from hitting bottom were removed, making it harder for adults to intervene in a timely manner.”

Changing these statistics will take effort on the part of parents, schools, medical and mental health practitioners alike, says Tucker. Universal screening for anxiety, depression and trauma should be done in schools and doctor’s offices to identify youth who are struggling.

“In order to reverse this trend, schools need to bolster school counseling programs and free school counselors from spending the majority of their time on administrative tasks like testing and scheduling. School counselors see a majority of American children and are in a prime position to do preventive education and identify kids who are struggling before they become so distraught that hospitalization is required,” Tucker says.

“Additionally, parents and caregivers should be encouraged to monitor children’s and teens screen time and limit it to be sure that youth are getting adequate sleep, exercise and in-person interaction,” she continues. “Social media should be carefully monitored in younger children. Parents can reduce late-night use of phones by turning off WiFi after bedtime or not allowing phones or other screens in bedrooms. Counselors in agencies and private practice settings can help by encouraging parents to be alert to behavioral changes, monitoring screen time and helping kids manage their symptoms.”

 

 

****

 

Find out more

 

Read the full article at the journal Pediatrics

 

From NPR: “Hospitals See Growing Numbers Of Kids And Teens At Risk For Suicide

 

The Association for Child and Adolescent Counseling‘s next national conference (July 25/26, 2019 in Austin, Texas) will have a theme of technology use and adolescent mental health

 

This news comes as overall rates of suicide — across all ages — have been on the rise in the United States. In 2016, the country’s rate of suicide reached its highest point since 1986.

 

American Counseling Association members: Log in to access practice briefs on suicide prevention with children, youth and in school settings

 

From the Counseling Today archives:
Raising awareness of suicide risk

’13 Reasons Why’: Strengths, challenges and recommendations

Aspiring to make suicide a relic of the past

 

 

****

 

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

 

 

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

 

 

****

 

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.

 

 

 

Guiding lights

By Bethany Bray May 30, 2018

Counselor supervision is a rite of passage for professional counselors. Although supervision requirements vary from state to state, the crux of the experience — learning that is based in a relationship between a beginning counselor and an experienced practitioner — is universal. As is the case for any relationship to remain healthy and beneficial, the supervisor–supervisee pairing requires care, hard work, respect and trust from both parties.

Supervision is meant to be “the other half” of counselor education, bridging classroom learning and in-session counseling skills, says Summer Reiner, a licensed mental health counselor (LMHC), clinical supervisor and associate professor and school counseling coordinator at the College of Brockport, State University of New York. “There’s no way you can fully prepare the student in a classroom. Supervision is to fill out your education,” says Reiner, president of the Association for Counselor Education and Supervision, a division of the American Counseling Association.

Supervision begins “a lifelong process of always stepping back and looking at what went well and what didn’t,” she adds. “Supervision is training to be able to do that throughout your career, a constant of thinking what went well and what do I need to do differently? It’s a supervisor’s role to get that internal dialogue moving, by demonstrating it first and letting [supervisees] know that they will self-evaluate, in a healthy way, throughout their career.”

Balancing act

The supervisor–supervisee relationship is different from the therapeutic bond forged between counselor and client. However, many counseling skills come into play as supervisors support and foster growth in their supervisees. Although supervisors never shed their identity as counselors, they must learn to shift gears between working with clients and working with counselors-in-training or beginning professionals.

Supervisors must also achieve a balance between two primary roles that can, at times, feel like they are at odds with each other: fostering an open and honest dynamic with supervisees and evaluating supervisees. The best learning opportunities often arise when supervisees feel comfortable with and have enough trust in their supervisors to ask questions and admit when they are struggling.

“It’s a delicate balance,” says Kevin Doyle, a licensed professional counselor (LPC), clinical supervisor and adjunct instructor of counselor education at Virginia Tech. “The supervisor has the power, but it still needs to be an open relationship. … A supervisor should focus on creating a connection that is similar to counseling, with focus on the supervisee’s professional growth and development. Transparency is paramount, even though there’s a grade or evaluation piece to the situation.”

“It’s one of the biggest fissures in supervision: There’s this evaluative piece. It’s similar to a counseling relationship, but you also have the responsibility to assign grades or to be a reference for a future employer,” says Doyle, a member of ACA. “It’s not a counselor–client relationship, but it also shouldn’t be an inverted relationship” with a power imbalance.

Supervisors are a unique blend of teacher, counselor, evaluator and role model, and they need to be able to nimbly weave in and out of those roles as the moment demands, Reiner says. Throughout the process, counselor supervisors should remain very supportive of their supervisees while also offering honest feedback.

“Help them understand that we’re not evaluating them as a person, or as a counselor, but with each intervention they use with a client,” says Reiner, whose experience is with graduate student supervision as a counselor educator. “This isn’t me judging you; it’s me helping you see what was your intent in this process? What was the intended outcome? If that didn’t happen, what would you have changed?’”

“At the same time,” she continues, “it’s important not to be a cheerleader. Don’t let them feel like everything’s OK when it’s not. It’s this balancing act of having students hear critical feedback without personalizing it and [then] using it constructively.”

Stacey Brown, an LMHC and clinical supervisor in Fort Myers, Florida, stresses that the best supervision happens when the relationship is central to the experience, which transcends simply going through the motions of clocking the needed hours and ticking items off of a to-do list. “For me, it’s about becoming a counselor — beyond the techniques they learn in grad school,” says Brown, an ACA member. “It’s very easy to forget the human part of the equation, and our role as nurturer and encourager, as there are so many boxes to tick. Don’t make it so structured that [supervision] sessions are repetitive or predictable. Be open and allow flow to happen, like you would in a counseling session. You can still cover everything you need to cover, but be creative and open to what comes. Otherwise, you may lose out on [teaching] opportunities that pop up.”

For example, a supervisor might have a stack of case studies ready for review with a supervisee, but the beginning counselor walks into the room with tears in her eyes because of professional stress or something going on in her personal life. In that case, “You shouldn’t push forward with your case reviews,” Brown says. “You should take a step back, ask what’s going on and how can you [the supervisee] manage it? But if I have some kind of checklist to get through, I will miss out on opportunities to help her become a counselor. Teach [supervisees] flexibility, intuition, being present and learning that they have to deal with their own stuff and take care of themselves to be able to help other people. What better way to teach that than by doing it?”

Modeling and forging a bond

Doyle says the skills that supervisees gain through counselor supervision can be divided into two realms: everything that happens in the room with clients, and everything that happens outside of the counseling room.

The first part of the equation, the “nuts and bolts” of counseling, as Doyle calls it, is developed through case review and the one-on-one guidance that a supervisor provides. It involves real-time application of the knowledge base that counseling students were introduced to in graduate school.

The second part encompasses learning that can’t truly be acquired from textbooks. It involves preparation for the entirety of the job of being a professional counselor, Doyle says. Much of the knowledge acquired in this sphere is based on how supervisors model their own professional skills, both inside and outside of client sessions, in the presence of their supervisees. Supervisees watch and absorb not only their supervisors’ interactions with clients, but also the professional boundaries that supervisors set, how much they focus on self-care and how they manage time, professional ethics and other aspects of the job.

Supervisees “absorb so much from how we carry ourselves and what we do in supervision,” says Doyle, who wrote his doctoral dissertation on how supervisors can model wellness and how that influences supervisees’ wellness.

A little self-disclosure, when appropriate, on the part of supervisors can help keep the supervisor–supervisee relationship open and honest, says Kathryn Henderson, an LPC and an assistant professor at the University of Saint Joseph in West Hartford, Connecticut. When supervisors disclose, for example, that they sometimes struggle to prioritize self-care, it demonstrates not only that even supervisors are imperfect but also that wellness will need to be a career-long goal.

“I stress that we’re in this together,” says Henderson, an ACA member. Supervisors share “our knowledge and experience, but we’re learning from [our supervisees] and growing ourselves. We’re learning just as much from them as they are from us. It’s mutually enriching.”

Brown says she is upfront with her supervisees that counselors are no different from the general population in that they sometimes have trauma in their past, struggle with an inner critic or anxiety, or face other challenges. “Part of being a good counselor is being comfortable with yourself and coming to terms with your own issues. I can’t be [my supervisees’] therapist, but as a supervisor, [I] can recommend they see a therapist,” Brown says. “I tell people right off the bat, there’s no reason to hide who you are.”

Brown also thinks that supervisor self-disclosure, within ethical boundaries, can strengthen the relationship with supervisees and help them realize that being honest about their struggles won’t sabotage their evaluation. Brown recalls one supervisee who had an infant at home. When Brown would check in with her about her stress level and self-care routine, the supervisee would insist she was fine. In truth, she was struggling with breastfeeding and a severe lack of sleep. The supervisee opened up only after being shown photos of Brown’s children and having Brown share a few of her own struggles during motherhood.

“My job, as I see it, is not to be rigid or pretentious at all, but to be real,” Brown says. “Being a real person who can share my experiences, my missteps, my learning, my boundary conflicts, my wellness efforts, etc., helps supervisees to be willing to be real with me. Then I
can see who they are and can offer suggestions that can help them personally and professionally.”

“The relationship is the most important part of the supervision,” she continues. “Elements of trust, mentoring, nurturing, directing, humor, compassion and tutoring are all there, just as in the counseling relationship. The difference is that in supervision, the supervisee will one day be completely equal or surpass me in credentials and expertise. I treat them as colleagues while still offering the nurturing and guidance and respect they need and deserve.”

Henderson agrees that trust is paramount in creating a good supervision experience. For supervisors, this includes trusting their supervisees enough to give them room to find their own way professionally. For supervisees, this means trusting the relationship enough to be able to share — and, in turn, work on — their weaknesses and areas of struggle.

“You can’t give someone insight; [a supervisee] needs to find that on their own. But we can create that opportunity in supervision,” says Henderson, co-editor with Alicia M. Homrich of Gatekeeping in the Mental Health Professions, published by ACA in May. “Supervision is their first time working with real clients in a real-world setting and applying what they’ve spent so many hours learning. That can be scary and overwhelming — there’s a fear of inadequacy. … The crux of supervision is that you’re not alone in that. This is exactly where you go to talk about those concerns and get the support and help that you need to grow in your own self-awareness and confidence in your skills.

“Supervisors are the ones to build that support [by offering] encouragement and validation. All of that helps create an environment where I [the supervisee] can come and bring my greatest concerns and failures, be vulnerable and not be afraid of being judged or of negative outcomes or consequences. Trust is so needed to create that environment.”

It takes two

What does it take to establish a healthy and beneficial supervision experience? In part, both parties must contribute by being flexible and practicing open and honest communication.

Suggestions for supervisees

Shop around to find the best fit. Look for a supervisor with whom you click, both professionally and personally. Alicia Simmons, a counselor intern working toward counselor licensure in Florida, found her supervisor, Stacey Brown (quoted in this article), by searching online and talking with friends from graduate school. She called and spoke with Brown before meeting her in person to test the waters of what would become a very positive supervision relationship. Simmons and Brown co-presented a session, “Intuitive Clinical Supervision: Creative Solutions for Helping New Counselors,” at the ACA 2018 Conference & Expo in Atlanta this past April.

“Look for someone who is going to walk beside you for … however long it takes,” says Simmons, a clinician and play therapist at an agency that serves children removed from their homes due to trauma or neglect. “Don’t be afraid to ask questions before you begin. You want to know you’re in the right fit. Don’t be afraid to try more than one supervisor. … Look for someone who is going to be flexible and work with you in the way you need to work. If you don’t know what that is, work with someone who will help you figure that out.”

Speak up. If you have a need that is not being met through the supervision experience, talk to your supervisor in a tactful but honest way. Doyle acknowledges that this can be a tall order because supervisors are seen as authority figures. At the same time, identifying any area where you might be struggling in the relationship will actually help your supervisor, he says. Counselors who provide supervision have so much to focus on — including client needs, scheduling, paperwork and so on — that they may not notice everything going on with their supervisees.

“Advocate for your needs [even though] that’s a lot to ask at the outset,” says Doyle, who will be starting a new job as assistant professor of mental health counseling at the University of Tennessee at Chattanooga this fall. “Speak up when you need support. Realize that the supervisor will rely on that. … When you come to see your supervisor as a safe person, you will really connect with them and [that will] make it easy to disclose your struggles.”

Respect the process. Keep in mind that your supervisor likely took on this extra responsibility because he or she wanted to “pay it forward” to the profession, Reiner says. Yes, supervisees have needs that should be met through the supervision experience, but at the same time, they must remember that a counselor’s first priority will always be client care.

“Step one is being appreciative that someone was willing to take you on as a supervisee and has trust in you that you will be able to serve clients well,” says Reiner, an ACA member. “Keep in mind that you are practicing under the license of someone else. If the [supervisee] does something really inappropriate, it can open the supervisor up to a lawsuit. They are taking on a personal risk as well as an additional workload. … Recognize that the supervisor is investing in the future of the profession and has no obligation to do that. Realize that they care about your future and the clients you are going to work with.”

Be authentic and drop preconceived expectations. Bring your true self into supervision. Don’t act one way with clients and another way with your supervisor. There should be “a thread of authenticity” throughout your work in supervision, Simmons says. “Counseling is basically holding up a mirror and showing somebody what’s there. Supervision I think ideally would be the same way.” Authenticity, both on the part of the supervisee and the supervisor, builds trust, she asserts.

In addition, it might be best for supervisees to leave behind their ideas of what supervision should look like. The important thing is for the supervisor and supervisee to be working toward the same goals. “What I had heard about clinical supervision was mostly [about] case review and going over the work with clients — very textbook and academic,” says Simmons, an ACA member. “What I’ve learned is that it can be much more fluid than that. All the in-between stuff is what has stuck with me and helped me develop my own style and confidence in my abilities. It’s about more than just the logistics of what’s going on in each [client] case.”

Remain open to feedback. Having a relationship built on trust makes it easier for supervisees to remember that any critical feedback they receive from their supervisor is meant to help them and that they are both working toward the same goal: the supervisee’s growth and development as a counselor. “It’s the same as the counseling relationship — you have to have that rapport,” Simmons says.

Regardless, being critiqued can prove challenging. “As a supervisee, it’s our responsibility to be able to receive feedback,” Simmons says. “If there’s something that’s getting in the way, perhaps that’s something [we] need to work through. We may need to seek therapy ourselves to work on it. Check yourself: Is it something related to the supervisor, or is it something unrelated that you need to work on?”

Think for yourself. At the same time, do not accept feedback blindly. Think it through and talk through any areas you have questions about with your supervisor, Reiner advises. But first, take a step back and consider whether you have received similar feedback from others in the past.

“Critically examine any feedback that you are receiving and be open to being the one who needs to grow and change. Or simply say ‘thank you for that feedback’ and ‘I’ll be mindful of that in the future,’” Reiner says. “I don’t think that supervisees know that supervisors are sometimes uncomfortable sharing critical feedback. They have probably thought it through [before telling supervisees] and were anxious about it themselves.”

Suggestions for supervisors

Temper criticism. Set realistic expectations and frame criticism in a way that lets supervisees know you’re focused on their growth, Doyle says.

In Reiner’s work supervising graduate students, she assures them that she won’t start evaluating them for a grade until halfway through the semester, once they have settled into the experience. It is important to stress that feedback is never personal but rather focused on supervisees’ development, Reiner says.

“There’s also an element of modeling for your supervisees — ‘This is how you have hard conversations with people.’ [They] will need to do that as a counselor,” Reiner says.

Debunk myths of perfection and the existence of one right way. Henderson shares an important lesson with her supervisees that she learned through her own supervision: There is no such thing as a perfect counseling session. Supervisees often put enormous pressure on themselves to find the “right” way to do something, she says. The truth is, clinicians can work with the same client in multiple ways and take different therapeutic directions and still arrive at a positive outcome, Henderson says.

Prioritize fostering growth. Might your supervisees end up working for a local competitor or leave your agency and move on once they’re licensed? Be supportive and invested in their growth, even if it won’t benefit you in the long run, Doyle urges. “Don’t think of [supervision] as just one more thing to get through. Don’t think of it as a task but as a relationship to foster,” he says.

One mark of a good supervision relationship is when a supervisor is comfortable enough to allow — or even to encourage — a supervisee to seek additional skills elsewhere, Simmons says. For example, if supervisees use different therapeutic modalities than their supervisors do, they might want to look for workshops or online training while
in supervision.

Help supervisees embrace their counselor identity. Supervisors can help prepare supervisees for work environments in which they may be the only counselor. “Once people get into a work environment, there becomes a lot of pressure to do things not in the way a counselor is trained to do. Part of a supervisor’s job is to train a supervisee not to lose their identity as a counselor,” Reiner says. “Sometimes you might get the message, ‘We know that’s what you learned in college, but that’s not how we do it.’ Be mindful of teaching them to be a team player yet [also] an advocate for counselors and counseling.”

For example, a counselor in a school setting may be the only person in the building with a counseling background, and he or she may repeatedly be asked to spend time as a test proctor or hall monitor or to perform other noncounseling duties. “How do you politely tell your principal that counselors are not lunch monitors?” Reiner asks. “Instead, explain that your approach will be different. ‘I will do it, but I’ll do it within my counselor identity. Instead of being a disciplinarian, I will use it as an opportunity to talk to students.’”

Lift supervisees up. Supervisees should leave the supervision experience even more energized about the counseling profession than when they began, Brown says. “The way I see it, our job is to lift them up. To help them see that they are more capable than they think they are. To teach, to offer guidance and education, and to model how we do what we do. … Yes, there are techniques and ethics and strategies, but there is also joy in the giving. Graduate students don’t often pick up on that part in grad school. I believe that is the key element we, as supervisors, need to be offering to new counselors. This will help keep integrity in the profession and prevent burnout [by] shining a light on the ability to truly offer healing to clients.”

Navigating the ups and downs

Because supervision is an experience that involves two human beings, it is only natural that not every experience will be positive. Frustration, awkwardness and other negative feelings may surface.

Conflict can arise easily in supervision relationships in which expectations are unclear, Henderson notes. To decrease the likelihood of that happening, she recommends that supervisors document their expectations thoroughly before supervision begins, regardless of whether that process is mandated by the state in which the supervisor practices.

Among the details that should be included:

  • How the supervisee will be evaluated
  • How often the supervisor plans to meet with the supervisee
  • The cancellation policy should a supervisee need to miss a meeting
  • The length of the supervision or how many hours are expected
  • How much the supervisee will pay the supervisor (if applicable)

These details should be talked through with supervisees before they agree to sign the document.

This is also a good time to map out wellness goals, says Doyle, who has supervisees include self-care in the learning contract they create at the beginning of supervision.

“In many ways, it’s on the supervisor to try and develop a welcoming, supportive, yet honest and challenging relationship with their supervisee,” Reiner says. “That starts out with being very direct and forward with your supervisee about what is expected and how they will be evaluated.”

The importance of being direct also extends to addressing any differences between supervisors and supervisees, from level of expertise to gender identity to spirituality, Reiner says. She recommends asking supervisees upfront, “How are you feeling about these elements of who you are and who I am and how that comes together in our space together?” In addition, she says, supervisors can offer assurances to ease supervisees’ concerns about those differences: “If there’s ever a time when I’m not hearing you or not understanding you, please tell me. I want to hear it because it will only help our relationship.”

When tough conversations arise or when things aren’t going well in supervision, it is helpful to keep the discussions focused on growth opportunities. In her role as a counselor educator, Reiner sometimes has to mediate meetings between supervisors and supervisees who aren’t seeing eye to eye. She begins by asking both, individually, what is going well, what can be improved on and what they would like to do or see in supervision that hasn’t happened yet. Reiner tries to frame the conversation so that both parties are able to take personal ownership of what has transpired without placing blame. That way, they are able to share and focus on what they want from the experience that they haven’t yet received.

Clear and open communication is essential when the supervision relationship is having its ups and downs, agrees Henderson, and that is when a supervisor’s counseling skills especially come into play. Supervisors should focus on concrete expectations that aren’t being met rather than vague or arbitrary attributes that they may not like, such as a supervisee’s personality or professional style. If necessary, supervisors can also refer to the contract put in writing at the beginning of the relationship, she adds.

“Many times, we talk around things without talking about the process that’s going on in the room, that here-and-now experience,” says Henderson, who presented on supervision and ethics at the ACA 2018 Conference & Expo in Atlanta. “Oftentimes we need to go to that level of metacommunication, to use counselor lingo, to address the dynamics that are happening between us and what’s contributing to it. That can be a very difficult conversation to have, especially considering the power differential. I like to make it as concrete as possible. Having clear expectations and a contract helps focus on competencies and what’s not being met.”

“[Sometimes] it’s these unexpected lessons that find us, that we’re not looking for, that can be the most difficult but that lead to the most growth,” she adds. “When we are having these conversations, keep in mind our mutual goals. What’s our purpose? The supervisee’s growth as well as client welfare. Monitor both.”

Keep it going

Peer support and feedback, mentorship and case review with colleagues can play a vital role throughout a counselor’s career, long after formal supervision leading up to licensure has ended. Doyle recommends that counselors engage in lifelong supervision, whether in an informal or formal capacity, to continue learning and to find support.

“It’s extremely rewarding work that we do, but it’s extremely taxing too. Peer support becomes that much more important after formal supervision ends,” he says. “It’s hard to describe the grind you go through daily as a counselor and the emotional toll it takes. Connect with people who can understand that. Connect with peers across the profession, whether that’s within a professional organization or the practitioner in the office next to you. Make sure you have a support network, wherever you are.”

Henderson says one of the things that stuck with her most from Irvin Yalom’s keynote at the ACA 2017 Conference & Expo in San Francisco was that he — a noted psychiatrist, author and scholar — had sought support from peer groups throughout his storied career. “Even though he’s a giant in the field, he continues to work on his own development,” she says.

“The message that we want to send is that the journey doesn’t end when you get that license or degree,” Henderson adds. “The journey is ongoing, and we don’t want to be alone in that journey.”

 

****

Related reading: Counselor supervision: Reflections and lessons learned,” an online-exclusive companion piece to this article: wp.me/p2BxKN-58U

 

Additional resources:

From the Counseling Today archives:

 

****

 

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

 

****

 

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.

Integrated interventions

By Laurie Meyers May 25, 2018

W hen people think about integrated care, they may imagine a mental health care professional (or two) working in the same building with a physician or other medical professional and following a mutual agreement to refer cases to one another as needed. Others might picture a specialized setting, such as a pain clinic or cancer treatment center, where mental and emotional health concerns are addressed in relation to the medical or physical issue. However, multidisciplinary integrated care teams can now be found in hospitals, outpatient medical centers and community mental health clinics. Professional counselors who operate in these settings say that working in concert with other medical, mental and physical health professionals is the best way to provide clients with whole-person care.

Integrated care facilities are often in medical settings such as primary care clinics, but this doesn’t have to be the rule. Sherry Shamblin is chief of behavioral health operations for Hopewell Health Centers, a group of nonprofit community primary care and behavioral health clinics with 16 locations in southeast Ohio. She helped to develop a system that features primary care facilities in which counselors can conduct brief behavioral interventions and centers that focus principally on mental health but also offer primary care resources.

Shamblin’s thinking is that clients who already are struggling to manage serious mental health issues are often too overwhelmed to seek medical care. “If you’re depressed, you don’t really take care of yourself,” says Shamblin, a licensed professional clinical counselor with supervision designation. “You’re not valuing self-care and taking care of your [physical] health.” In addition, many psychotropic medications have side effects such as weight gain, which can increase clients’ chances of developing diabetes and other chronic illnesses, she notes.

“When you physically feel better, your mood improves, your energy is better, [you] feel more like tackling things that seem overwhelming and your overall coping improves,” says Shamblin, a member of the American Counseling Association. “Although mental and physical [health] have been separated for a long time … [the division] is artificial. It’s all connected.”

Counselors at the mental health clinics ask clients at intake whether they have a primary care physician and, if so, who that person is and when the last time was that the client saw their physician. Counselors will also try to get clients’ permission to access their medical records. That way, counselors can work with clients’ physicians to help ensure that clients are getting the health care they need, Shamblin explains.

If mental health clients don’t have a primary care physician or only go when they are feeling really ill, the counselor talks to them about health and wellness and the importance of receiving regular checkups. “We try to help them view it [regular health care] as another component of staying well,” Shamblin says.

If Hopewell Health Centers’ clients don’t have a primary care physician but would like to start taking better care of their health, they don’t have far to go — the mental health care facilities have exam rooms and primary care providers on-site. Having these resources readily available not only makes it easier for clients to access health care but also allows them to receive it in a setting in which they already feel comfortable, Shamblin says. The counselor (or other mental health professional) and onsite primary care provider then become a team dedicated to maintaining the client’s physical and mental health.

In Hopewell Health’s primary care clinics, counselors (who are called behavioral health consultants, or BHCs) play several roles. In some cases, the BHC is brought in to help the client manage a chronic illness. For example, Shamblin says, a primary care physician might see someone whose diabetes or high blood pressure is not under control despite treatment. This would provide an opportunity for the physician or nurse to explain that they have a colleague on the team who might be able to help the patient with this struggle. They would then ask if the patient would like to meet with the BHC.

The BHC would then try to determine the factors that are keeping the patient from progressing. For instance, is the person not taking medicine consistently or not watching their diet? If treatment adherence is a problem, the BHC assesses whether patients are ready to change their behavior and, if so, works with them to set goals and offers ongoing support. If patients are not open to making a change in a particular lifestyle area — such as diet, for example — the BHC would work with them to identify another positive lifestyle change they could make, such as stopping smoking or getting more exercise, Shamblin explains.

In other cases, the BHCs working in the primary care clinics conduct brief interventions with patients. The primary care physicians screen patients by asking questions that assess for signs of depression or substance abuse. If the physicians get an answer that concerns them — perhaps a patient saying that they have been feeling overwhelmed or depressed, for example — they ask the patient whether they can bring in someone who might be helpful, Shamblin says. The BHC will then ask brief questions to help determine whether the patient needs intervention.

Sometimes patients feel better just being given the opportunity to have a short conversation about their worries, Shamblin says. In such cases, the BHC will ask if it is OK to check in with the patient the next time the person returns to the clinic. In some cases, the BHC will ask the patient to come back for a few brief counseling sessions. In other instances, the BHC determines that patients need more intensive mental health care and will refer them to the clinic’s mental health professionals who oversee long-term care, Shamblin explains. The BHC then becomes the liaison between the primary care and mental health providers and will check in with the patient periodically to see how the person is doing, she says.

Hopewell Health Centers was created in 2013 when two organizations, Family Healthcare Inc. and Tri-County Mental Health and Counseling Services Inc., merged in order to provide integrated care. Shamblin notes that the frequency of Hopewell Health Centers’ screenings and treatment of substance abuse has gone up with the introduction of the integrated care model. Some data have suggested that the area of Ohio where the clinics operate has the lowest depression rates in the state, she says.

Leading the way in integration

Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, is a leader in hospital and outpatient integrated care. Just ask ACA member Laura Veach, who explains that the Wake Forest system has moved beyond the concept of integrated medicine being simply “co-located” care. In fact, the system is so integrated that Veach, a counselor educator, is a full professor in the Department of Surgery in the Wake Forest School of Medicine, a position that Veach thinks may be unique. Veach is also the director of counselor training at Wake Forest Baptist Medical Center. Though affiliated with Wake Forest University, the center also works with other counselor educator programs.

Veach has played a crucial role in the medical center’s emphasis on integrated care. She says she feels particularly fortunate because she works with a group of surgeons “who get it and want the best for patients.”

“We [counselors] are embedded in the medical team,” Veach explains. “We started in surgery in the specialty of trauma surgery and began to test the feasibility of doing counseling and screening and intervention at the bedside and [then] became a training site. Now we include posttraumatic stress disorder [PTSD] intervention work, crisis intervention and grief and loss work with trauma patients who have suffered the loss of a loved one in a trauma incident that brought them to the hospital. That led to the pediatric trauma unit, where we work with families of children who are traumatically injured, as well as the children themselves.”

Counselors are also part of integrated care efforts in the facility’s burn center, which is one of the only certified burn centers in North Carolina. Those efforts include providing ongoing counseling sessions in the burn intensive care unit and the step-down unit. Wake Forest Baptist Medical Center has also expanded integrated care into medical inpatient units, where people come in for issues such as pancreatitis, infections, pneumonia and so on.

Wake Forest Baptist Medical Center has a system that scans medical records to help identify patients who might need counseling help. For instance, when patients come through the emergency room, nurses ask them about depression, anxiety, suicidal thinking or past suicidal behavior. Other patients may receive bloodwork that shows elevated blood alcohol content or urine drug screens. Veach emphasizes that these are not for legal use but to help the medical center provide better integrated care. Some people may have elevated liver enzymes, which can be a sign of alcohol abuse, she continues. The medical records also include the physician’s account of what the patient’s complaint is. The chart-scanning system analyzes all of this information to help identify and prioritize who the counselors and other mental health professionals on staff should see first, she says.

Counselors introduce themselves as part of the team to patients and let them know that they are there to support the patients’ recovery and health. They then ask if the patients are open to the counselor spending some time with them. The counselors are rarely turned away, according to Veach.

After reviewing informed consent and confidentiality policies with each patient, the counselors simply listen, Veach emphasizes. “We try to just be present with them, to not ask questions, to hear what they are struggling with,” she says.

Veach notes that most of the medical center’s patients have never been to see a counselor before. So the counselors and counseling graduate students who work on the integrated teams at Wake Forest Baptist Medical Center are essentially educating these individuals about what counseling can provide. They tell patients they are prepared to listen to whatever the patients most want to talk about or need help with.

“What we find most often is that people have a lot to share,” Veach says. “We’re not someone who’s coming to do something to them; we’re someone who is coming to be with them. They might say, ‘I really want to talk to my family about this, but they’ll worry.’ A counselor or addictions specialist can be there and not be judgmental.”

In the medical center’s trauma and burn units, counselors stay on the alert for signs of acute stress or PTSD in patients, Veach says. After being released from the medical center, patients return for medical follow-up visits for the next six months, and counselors continue to check in and evaluate their recovery during this time. In certain cases, the counselors set up extended mental health therapy sessions with patients (scheduled adjacent to their medical visits) or recommend that they see a trauma specialist, such as someone trained in administering eye movement desensitization and reprocessing therapy.

When Veach first started working in integrated care, it was common for surgeons to state that they didn’t need or want to know about patients’ emotional issues — they just needed to know how to repair individuals surgically. “In the past decade, we’ve seen a big shift to asking how do we more fully treat this person to help them have a better chance of healing and without experiencing more trauma,” Veach says. “I think more trauma surgeons [today] know that if we don’t address [these emotional issues] now, we’re going to see them here again.”

Many people undergoing medical treatment aren’t aware of the types of issues that counseling or addictions treatment can help them address, or they don’t know how to access those services themselves, so having counselors as part of the team at Wake Forest Baptist Medical Center is particularly valuable, Veach says. Counselors on staff can make recommendations and point patients toward other resources. For instance, Veach says, families may have been struggling for years to get a loved one into treatment for substance use; counselors on staff at the medical center can offer information on which addictions centers in the area offer family support.

In the trauma and intensive care units, the teams offer dedicated support time for families two days per week. Counselors are on hand during these times to offer snacks and encouragement, Veach says. The integration of mental health into the hospital also extends to support groups, including a weekly trauma survivors’ network, a family member support group and a peer-led burn survivors group, she adds.

Veach has been helping to implement brief intervention counseling services at Wake Forest Baptist Medical Center for a decade. As counseling services have expanded to be included in more and more of the center’s departments, she has been surprised at how receptive medical patients are to counseling. She says she has witnessed “a deeply heartfelt responsiveness” on the part of patients to being heard and understood. In addition, surgeons have begun to tell Veach how valuable counselors are to the team. They tell her they are heartened to see patients getting care from counselors that they, as surgeons, can’t provide themselves.

Putting people first

Marcia Huston McCall, a national certified counselor and doctoral student in counseling and counselor education at the University of North Carolina at Greensboro (UNCG), spent several decades in health care management before becoming a counselor. She worked in the finance department at Massachusetts General Hospital and then became the business director of several different departments in an academic medical center in Winston-Salem, North Carolina.

McCall, an ACA member, says she went into health care management as a means of helping patients. She thought her business acumen was her strongest skill set and her best way of contributing. Over time, however, she became convinced that the business side of health care was moving farther and farther away from helping patients. “Health care management got so corporate,” she says. “I felt separated from the patients, and I wanted to have that contact.”

McCall realized that the people part of her job was what she loved best and decided that a career shift into counseling would be a better fit. She entered the counselor education program at Wake Forest University and completed her practicum and internship hours in inpatient integrated care at Wake Forest Baptist Medical Center. UNCG also has a relationship with Wake Forest Baptist Medical Center, so McCall completed her doctoral internship there and continues to work at the center as a graduate assistant.

McCall has worked in both the outpatient clinic and the inpatient section of the medical center. She says it is crucial for counselors to be full members of the team by participating in rounds and team huddles. “Having the counselor as part of the team when all the patients are being discussed is really important because you’re not only offering perspective but also picking up on things that might be issues,” she says. “They’re talking about patients you might not see [in the outpatient clinic], but you can pick up on patients that you do need to see.”

“In inpatient, we screen patients ourselves, so we review all the new admissions to our floors and identify the patients we think [will] need our services,” says McCall, a member of ACA. If she notices a history of substance abuse or other mental health issues, McCall brings this up before rounds or in the team huddle.

McCall and the other mental health professionals at the medical center conduct brief assessments with patients for signs of substance abuse, depression, anxiety, suicidality and delusions. In some cases, they conduct brief treatment and perhaps even see the patient a few times, depending on the length of stay. McCall also refers patients for further psychiatric or substance abuse care if needed.

Counselors working in integrated care settings frequently need to use their skills to build rapport with patients. For example, a physician might see signs indicating that a patient has possible substance abuse issues and call a counselor in for an assessment. In many cases, patients will not have sought treatment for substance abuse previously and may have avoided acknowledging that they have a problem.

“We’re walking in, and they may not be very interested in talking about their substance issues, particularly with a stranger,” McCall says. “We have to approach resistant patients in an indirect way and try to understand what their issues are and what they want to do about them,” she explains.

In such instances, McCall says that she rolls with the resistance. Friends and family members have likely been asking these individuals to seek help, but the patients haven’t been ready to acknowledge that they need treatment. McCall validates their resistance by verbalizing the arguments they are making against getting help. She says these patients often respond to her validation by saying, “Yeah, but I really do need help.” She then asks them what they are willing to do to get that care. If these patients voice a desire to pursue substance abuse treatment, counselors at the medical center connect them with specialty resources outside of the inpatient or clinic setting.

“We help them find that treatment and do as much as possible to ensure they actually get there — that everything is set up,” McCall says.

Counselors serve as consultants for the medical team at Wake Forest Baptist Medical Center but also act as advocates for the patients, McCall says. A lot of bias still exists among medical personnel about mental health issues, she explains, so counselors are there to help ensure that patients are seen as human beings who have needs, no matter what they have been through.

Counselors may also get called in when a physician is questioning whether a patient might need psychiatric services. The medical center doesn’t have many psychiatrists on staff, so the physicians are hesitant to call them for a consultation if there is no need for immediate inpatient treatment, McCall explains.

By working in integrated care, McCall says she gets to be a kind of ambassador for the counseling profession. “I have the opportunity to work not just with physicians and nurses, but residents, medical students, pharmacy students and physician assistant students,” she says. “[I] really have the opportunity to interact with people who aren’t used to having counselors as part of the team.”

McCall would like to bring even more of the counseling perspective into integrated care. She contends that “behavioral health” is too narrow of a designation and believes that counselors should define their own roles and use terminology that is more appropriate to the counseling profession. McCall says she wants her team, as well as other medical personnel working in different integrated care settings, to be aware that professional counselors are not just behaviorists but also possess many other skills. For example, McCall envisions counselors having a central role to play in helping patients who have gotten a shocking diagnosis or who are struggling with the inherent vulnerability of being in the hospital.

McCall also cautions counselors entering the field to be aware that supervision in integrated care settings is rarely provided by other counseling professionals. It is vital for counselors to maintain their professional identity while operating within integrated care, she emphasizes, even if that means pursuing additional supervision outside of the integrated care setting. Receiving ongoing supervision when working in integrated care is critical because the work can be intense and overwhelming, McCall says. Peer support and supervision can help counselors deal with stress and avoid burnout, she concludes.

Training students in integrated care

Some counseling students interested in integrated care are adding medical knowledge to their counseling skills. Rachel Levy-Bell, assistant professor of psychiatry and associate program director and director of clinical training in the mental health counseling and behavioral medicine program at Boston University School of Medicine (BUSM), teaches and trains counseling students to work in integrated care. The program at BUSM focuses not just on counseling but also behavioral medicine, so students take integrated care courses, learn about psychopharmacology and human sexuality, and get bedside training in getting to know the patient beyond the disease, says Levy-Bell, a member of ACA. She supervises practicum and internship students working in Boston University-affiliated clinics and other Boston community centers.

As part of practicum, Levy-Bell trains small groups of counseling students to conduct biopsychosocial interviews. Each week, the 10-member group receives a list of patients and their medical issues. As the counseling students visit the patients, they take turns being the lead interviewer. Students ask patients about what brought them to the hospital and deduce whether they fully understand their condition and how their disease affects their lifestyle, relationships and work. They also ask how patients physically manage their disease, how they cope with its demands and whether spirituality or religion plays a role for them. They also assess for substance abuse.

At the end of the interview, Levy-Bell asks the patients how they felt the students performed. Many patients share that they like that the students spent more time with them than the medical personnel typically do and also comment that the students are better at maintaining eye contact with them when talking and listening. Afterward, the group goes back to class to evaluate and discuss the interviews: What went right? What do they need to improve? What did they learn?

Part of the training process is getting counseling students used to working in medical settings and grappling with issues such as how to build therapeutic rapport when the patient has a roommate or when medical equipment is everywhere and beeping noises are constant, Levy-Bell says. Students are also exposed to things that they’ve never seen before. These experiences might make them uncomfortable, but they have to learn to control both their verbal and nonverbal reactions to ensure that they aren’t indicating discomfort, she says. Levy-Bell also focuses on practical aspects such as teaching students not to faint — or, at a minimum, fainting away from the patient. She also teaches students to wear light clothing (hospitals are hot), to stay hydrated, to make sure they eat and to take a break if they feel unsteady — but to always come back.

Sara Bailey, an ACA member who works at Wake Forest Baptist Medical Center as part of her postdoctoral fellowship, says that regardless of whether counselors plan to go into integrated care, working in a behavioral health setting provides excellent training. In integrated care, counselors-in-training get the chance to see how other professionals such as doctors, nurses and other mental health practitioners work and handle challenges, she says. They also quickly become aware that all practitioners encounter individuals with alcohol or substance abuse problems.

“In a perfect world, this would be required,” Bailey says. “You get to hone your reflection and rapport-building skills and have to learn to do your best in a short amount of time.”

 

 

****

 

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:

Counseling Today (ct.counseling.org)

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

  • “Integrated Care: Applying Theory to Practice” with Russ Curtis & Eric Christian (HT030)

ACA Interest networks (counseling.org/aca-community/aca-groups/interest-networks)

  • ACA Interest Network for Integrated Care

 

****

 

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

Letters to the editorct@counseling.org

 

****

 

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.

Counselor supervision: Reflections and lessons learned

Compiled by Bethany Bray

[EDITOR’s NOTE: This is an online-only companion article to “Guiding lights,” a feature on the ins and outs of the counselor supervision process appearing in the June issue of Counseling Today.]

 

Counselor supervision can have quite a steep learning curve — one that often comes with several ups and downs for beginning counselors.

Counseling Today recently asked several American Counseling Association members about their experience navigating the supervision learning curve. They share their thoughts here so that others can learn from their journeys along the sometimes-bumpy road into professional practice.

 

Fill in the blank: I wish I had known ________ when I was in my supervision.

 

“I wish I had known that it was OK to think outside of the box. I am a naturally creative and intuitive person, but I tried to reel all of that in during supervision. My supervisor was very structured. I still learned a lot, but it took me many years of practicing as a counselor before integrating who I am into my work as a counselor.

Be open to your supervisees interests — you can miss out on opportunities for them to grow, otherwise.”

Stacey Brown, a licensed mental health counselor (LMHC) and clinical supervisor in Fort Myers, Florida

 

” [In supervision,] I felt that I couldn’t make a mistake because it would be evidence that I’m not a good counselor. I felt scared, instead of realizing that my supervisor was interested in knowing me as a person and interested in my development. [My supervisor] wasn’t looking for me to be a fully-formed counselor, they were expecting me to be a novice, and expecting to provide modeling and encouragement for improvement.

Now, I remind my students: If you’re scared and hiding [things from your supervisor], those are the students who don’t do as well, as opposed to those who are open and seeking growth. Be honest about your weaknesses instead of not acknowledging them.”

Summer Reiner, LMHC, clinical supervisor and associate professor and school counseling coordinator at the College of Brockport, State University of New York and president of the Association for Counselor Education and Supervision

 

“One of the hardest lessons for me in supervision was [learning] the boundary of my own responsibility with my client. I was always wanting more [for them], feeling like I was responsible for more of their change and their experience. [Feeling that] it was somehow my fault or responsibility that they weren’t making progress in a way we wanted to see.

It took some very strong and honest supervisors [for me to learn not to feel that way]. That’s a level of insight, something you can’t give anybody. They helped me find my way.

One supervisor challenged me with ‘where does Kathryn end and where does your client begin?’ At first, I didn’t know that that meant. But it has really stuck with me.

It’s a very common, normal part of development as clinician [feeling responsible for client change]. We can have a parallel process of that, as supervisors — feeling responsible for the growth of supervisees: Where do they begin and we end?

It’s really about being the best that we can for our clients, and supervisees, and acknowledging that we don’t have all the answers.”

Kathryn Henderson, a licensed professional counselor (LPC) and assistant professor at the University of Saint Joseph in West Hartford, Connecticut

 

“I wish I knew how to advocate for myself within supervision. A lot of times, I didn’t speak up when I was in situations I didn’t feel comfortable in. I wish I had known how to advocate within supervision and how to broach [tough] conversations. But more importantly, knowing how to spot a supervisor who would be willing to broach [those conversations] and model wellness.

I wish I knew [then] how to spot a strong supervision relationship from a weak relationship because ultimately that’s how we benefit.”

Kevin Doyle, an LPC and counselor educator who begins a position as assistant professor of mental health counseling at the University of Tennessee at Chattanooga this fall

 

I wish I had known:

  • How to navigate cultural barriers in the supervisee/supervisor process
  • How to advocate for quality over quantity for clients (providing quality clinical services to the client while meeting the agencies financial demands)
  • How to obtain clarity of expectations for my role in practicum/internship
  • That the process would be arduous at times

Kerri Legette McCullough, an LPC, licensed clinical professional counselor (LCPC), doctoral candidate at Argosy University and a mental health therapist at Hillcrest Children and Family Center in Washington, D.C.

 

 

“I had learned that in clinical supervision, I would learn how to function in the role of a counselor. Here’s what I didn’t know: I did not know that it was okay to not know things — that actually, it was pretty much expected that I wouldn’t.

I was unaware that clinical supervision could be an intuitive process — or that I would learn so much just within the context of the supervisory relationship. I was unaware of the full potential and was not expecting it to be as transformative as it has been for me, in both professional and personal ways.  I think that if I had known this in the beginning, I definitely would have had a lot less anxiety about the process. But experiencing it in real time has been a valuable part of becoming a counselor.  I wouldn’t change it.”

Alicia Simmons, a counselor intern working toward counselor licensure in Florida and a clinician and play therapist at an agency that serves children removed from their homes due to trauma or neglect

 

 

 

 

 

*****

 

 

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

 

****

 

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.

 

 

Past trauma in counselors-in-training: Help or hindrance?

By Bethany Bray May 20, 2018

Counselors are not immune to trauma — in fact, far from it. Many practitioners say that personal or familial experience with trauma or mental illness actually spurred them to become professional counselors.

The connection between personal experience and the pull to become a counselor is something that is hard to quantify, but “in my personal experience, I encounter it pretty frequently,” says Allison Pow, a licensed professional counselor in North Carolina and adjunct professor at both Wake Forest University and the University of North Carolina at Greensboro. “For a lot of people, past experience draws them into the counseling field, and trauma can play such a pivotal part in someone’s life. It’s a common thing that we see as supervisors and counselor educators.”

Past trauma can be either an impairment or a kind of “benefit” for counselors-in-training, depending on how much the person has worked through and processed the effects of trauma, say Pow and Amber Pope, a licensed mental health counselor and program chair of the clinical mental health counseling program at Hodges University in Fort Myers, Florida.

Counselor educators and other professionals in the field who have close contact with counselors-in-training should keep an eye out for red flags that may indicate that a person’s past trauma is interfering with their growth as a counselor or, in a worst-case scenario, has the potential to cause harm to clients.

“Just because you’ve been through trauma doesn’t mean you can’t become a counselor. You can become a great counselor if [your trauma] is processed correctly,” Pope says.

Pow and Pope co-presented a session, “Wounded healers: How to support counselors-in-training who have experienced trauma,” at the 2017 ACA Conference & Expo in San Francisco. The term “trauma” can encompass a wide variety of experiences, from an acute event to yearslong, developmental trauma, Pow explains.

People who have processed the effects of past trauma — often with the help of a therapist of their own — can become excellent counselors, Pow says. Posttraumatic growth and healing from the experience can foster empathy and strengthen coping skills.

“Going through trauma is a very unique experience [through which] you understand the way your brain works and your body reacts. That is hard for someone to understand who hasn’t gone through that,” Pow explains. “I have had some students who were very resilient because they have been forced to cope [in traumatic situations] in the past.”

“The reason a lot of people become very, very good counselors is their life experience,” Pow adds.

However, people who haven’t fully processed the trauma in their backgrounds can run into trouble as professional counselors. For example, in client sessions, they risk becoming triggered by topics that clients bring up and may be unable to regulate their own emotions or other behaviors in response. These reactions can harm the delicate balance of trust between practitioner and client.

“They may unwittingly be using their role as a counselor to work through their own unprocessed material or to recapitulate an unhealthy power dynamic to feel that they’re in control,” Pow says. “Control is often something that people seek after going through trauma. It may come from a lack of self-awareness.”

 

Red flags

Interactions with classmates and colleagues might be one of the best indicators of whether counselors-in-training have a trauma history that still needs to be worked through. During moments of vulnerability, do they become aggressive or reactive or express other strong emotions? In general, a lack of self-awareness, such as oversharing in class or being unaware of how the people around them are feeling, can be an indicator of unprocessed trauma, says Pow, who has a private practice in Greensboro, North Carolina.

Also watch for attachment issues or signs of avoidance, such as skipping classes or evading one-on-one contact with a professor or authority figures, Pow says. It can also be indicative of a trauma background if students do not generally have themselves together, including missing assignments or being late to class repeatedly, Pope says.

Other indicators can include:

  • Poor boundary keeping: This may manifest as oversharing, attention-seeking or disruptive behavior in the classroom, or an unhealthy preoccupation with relationships with classmates or colleagues.
  • Low self-confidence: Students with unresolved trauma may demonstrate low belief in themselves regardless of past successes. They may feel like they can “never do enough,” Pope explains. These students may lack motivation or even self-sabotage, such as missing a deadline even though they are capable of meeting it.
  • Rigidity in thinking: If students aren’t open to receiving feedback and unwilling to take constructive criticism, it can be a major indicator of past trauma that hasn’t been resolved. This attitude can stem from a black-and-white way of thinking in which the student categorizes things as “all good” or “all bad” with no in between, Pope says.

Everyone has bad days now and then that can set them off. However, if a student is repeatedly unable to regulate their emotions, such as becoming reactive or upset in class, it is a red flag, Pope says.

“When a student is so set in their values or way of thinking that they try and impose it on others, that can stem from trauma. If they can’t become more flexible in their thinking process or relationships with others, then they’re going to have a difficult time with clients,” she explains.

 

When it’s time to intervene

It is beneficial, for any number of reasons, for counselor educators to get to know and connect with the students in their program, Pope says. If a particular student seems to be struggling with challenges that could keep them from becoming a proficient counselor — such as issues related to unresolved trauma — it is better to intervene sooner rather than later.

Be prevention-focused instead of reactionary, Pope suggests. The longer a student continues in a graduate counseling program, the harder it will be to check their behavior or make decisions about their future.

“Don’t let students waste time and money if they’re not going to be a good fit,” she says.

Counselor educators who identify students raising red flags should pull them aside after class or ask them to stop by the counselor educator’s office, Pope advises. The first interaction with the student should be kept informal and light. Let them know that you have noticed some patterns and indicators in their behavior that require some attention, and ask them what supports they need to help them make improvements, she says. If appropriate, other professors or colleagues who know the student can sit in on this initial informal meeting to offer support, Pope says.

Check in with the student frequently during class breaks, supervision meetings and other opportunities. Ask how the student is doing and how they are practicing self-care. This conveys to the student that the professor wants them to succeed and grow, Pope says.

Pope emphasizes that this method should be applied only to counseling students who haven’t committed an egregious offense or intentionally gone against the ACA Code of Ethics. In those cases, a swifter and more formal response is necessary.

If a student does not begin to change their behavior after a first informal meeting, consider meeting with the counselor-in-training again to create a formal written behavior agreement. Spell out which behaviors aren’t acceptable, why those behaviors aren’t acceptable and what they need to do to continue in the counseling program. Be specific and include a timeline of when the expectations must be met, Pope advises.

If the student meets the requirements in the behavior agreement, they should be allowed to continue on with graduate school. If not, suggest that they take a semester or other time off to get the help they need, or leave the program entirely.

“When a student is given feedback and continues in their behavior patterns and doesn’t make any changes, that’s showing me that the student isn’t ready to change or do what they need to do to grow professionally,” Pope says.

Throughout the process, Pope says, she would recommend that the student attend counseling. There is some debate within counselor education as to whether it is ethical to require students to attend personal counseling . In the case of recommending a student to personal counseling, a counselor educator can request the student to provide proof, in the form of written letters from a provider, that they are attending therapy sessions and making progress to demonstrate their willingness to comply with their professors’ recommendation.

“We’re very open, telling students that we [their professors] have all attended or are attending counseling, and that it’s important to be as healthy as you can be, [to] take care of yourself mentally and emotionally,” Pope says.

Although sometimes uncomfortable, this process is also an opportunity for counselor educators to model what a healthy professional relationship should look like, Pope notes. It shows students that you can give critical feedback while caring and maintaining empathy.

“You can give suggestions and guidance while keeping professional boundaries. They may not have had that [example] in their life before,” Pope says.

“In my classes, I make a point of being very transparent with my expectations and predictable. I have a standard of which behaviors I respond to and which I don’t,” Pow agrees. “For a student who has gone through trauma, it’s not our job to be their counselor. But a lot of times their lives haven’t been predictable, and they haven’t had a safe base. We can be that predictable, safe base. We can talk openly about their struggles, getting help and that it’s not a bad thing that you’ve had some challenges in your life.”

 

Gatekeepers and guides

Counselor educators must strike a fine balance between acting as gatekeepers for the profession and serving as mentors and guides for those who need extra support, Pope says.

“When it comes to student trauma and challenges, for me, an ideal situation is when I can have enough conversations with a student so they can come to their own conclusions on whether the field is right for them or not,” Pow says. “Part of effective trauma treatment is creating choice and putting decision-making back into the person’s hands. That may be the choice to take some time off and return to the program. Emphasize where they have agency in things.”

It’s OK for a student to come into a graduate counseling program with unresolved trauma issues. They just have to be willing to work on it, self-process and accept help, Pow says. Students who are open to self-reflection and constructive feedback can experience a tremendous amount of growth, she says. “It’s unreasonable for us to expect, as educators, that people are going to come into these [graduate] programs having processed everything that has happened to them and be completely self-aware,” she affirms.

Processing and rising above trauma builds skills that are the hallmarks of a good counselor, including a strong sense of self-awareness, empathy and sensitivity. Counselors who have successfully processed their past trauma can become models for clients struggling with similar issues, Pope says.

“If you heal from a trauma, you really have to engage with the most vulnerable parts of yourself. It’s a depth that people who haven’t been through trauma may not fully understand,” Pope says. “That’s what creates really great counselors — [to be able to] engage with others at that level of vulnerability and intimacy. Knowing that going through something so challenging, you can become more whole, and in turn become a safe place for others. As a counselor, you’re better able to serve your clients.”

 

****

 

Related reading

  • For more on supporting counselors-in-training through the supervision process, see the feature “Guiding lights” in the June issue of Counseling Today.

 

 

Suggested resources

Want to learn more on this topic? Pow and Pope suggest these titles:

 

 

 

 

 

****

 

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

 

 

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

 

 

****

 

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.