Monthly Archives: January 2019

Voice of Experience: Facing the wind

By Gregory K. Moffatt January 22, 2019

Sofia’s clothes were stylish and neatly pressed, and her jet-black hair was immaculate. Cropped short, not a strand was out of place. Subtle makeup highlighted her athletic features and youthful appearance, making her look much younger than she actually was.

Only by looking closely could I see a hint of red in her eyes. She had cried on the way to our appointment. Not surprising. Her life as she had known it was over.

Just two months before, Sofia (not her real name) had been a typical wife of a dozen or so years and the mother of two grade-school children. Aside from her stunning beauty, she could have been any one of a hundred other mothers in a car-rider pickup line or wandering the aisles of the grocery store. The life she shared with her husband consisted of packing school lunches, shuttling children and their playmates to soccer practice, managing their suburban home and running a small real estate business.

But all of that changed in a heartbeat. One careless decision led to a fleeting affair, which Sofia confessed to her husband, and their marriage was over. He couldn’t bring himself to forgive her, so she agreed to move out. Sofia was living in a small garage apartment belonging to a friend and saw her children for only a few hours on Saturdays.

Sofia was consumed with grief and, although you couldn’t tell by looking at her, every day she could scarcely get out of bed. The burden of her sadness was so heavy that, as I got better acquainted with Sofia, I could almost see her regrets weighing on her shoulders.

This isn’t a novel tale. Any of you reading this could undoubtedly identify many faces from your own client files, male or female, that would easily slip into the general details I’ve just laid out. After all, one of the main reasons people come to see us is because they’re facing the pains of life.

But one thing set Sofia apart from all of my other clients over the years. She taught me a lesson that has not only made me a better therapist, but has also helped me to manage my own depression as it has waxed and waned through the decades.

As much pain as she carried, Sofia forced herself daily to get out of bed and face the day, regardless of the tempest that was her life in the moment. Please don’t mistake my details of her appearance as misogynistic. My intent is simply to be descriptive of how much energy she spent preparing for the business of the day.

Anyone who has worked with grieving clients, clients experiencing major depressive disorder or similar diagnoses knows that failure to attend to personal hygiene is common. I have had clients come to sessions without showering, with their hair not having seen a comb or a brush in days, and still wearing a food-stained sweatshirt-and-sweatpants combo that doubled as their pajamas.

Not Sofia. Yet her appearance wasn’t an expression of vanity. It was one of professionalism and determination. She took full responsibility for her role in the dissolution of her marriage, but she refused to wallow in regret. In the most healthy way, she said to me more than once, “It is my fault, I am devastated, and I’m so sorry, but I will rebuild my life.” And she did.

Sofia’s appearance was an apt metaphor for a philosophy that said, “I will not be defeated.” And it worked for her.

In those early days of her new life, Sofia awoke each morning to face a strong headwind, but she plodded forward. Over the course of her recovery, the gale weakened into occasional gusts and, eventually, manageable breezes. All the while, the hole in her heart also began to heal.

As I’ve helped other clients work through life’s difficulties, I’ve recounted Sofia’s story numerous times. Even when she didn’t feel like it — even when it seemed her life was over — she got up, faced the day and conducted the business of life. What a powerful example.

Our final appointment was very brief. The cost of therapy was part of Sofia’s decision to terminate, but not the biggest reason. She explained that her days were getting easier and, just 15 minutes into the session, she thanked me and said, “I think I will be OK.” I couldn’t argue with her. As the door closed behind her, I knew she possessed the skills she needed to continue her recovery.

I was a very new therapist in those days, and I sometimes wonder which of us got the better deal. I doubt Sofia remembers me, but because of the lesson of courage she demonstrated, I’ll never forget her.

 

 

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Gregory K. Moffatt is a veteran counselor of more than 30 years. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

 

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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.

Technology Tutor: Taking a closer look at telehealth

By Rob Reinhardt January 16, 2019

As people in a helping profession, many counselors know the frustration of something getting in the way of us being there for our clients. At some point in our careers, we all must deal with scheduling conflicts, illnesses, weather delays and other events outside of our control. Typically, these are temporary setbacks, and we find a way to adjust. Other situations, especially those we don’t feel make sense from a client care perspective, can be particularly frustrating, however.

A modern, timely example of this is when trying to help clients from outside of our own state. Many situations can cause this to occur. Among the examples I have personally encountered include:

  • Working with an adolescent who later went off to college in another state
  • Working with a businessperson whose career required being out of state for weeks at a time
  • Working with a military family that was reassigned to a new location in another country

The list of potentially similar circumstances is endless. The good news is that modern technology makes it possible to continue working with these clients through telehealth (i.e., using secure video while complying with the Health Insurance Portability and Accountability Act). In fact, there is mounting evidence that counseling services delivered via telehealth can be as effective as in-person services (see ncbi.nlm.nih.gov/pmc/articles/PMC5723163). Problem solved, right?

The barrier to telehealth

Unfortunately, there continues to be a significant barrier to this interstate solution: the lack of counselor licensure portability/reciprocity between states. Our professional licensure is “state based,” meaning that we have to apply for licensure in each state individually. Even if we are licensed in one state, we start from scratch in applying in another. Currently, our licensure will not transfer. (Note: In October, the American Counseling Association Governing Council approved the initial endorsement and funding of a professional occupation interstate compact for professional counselors that could help to make licensure portability a reality in the future.) This matters for telehealth because we can’t practice counseling in a state in which we are not licensed, at least not without permission. More on that in a bit.

I’ve often come across counselors who have made assumptions such as: “Well, my client is going to be there for only a couple of weeks, so it shouldn’t matter” or “My client’s not going to be an official resident of that state for a while.” Both of these assumptions, as well as other related assumptions, are problematic.

Here’s the simple reason why: State counseling licensure boards exist to protect everyone in that particular state. It ultimately doesn’t matter how long that person is there.

Yes, state counseling licensure boards do things such as process our applications and ensure that we are getting enough continuing education. But they do these things to serve their primary purpose: protecting the public. The laws they enforce won’t allow just anyone to call himself or herself a licensed professional counselor, which helps ensure that the public receives proper, ethical care. Following that logic, to protect people within their borders, these boards won’t allow just anyone to “telehealth in” from another state to provide care.

Yes, we can argue that this sometimes presents a barrier to providing clients needed care. Yes, we can argue that it’s a barrier to quality mental health care in general. Hopefully, we can take it many steps further, arguing vociferously until we have a national counseling licensure or at least reciprocity between states. In the meantime, however, we cannot ignore the legalities and liabilities of the situation. And it doesn’t mean that we are currently without options. Some states will allow counselors to practice there temporarily, but this will require you to do some research and to make some contacts.

Tracking telehealth laws

A good starting point is Epstein Becker Green’s telemental/telebehavioral health survey (see ebglaw.com/telemental-telebehavioral-survey). This survey endeavors to track telehealth laws as they pertain to the provision of mental health care in all 50 states. It breaks down telemental health laws not only by state but also by professional licensure. The survey includes information on whether each individual state allows out-of-state providers to temporarily practice within the state, and it also includes links to governing boards.

It is important to note the following caveat: The original survey was done in 2016 and has been updated with a 2017 appendix that is 316 pages long. Telehealth laws are changing that quickly. Given that fact, it will be important that you:

1) Visit the state board website in question to investigate whether any changes or new information have been added

2) Contact that state board and ask it directly about your situation and the granting of temporary privileges

3) Document everything

It is also important to be aware of your own state’s licensure laws to ensure that they don’t include any restrictions that might affect you. As always, consultations with your attorney and your liability insurance company are also advised. You must also be aware of other ethical, legal and counseling ramifications before providing telehealth services (for more, see tameyourpractice.com/telehealth). With a bit of due diligence, you may be able to continue providing care to clients in many interstate situations.

 

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Rob Reinhardt, a licensed professional counselor supervisor, is a private practice and business consultant who helps counselors create and maintain efficient, successful private practices. Before becoming a professional counselor, he worked as a software developer and director of information technology. Contact him at rob@tameyourpractice.com.

 

Letters to the editor: ct@counseling.org

 

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

The pros and cons of contracting with online counseling companies

By Melanie Person January 15, 2019

The day I decided to close my private practice and move to another state was one of both excitement and remorse. I knew that I would be starting from scratch in building a practice in a new region, yet I did not have the time and energy to devote to the marketing and networking that are essential to building a practice. As I scrolled Facebook trying to avoid my grief and frustration, I repeatedly saw ads for online therapy platforms: iCouch, Talkspace, BetterHelp and so on. My interest was piqued. I had a desire to start working with clients again, but I wanted to exert minimal effort in obtaining them. So, I ultimately decided to attempt to supplement my practice by contracting with online counseling providers.

In the 21st century, technology has become a regular and expected part of our daily lives. The convenience it affords can be overwhelming to consider. As a counselor educator and professor in a graduate training program, it is essential that I keep my finger on the pulse of the counseling world, and I believe that technology will continue to be integrated into our work as helping professionals.

I have used technology in my private practice over the years for tasks such as managing client files, sending out reminder texts, recommending apps for mindfulness and other coping strategies, and assessing client satisfaction. Technology has become more integrated into the counseling profession over the past few years, and I cannot envision a future in which this trend does not continue.

But even setting aside our society’s propensity toward all things technological, I decided that contracting with online counseling providers would be the most hassle-free way for me to build up my practice. Here is what I learned.

Selecting a company

Several companies currently provide clients with access to counselors through online chatrooms, messaging forums, and video and phone sessions for a monthly subscription fee. Frequently, these companies will advertise a service that provides subscribers with unlimited access to a counselor for one low monthly charge.

Intrigued by the direction this field is moving, I decided to contact three of the most well-known providers of this service. All of these companies followed up with me immediately, but each had a very different process and focus. One company simply wanted information from me so that I could be registered with its agency, whereas the other two companies provided a screening process and were interested in my competence with providing counseling, both in general and over the internet. I have no desire to make this my full-time practice, so I decided to focus on the company that provided the most rigorous professional assessment process.

One particular piece of screening that I appreciated from the company I chose was the statement that my application would become inactive if I did not respond to homework assignments or provide the required information proving my status as a licensed counseling professional within one week. From my perspective, there was something reassuring and professional about the company taking this stance. Online counseling agencies frequently post job advertisements because they want prospective clients to have a wide variety of clinicians to choose from. This screening statement was one of the first hints I received that this online company valued the client and the integrity of the counseling profession and was not merely trying to add clinician names to its roster.

The ‘interview’ process

Once I settled on going with the company that I felt was most knowledgeable and invested, I began following through on the requests put forth by its management. For example, I answered homework assignments to demonstrate my potential responses to clients. I defended my theoretical orientation and discussed flexibility in that orientation to allow for meeting client needs. I quickly responded to these inquiries and somewhat enjoyed the guided exploration of my values and skills in counseling.

I shouldn’t have been surprised when the company contacted me with the final step of its process: an interview. However, the “interview,” which took place in the virtual space provided by the company, was not what I had been expecting based on my previous interactions. It consisted of a member of the administrative team asking to see my driver’s license, then describing to me how the company complies with the Health Insurance Portability and Accountability Act (HIPAA) and the ACA Code of Ethics, and avoids working with clients who have intense needs or are actively suicidal. He then proceeded to tell me that if a client were actively suicidal, the company would handle the transition of the client to a modality that would allow the client to access crisis services.

The interviewer had no desire to hear about why I was interested in this modality of counseling, didn’t care about my experiences and, admittedly, was not a clinician himself. After he finished explaining the process of client selection and screening, he asked me to fix a few minor details on my online profile that clients would access and requested that I reupload the photo of my counseling license. Once the video interview ended and we were disconnected, I was reminded that I was joining a business as much as I was joining a service.

Aside from the vetting process that this company requires, I was drawn to this company because it offers scholarships for clients who are struggling financially. As someone who is passionate about client care, I liked this focus on and care for those who are less privileged. So, I assuaged my concerns and continued on.

Getting going

After completing the minor changes and uploading my license for a second time, I received an email indicating that the company was giving my information a final look and would be in contact with me in the next 10 business days to confirm my contractual relationship. So, I was surprised when, three hours later, I received an email welcoming me to the company and asking me to pick a shirt that would later be shipped to me. The email also provided step-by-step directions for opening my profile online so that I could be assigned new clients.

Excited to start this process, I followed the directions and moved my cursor to indicate that I was “open” for new clients. Within three minutes, I was assigned my first new client — an individual struggling with a divorce that was not his choice. I immediately responded to his message, and the messages for that day began to flow. Within 10 minutes of obtaining my first client, I was assigned my second. Within 30 minutes of the second, the third appeared. By the end of the day, I had nine new clients and was sufficiently overwhelmed with the relational requirements of connecting with each of these individuals.

It would be difficult enough to establish therapeutic alliances with nine new clients as they sat directly across from me, but trying to remember details about and establish relationships with these online clients, including some who didn’t provide a name, proved almost too much for me to manage. These clients were able to use initials or pseudonyms instead of their real names, and only one of the nine clients had a picture associated with their profile. I consider myself to have an excellent memory, but I was struggling to connect issues to the names (or, sometimes, just a single initial) provided by the clients.

Suffice it to say, my first day of contracting with this service was exhausting. Of course, I must acknowledge that I am someone who likes to take care of communication with others as soon as possible. As a professor, I have received several rounds of applause over the course of my career for being a faculty member who immediately answers student emails. I gain a sense of accomplishment from an empty inbox and like to keep myself organized. If I can respond to an inquiry quickly, that is one less task nagging me when I slip into bed. I was not prepared for how this personality trait would translate to online counseling. I was going to need to reassess my boundaries and become comfortable with leaving a message unanswered at the end of the day if I was going to survive providing online counseling.

At the start of the second day, I considered quitting, but I weighed the pros and cons of continuing and found that my desire to learn this evolving form of counseling outweighed my desire to throw in the towel. This discernment led to a renewed commitment and a plan of action to create manageable expectations for myself and my clients.

Establishing boundaries

The first boundary I enacted for myself was switching off my “available to new clients” sign. After giving it much consideration, I determined that I could not successfully provide quality counseling services to more than five clients through the online service while also trying to get tenure and maintain my small in-person private practice (let alone raise my two young children). As soon as I switched off my availability, a wave of relief washed over me.

Now I had the task of managing the nine clients I had already been assigned. Three of those clients have not sent me any messages, meaning they have not required my attention (they remain on my roster though, indicating that they are still paying the monthly subscription fee). So, my job boiled down to managing the six clients who were actively engaged.

In attempting to find my footing, I inquired about the willingness of each client to meet for a video session. This was one of the smartest moves I could have made. I found that five of the six were excited and desired to meet through video. The other client had signed up for this service specifically to avoid the face-to-face contact. She remained content with message counseling.

Meeting the five clients individually through the use of video sessions allowed me to connect information to a face rather than just to a name or an initial. In turn, this solidified my conceptualization and understanding of each client. Plus, it was far easier and more time efficient to collaborate via voice and video rather than the pingpong of written words. Once I met with my clients through video, I was more comfortable and relaxed in this new format.

After limiting the number of clients I was willing to work with through this medium, I next needed to identify a schedule for checking and responding to messages. I looked at some of the online forums the company offered and read how their different providers were managing their schedules. I learned quickly that most of these providers had set hours and times that they would check messages and respond to clients. Some providers chose to check twice a day, whereas others indicated that they checked and responded every two to three days. This variability of schedules increases the need for any prospective provider to communicate upfront with their clients about what they can expect from the provider and the online service. This approach allows clients to find an online counselor who is available to the degree that they want. It also helps to prevent against a provider not meeting client expectations.

One of the hardest parts of learning this system for me has been receiving an email that a client has shared a message and not being immediately drawn to check and respond to that message. I was made aware from the outset that this is not a crisis service and that clients know that each counselor has his or her own method of responding to clients. Honoring this and not having unrealistic expectations of your ability to communicate with clients is imperative to being successful with these companies.

Six months after sending my first message to my first client, I am very thankful that I joined the site I selected. I have been able to engage with clients again and have made a fair amount of money working at my own pace and time. I would recommend this avenue for counselors looking to take on new clients and who have the freedom and flexibility to work with these contracting companies. Although the pay is poor and the process new, the experience has been more than I had hoped for.

Take-home lessons

1) Research and read reviews of the companies you are considering joining. There is a wide range of understanding and dedication to the field of counseling among these online services. Finding one that aligns with your view of the counseling profession is essential to successful practice.

2) Know your limits. Before accepting new clients, decide how much time you would like to devote to this type of counseling and have a manageable schedule and plan for responding to messages.

3) Find new ways to develop relationships. It was helpful for me to use the video sessions as a bridge in learning this new modality while holding on to a form of counseling that is comfortable for me.

4) Figure out how you will relay your commitment to the site to your clients so they will have realistic expectations of how available and responsive you will be.

5) Use the support systems found in many of these companies. Often, these companies will provide forums and discussion boards so that providers can connect and consult with one another. Embrace this new online professional community that you are joining and allow yourself to learn from others who have been providing these services for a while.

6) Be realistic about how much you will receive in reimbursement from these companies. The company I joined paid $10 for every 1,000 words communicated by me or my client (video and phone sessions are counted as 50 words per minute). It is also imperative that you identify the company’s monthly maximum reimbursement per client. The company I joined stop reimbursing after 12,000 words a month. If you are not mindful of these limits, you will be providing a lot of support and counseling without receiving any reimbursement.

7) Don’t forget that counseling is counseling, whether it is happening live or through some form of technology. Although the essential skills of counseling are still relevant in this form of counseling, they need to be modified and conceptualized slightly differently to be successful with this modality. For example, I learned to withhold confrontations until the clients demonstrated a willingness to be challenged. Because the therapeutic relationship can be more difficult to monitor through messaging, it is imperative that you learn how to check your clients’ readiness to be challenged. In this form of counseling, it is very easy for your clients to click a button and find a new counselor. This can be great for clients, but it can leave many counselors with unanswered questions about what happened and where their clients went.

 

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Melanie Person is an assistant professor in the Department of Counselor Education at Gonzaga University. She is a licensed clinical professional counselor and a licensed mental health counselor. Contact her at person@gonzaga.edu.

 

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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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.

 

Volcanic adolescence

By Chris Warren-Dickins January 14, 2019

In the early days, Caroline, a 14-year-old girl, started each session with a chin thrust indignantly at her counselor. She wanted to be seen as a warrior, and she offered answers that were blunt as a sledgehammer.

And why should she drop her defenses? She had seen too many adults — teachers, social workers, friends of the family — try to engage with her at first, and then seemingly lose interest. In the end, she felt that she was just an inconvenience to everyone around her. Why should Caroline believe that this counselor would offer a different type of relationship?

With any new client comes the challenge of forming a therapeutic relationship, but when that new client is an adolescent, there are additional factors to consider. Aside from the legal issues of capacity and consent, I discuss 10 of those therapeutic factors below.

 

1) A holistic assessment: It is important to adopt a strengths-based approach to assessment of adolescents. In addition, it is worth reviewing that assessment more regularly than with an adult client because more things are likely to change with a growing adolescent. As Urie Bronfenbrenner pointed out, a young person’s development is the result of a complex system of relationships that constitute the child’s environment. Therefore, assessments of young clients will include their developmental needs, the extent to which caregivers are meeting their needs, and their family and environmental contexts, including the influence that their school and peers have on them. The assessment should also gauge the influence of technology in the young person’s life.

2) Emotional “distance” from problems: As an adolescent, Caroline needs her counselor to appreciate that she does not have the same “distance” as adults experience from their problems. Adolescents have little control over their lives. They have to stay in the same home or school, even if these things might be the source of their depression, anxiety or other presenting issue.

3) Grasp of emotional language: As a 14-year-old, Caroline still has not developed her emotional language, so volcanic eruptions of anger or shoulder shrugs of apparent indifference are her only means of expressing how she feels. We have to see past the shoulder shrugging, which can easily be interpreted as nonchalance, and open ourselves to the possibility that young clients want to express themselves but just don’t know how to yet.

Images are a useful starting point, even if it is just looking at a series of facial expressions to try and help these clients identify the emotions they are experiencing.

4) The dominance of transition: Transition features heavily in adolescents’ lives. Each year, they are at a different stage of educational development and, each year, they experience bodily changes. On top of all of this, their ideas about who they are and how they fit in with their peers and wider society are in a constant state of flux.

At this level of fluidity, a counselor can offer Caroline some sort of stability. One source of this stability can be the therapist’s professional boundaries. The counselor can also offer Caroline the benefit of his or her life experiences, providing a deeper context than Caroline’s young perspective. But the counselor’s older years and life experience do not provide complete insight, no matter what the client’s presenting issues is, so a person-centered approach is crucial. We, as counselors, do not know Caroline’s worldview until we explore it with her, and we have to be careful not to make too many assumptions.

5) Disruption tenfold: It is hard for adolescents to experience so much transition, but it is even harder to manage at the same time as dealing with mental or physical health challenges, a chaotic home life or a sudden major change experienced by the adolescent’s parents (e.g., job loss, divorce, bereavement).

Because of the volcanic eruptions of adolescence, there is a danger that adolescents will become scapegoats in these situations. Just because adolescents may shout the loudest does not mean they are the source of the problems. Often, parents bring their adolescents for therapy, and these adults are completely unwilling to consider that the need for change might also rest on their own shoulders, rather than expecting just the adolescent to change and the whole family dynamic to become settled.

6) Discrimination experienced by minority adolescents: If an adolescent client is a member of the LGBTQ community or is an ethnic minority, it is likely that they have endured some sort of discrimination. If adolescents have to make sense of this — in addition to the transitions they are experiencing in their bodies, at school and at home — it can be challenging to deal with.

Is it any wonder that we sometimes see volcanic behavior in adolescents in the form of outbursts and defiance, screamed at us in a burning rage? If we are to help these youngsters, we have to see past the behavior that spews out like lava. We must dare to imagine what unmet needs might be fueling this volcano.

To help us, we can consider Abraham Maslow’s hierarchy of needs, and we can assess to what extent our adolescent clients may be getting their basic physiological needs met. Perhaps they are hungry, or there is the constant threat of homelessness hanging over them. Or perhaps their basic safety needs aren’t being met because domestic violence is present in the home. We can continue working our way up Maslow’s hierarchy (love/belonging, esteem and, ultimately, self-actualization) to understand what unmet needs may be fueling what appears on the surface to be irrational and unacceptable behavior.

7) Trauma-informed care: If the adolescent has a history of trauma, it is especially important to see past his or her volcanic eruptions of anger. In a 2017 article in Counseling Today about young clients in foster care (“Fostering a brighter future”), Stephanie Eberts states that therapists need to “help these children heal” by acting as a “translator” of the child’s behavior: “This includes explaining what a child’s behavior means and what motivates it, and then equipping both the child and the parents … with tools to redirect the behavior and better cope with tough emotions.”

8) Testing (to discover and take reassurance from) the boundaries: Adolescents may test boundaries more than adult clients do. Modeling behavior is important, and this is where congruence comes into play. If young clients are constantly pushing the boundaries by turning up late to sessions or missing them entirely, you can communicate the resulting emotion you are experiencing as a result of their behavior.

I like to think of this like a sonar device: Young clients are checking to see if you are still emotionally there and whether they are also still present in the interaction. You can share this with young clients, showing that certain behavior has consequences. Then you can jointly look for a way to resolve the matter.

Psychotherapist Rozsika Parker wrote about parents’ relationships with their children, but the following statements could apply equally to counselors and their young clients. Young clients “need to learn that they have an impact, that it’s possible to hurt” an adult, but it is also possible to “make it up with them.” Parker encourages adults to “show joy, hate, love, satisfaction — the full range of emotions — that will help the child to know themselves.” Parker wrote that she “heard the same note of reproach in their wails when they teethed, as in the studied criticism of me they could launch as teenagers.”

9) The resistant adolescent: As with any resistant client, adolescents need to feel that they are choosing to be in the sessions. But what happens if they are given no choice? If a therapist is working with a young client and the client’s family, and the young client chooses to leave the session early, what should the approach be?

I have heard some therapists adopt the following approach: They tell young clients that they are free to return to the session at any time but that the session will continue with the other family members. I quite like this approach because it avoids sessions becoming hijacked and held hostage by young clients, which might be a parallel process to other times in which these young clients have held more power than they knew how to handle. For example, they might have been forced to adopt a parental role with a younger sibling, or even a neglectful parent, at an inappropriately young age.

10) Mindfulness and meditation: I have seen and heard some of the criticisms of mindfulness and meditation. I struggle with this because, when I was starting out in this profession, my mentors raved about mindfulness and meditation. I need to see where this debate goes, but in the meantime, I cannot help but believe that there might be some value in mindfulness and meditation in our work with young clients.

Everything we offer our clients involves a balancing act between thoughts, feelings and bodily sensations. Society is built to engage the thinking side of our awareness, and this casts a shadow over our feelings and bodily sensations. Yet all three are important sources of information. If we focus solely on our thoughts, we are arguably functioning at only a third of our capacity. Short and simple mindfulness or meditation exercises can help young clients tap all sources of information, while also giving them a moment of relief from the constant demands of life.

 

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Chris Warren-Dickins is a licensed professional counselor in Ridgewood, New Jersey. Contact him through his website at exploretransform.com.

 

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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.

Leading an anti-bullying intervention for students with disabilities

By Katherine A. Feather and Tiffany M. Bordonada January 10, 2019

For more than 40 years, bullying in schools has remained relatively stable and today is recognized as a serious social problem. In 2014, the Centers for Disease Control and Prevention (CDC) and the Department of Education released the first federal standardized definition of bullying, which includes unwanted aggressive behavior, observed or perceived power imbalance, and repetition of behaviors or high likelihood of repetition. In addition, the CDC and Department of Education acknowledged direct and indirect modes of bullying and four types of bullying that school-age children can experience: physical, verbal, relational and damage to property.

According to the National Center for Education Statistics (2015), approximately 1 in 4 students in the United States reported having been bullied at school. However, evidence suggests that school-age children with disabilities are two to three times more likely to be bullied than are their peers without disabilities (for more, see the three-volume set Disabilities: Insights From Across Fields and Around the World). It is absolutely critical for professional counselors to assist those who are targeted and support proactive interventions that decrease bullying for students with disabilities.

Intervention strategies that are grounded in social learning theory and established on client-centered, community-based and experiential methods have been shown to be successful with children who have disabilities. Such interventions have a positive effect on children’s self-efficacy, self-determination and social skills. Furthermore, counselors can adapt experiential-based activities to provide these students with opportunities to learn new skills, make decisions, experience successes and take calculated risks. Finally, counselors need to recognize the strengths of students with disabilities, teach them to feel comfortable with who they are and empower them to implement bullying prevention skills.

This article will outline proactive prevention in terms of experiential group activities that focus on self-efficacy, self-determination and social skills training when working with school-age children with disabilities. The experiential group activity we will be describing was originally developed by Able SC, an empowerment and advocacy organization in Columbia, South Carolina, for people with disabilities. We collaborated with Able SC and tailored the activity to meet the needs of middle school and high school students with disabilities.

Aims

The experiential activity includes four primary objectives that positively affect self-efficacy, self-determination and social skills. The objectives are to help students:

1) Identify and understand various bullying behaviors

2) Recognize the warning signs when a person is being bullied

3) Learn strategies to manage bullying

4) Learn steps to take in the here and now to address bullying

Preconditions

Prior to engaging group members in the experiential activity, several preconditions should be met. First, counselors must have a strong therapeutic alliance with the participants before engaging them in the group activity. Second, counselors should provide proper accommodations to address the unique needs of the group members. Third, counselors must be willing to be creative and flexible to adapt the experiential activity to the individual strengths of the group members. Fostering a strengths-based approach is imperative when helping school-age children with disabilities to explore their self-efficacy. Finally, counselors must display competence with multicultural social justice counseling before working with children with disabilities.

The process

The first part of the group facilitation process involves assisting group members with understanding the various types of bullying (i.e., physical, verbal, relational and damage to property). The role of the group leader is to facilitate a discussion about these various bullying types, which may prompt group members to recognize specific examples. Additionally, the group facilitator should discuss the importance of recognizing real or perceived power imbalance and determining how often the power differential occurs. In other words, was this a one-time incident, or was it done repeatedly to hurt the individual? The group facilitator must guide students in understanding these two concepts that help to define bullying: observed or perceived power imbalance and repetition of behaviors. The group facilitator should also assist students in understanding the confusing distinction between when someone is joking versus when someone is actually engaging in bullying behavior.

To foster another mode of understanding, the group facilitator can also engage group members in a role-play demonstration to act out the different types of bullying. If the participants find it difficult to participate in the role-play, group facilitators can provide examples of the types of bullying to ensure support for students during the demonstration. In addition, it is important to identify the individuals involved with the bullying episode (i.e., bully, target and bystander) to provide clarity during the role-play. For instance, the group facilitator should discuss with group members how the bystander can be the most influential person in the situation either by acting as a solution to the problem or by instigating the bullying. Finally, the group leader encourages group members to identify characteristics of being a bully.

This will help students to recognize these traits so they can avoid engaging with those who display such behaviors.

The second part of the experiential group activity consists of identifying warning signs that an individual might be being bullied. These signs include:

  • Physical signs (e.g., cuts, bruises, scratches, headaches or stomachaches, damaged possessions, missing possessions)
  • Emotional signs (e.g., withdrawal or shyness, anxiety, depression, aggression, suicidal ideation)
  • Behavioral signs (e.g., changes in eating or sleeping habits, nightmares, no longer wanting to participate in school or activities that he or she once enjoyed, bullying siblings)
  • Academic signs (e.g., changing the manner in which he or she gets to school, being driven to school instead of riding the bus, having a noticeable drop in grades)

After determining the group’s understanding of the warning signs, the group facilitator can propose an experiential group activity in which the group members identify strategies to manage bullying. The group facilitator can engage the students in a role-play scenario in which the target initially fights back. The facilitator should then prompt a dialogue on the positive and negative consequences of engaging in this approach. Next, the group facilitator encourages the group to identify nonviolent strategies that the target can use in the same scenario. This will prompt group members to recognize how implementing a nonviolent approach to bullying can be an effective option.

Next, the group facilitator needs to co-construct with the group members prevention strategies to manage bullying behavior. A few general prevention tactics include:

  • Telling an adult
  • Walking away
  • Ignoring the bully
  • Avoiding the bully by interacting with friends or avoiding places the bully is known to be

Group members should be taught to understand the differences between the roles of bully, target and bystander and recognize appropriate prevention strategies that they can use if they find themselves in any of these categories. For example, the group facilitator could encourage the group members to identify effective prevention strategies specifically for the bystander role. These strategies include telling the bully to stop, helping the target to walk away, recruiting friends to intervene and getting an adult.

To reiterate, it is important to provide group members with specific scenarios to ensure that they understand the differences between the three roles and know which prevention strategies are appropriate for each scenario. Furthermore, have group members share times when they have fallen into the specific category of bully, bystander or target to guarantee that they are addressing their personal experiences with bullying.

Additionally, the group facilitator can engage the group in a role-play exercise to review the three categories and to collaboratively identify:

1) The bullying behavior

2) How the target reacted to the bullying

3) How the bystander(s) reacted

4) How the bully responded to the situation

5) Whether the bullying was managed in an effective way

6) How the bullying scenario could have been handled differently

7) How the group members would feel as the target in the scenario

This role-play provides group members with a greater sense of self-awareness as it relates to self-determination, self-efficacy and social skills. In addition, the role-play increases empathy toward others because group members vicariously experience the thoughts, feelings and behaviors of the target.

Finally, the group facilitator can engage the group members in personal action plans to reinforce what was previously reviewed and to address steps to manage bullying (for a detailed figure outlining the personal action plan, see Katherine A. Feather’s 2016 article “Antibullying interventions to enhance self-efficacy in children with disabilities,” published in the Journal of Creativity in Mental Health). The facilitator asks the group members to independently acknowledge personal situations in which they have been bullied; their thoughts, feelings and reactions to the experience; how they handled it; and what they could have done differently. Once they have completed the chart, group members are prompted to share their stories if they feel comfortable. The personal action plan is an important part of the experiential activity because it gives group members something tangible they can take with them to remind them of what they have learned and that they can reference in the future.

Finally, at the discretion of the group facilitator, group members are encouraged to discuss assertive communication and the various communication styles, such as the difference between “I” and “You” statements. This particular discussion can transition into recognizing the importance of self-advocacy and one’s ability to make informed choices. The group facilitator can end the session by reinforcing individual empowerment and emphasizing the group members’ potential to manage bullying. The tools used to combat bullying speak to the group members’ self-efficacy, showing them that they have the ability to exert control over their own behavior, motivation and social environment (as explained by Albert Bandura in his 1977 article “Self-efficacy: Toward a unifying theory of behavioral change”).

Modifications to the process

Counselors who use this experiential activity may wish to adapt the group in the following ways:

1) Assess whether a particular student would be a better candidate for individual counseling and modify the activity for individual, rather than group, counseling.

2) When implementing the experiential training, augment the activity to meet the needs of the group participants. For example, for the personal action plan, participants can use numerous mediums to complete the activity (e.g., act out the steps, cut out pictures from a magazine, draw, write, use note cards with words, use assistive technology, discuss steps verbally).

3) Delivery of the experiential group activity must be based on students’ presenting characteristics to ensure full understanding of the material. For example, counselors need to address a comprehensive range of needs among students with disabilities. Therefore, counselors can provide additional scenarios of the components for the activity. This will encourage repetition and opportunities for practice. Counselors are also encouraged to collaborate with school personnel to ensure that they are meeting the needs of the student and integrating all necessary interventions to promote student success.

4) This experiential group activity may not be applicable for all students with disabilities. We suggest that counselors consult and collaborate with school staff to gauge the appropriateness of the intervention for individual students.   

Considerations

Counselors must intervene in a timely manner by recognizing, assessing and engaging students in activities that will combat bullying and provide them with the skills to be successful in the school environment. However, counselors must be sensitive to group membership. Therefore, counselors may want to consider making the group available to peers without disabilities. Inclusive practices may buffer against bullying by providing peer models to students with disabilities, as well as by promoting social competence among all students. Isolating students with disabilities does not provide them with the practice and validation they need to develop appropriate social skills. Thus, combining students with disabilities and their peers without disabilities fosters an inclusive approach and ultimately enhances a community of knowledge and understanding.

Finally, prior to implementing this experiential activity, we encourage counselors to become familiar with the social model of disability and the capabilities framework versus the medical model of disability. The social model of disability is a different way of viewing the world and challenges the typical attitudes toward disability. Fostering a capabilities approach validates the ideologies of inclusion that stress equality, acceptance and valued participation. The capabilities approach is a holistic social justice initiative that assesses disability on the basis of one’s abilities and functioning within society. Counselors need to recognize the impact that society has on the individual and the barriers that students with disabilities face on a daily basis.

 

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Helpful resources for counselors

  1. PACER’s National Bullying Prevention Center (pacer.org/bullying/resources/students-with-disabilities)
  2. StopBullying.gov page on bullying and youth with disabilities and special health needs (stopbullying.gov/at-risk/groups/special-needs)
  3. “Bullying and Disability: An Overview of the Research Literature” (tinyurl.com/BullyingAndDisability)

 

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

Katherine A. Feather is a licensed professional counselor in Arizona and an assistant clinical professor in the Department of Educational Psychology at Northern Arizona University. Contact her at Katherine.Feather@nau.edu.

Tiffany M. Bordonada is an assistant professor in the Department of Counseling and Human Services at the University of Scranton. Contact her at Tiffany.Bordonada@scranton.edu.

 

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.