Monthly Archives: March 2019

Establishing a private practice

By Laurie Meyers March 22, 2019

“If you build it, they will come.” Most of us are familiar with this popular misquote from the movie Field of Dreams (the actual quote is “he will come”), in which a ghostly voice urges Kevin Costner’s Iowa farmer to build a baseball diamond in his cornfield. Following through on this vision despite the risk of bankruptcy, Costner’s faith is eventually rewarded when he gets the chance to reconcile with his deceased father and multitudes of fans start flocking to his “field of dreams” to watch baseball games.

It’s an attractive and enchanting thought: Give the people what they want (or need), pursue your dreams, and the rest will follow. However …

Remember the dream part? In real life, establishing a small business such as a private counseling practice requires a lot of preparation, planning and ongoing maintenance. Being a good clinician is not enough. Counselors who have established their own practices say that the other major requirement for success is business skill — and more of it than many of them expected they would need.

How will you market your practice? Who will do the scheduling and billing? File the paperwork? Balance the books? These are just a few of the questions counselors need to consider as they contemplate establishing a private practice.

Counseling Today asked four American Counseling Association members with experience in private practice to share their stories, their lessons learned and tips for others in the profession who might be looking to strike out on their own.

 

Tapping into the power of the internet

Ryan Thomas Neace, a licensed professional counselor (LPC) and founder of Change Inc., a private practice located in St. Louis, first discovered his entrepreneurial spirit when he established himself as a local DJ at age 15. Neace started working in entry-level mental health positions during his first year of graduate school, and over the course of eight years gained experience in residential, agency, school, in-home, college and community counseling. Along the way, he discovered something crucial: He was an excellent clinician but a terrible employee.

“I tended to do first and ask forgiveness later, whether or not it coincided with what I thought management might want, because I typically thought my ideas were better and less bound to inside-the-box thinking,” Neace says. “I was right, I think, but it wasn’t a very good way to
stay employed.”

Fortunately, Neace’s entrepreneurial spirit and good connections put him on the path to self-employment. “In the course of all of that action [working in numerous counseling environments], I had latched on to a mentor who saw a lot of promise in me and recognized I was gifted in some ways he was not — business acumen, administration, etc. — and he asked me whether I’d consider starting a private practice with him in Virginia. We started brainstorming, and that was that. He put up about $10,000 for office furniture and technology, and we found the space we liked.”

Neace and his mentor co-owned and ran the practice together for several years, but, eventually, both wanted to move to different areas of the country. “I moved back to St. Louis in 2013 and started my first sole ownership practice there,” Neace says. “Five years later, it has two locations, 12 therapists, several support staff, and we’re conducting approximately 700 client sessions per month.”

Although Neace’s move was obviously a success, he acknowledges that it took a substantial amount of hard work and planning to achieve. “About 18 months before I moved back to St. Louis, I started looking online at where all of the counseling practices were,” he says. “I noticed that there tended to be a large accumulation of practices in the western county parts of the metropolitan area but not a ton in the up-and-coming urban areas that for several years were being revitalized and developed. While the county regions were clearly where a majority of the local wealth was, I decided that if I priced our services effectively, there was a decided advantage to being more local to the city itself. We could pick up [gain] residents who were tired of driving to the county for mental health services, and we could even get county residents who were dissatisfied with the kinds of therapists who dominated the landscape in their neck of the woods or [those residents] who worked in the city and might find the idea of getting therapy in the city attractive from a convenience standpoint — [for example] on their lunch hour — or from the perspective of having a bit of geographic distance between themselves and their therapist’s location.”

During this period of research, Neace was also building a website for his practice on WordPress. He already had some experience working with websites, and anything that he didn’t know, he found through online tutorials or support forums. Recognizing that the most essential part of having an online presence is showing up in search results, Neace sought help from a friend who was an expert in search engine optimization (SEO).

The friend taught Neace how to ensure that Change Inc. would show up whenever someone searched online for terms such as “St. Louis____ (anxiety, depression, LGBTQ, etc.) counseling.” Three to six months before Neace was even scheduled to make the move to St. Louis, he was already getting one to two phone calls per week from prospective clients. One month before Neace opened the doors to his new practice, he already had his first few clients scheduled.

Today, Neace’s practice continues to focus on SEO even as it has developed a stream of referrals from previous clients and area clinicians with whom Neace has built relationships. Change Inc. has also taken a nontraditional approach to marketing.

“Instead of spending money on traditional print or other marketing efforts, we partner with other small businesses — typically nonprofits — that have a mission we feel is supportive of our own and that reach a target demographic similar to our own,” Neace says. “We offer these organizations financial support in exchange for direct marketing opportunities to their target audiences and brand association, [such as] event or web advertising where our brand and their brand is featured together in a prominent way.”

Neace acknowledges that owning his own practice can be demanding, but for him, it produces less anxiety than trying to work within someone else’s confines. “Certainly, owning a practice increases the stress, though I think it’s a qualitatively different kind of stress,” he says. “Perhaps the most prominent difficulty in ownership for me is the heightening of my personal sense of loneliness, in that no one sees how much I’ve risked or how hard it can be, simply by virtue of the fact that they aren’t owners. But if you’re an entrepreneur of my kind, it is a labor of love where the rewards far outweigh the additional stress.

“Again, I’m highly motivated by the autonomy and independent decision-making, as well as the notion that each decision I make stands to increase my interests financially and otherwise. And I love getting to create an environment that prioritizes the elements of counseling that I believe are most important to transformational clinical work.”

When asked what advice he would give to counselors interested in setting up their own practices, Neace emphasized the following:

  • “Learn and implement SEO like your life depends on it. People should be able to search ‘Your city, Your industry, _____’ and you come up in the top five every time.”
  • “Find someone you trust who has a business that is thriving and ask them every question [you have]. Trust that if you are annoying them or if they don’t want to answer, they will tell you. Otherwise, be totally relentless about learning from them.”
  • “Remember that most people selling business how-tos are actually in the business of selling business how-tos, not in the business of having a successful, meaningful business. Most of the good information is free [from] mentors/friends … or next to free [from] books.” (Neace particularly recommends The E-Myth Revisited: Why Most Small Businesses Don’t Work and What to Do About It, by Michael Gerber, and Built to Sell: Building a Business That Can Thrive Without You, by John Warrillow.)
  • “Don’t be bogged down by convention. Do it the way you want to unless it absolutely makes no [financial] sense. Expect that people will tell you you’re breaking the rules and to generally be appalled that you have the audacity to think outside the box.”
  • “When you get scared and want to quit, run the numbers. Calculate the amount of money you need to keep the business afloat each month, and let that be your true north.”
  • “It helped that I had a side hustle [adjunct teaching online]. On the other hand, eventually it will eat into your ability to do the business. There’s definitely something to being all-in. If you keep a side hustle, keep one that doesn’t give you enough to live on. Let the hunger you feel drive you.”
  • “Don’t try to have everything at once. For the first two years, I worked in a space with old carpet and paint, three empty offices and a waiting room with the couch from my basement and some chairs I bought off Craigslist. Rome wasn’t built in a day.”

 

Knowing your strengths and maintaining flexibility

“In my 25 years as a therapist, I’ve been in and out of private practice depending on the needs of myself and my family,” explains Keri Riggs, an LPC currently practicing full time in the Dallas area. “So, I’ve worked full time as executive director of a nonprofit and full time as an intensive outpatient coordinator at a hospital. I always wanted to keep my hand in counseling, so I often contracted through agencies or under other therapists or had a solo practice while still being employed.”

“I believe when counselors are just starting out, the decision about solo practice depends a great deal on their economic or marital status,” Riggs says. “If you have a stable family income with benefits, your options are different than if you are a single parent or sole income provider for your household.”

Riggs cautions others to think carefully about giving up additional sources of income while building a practice. “I … regretted quitting my part-time agency work while building my practice. I only made $17,000 that year, and it was the toughest year ever,” she says.

Riggs has used a variety of methods to attract clients. “I see many resources on Facebook or online promising people can have a flourishing full-pay, noninsurance practice within a year, but that hasn’t been my experience,” she says. “I believe it depends on demand in the geographical area [and whether] a counselor elects to accept insurance or employee assistance program work.”

In Riggs’ experience, it usually takes two to three years to build a full practice. “I do believe it’s valuable to network and to have a niche but also not to over-focus on that,” she says.

However, Riggs does recommends that counselors focus their marketing efforts. “Don’t just send flyers to doctors’ offices. They end up in the trash before a doctor ever sees them,” she says. Instead, she advises that private practitioners find ways to speak directly to their target client populations, such as by holding workshops or giving presentations at service organizations.

Riggs enjoys running her own practice but grants that being a CEO and a counselor is a tough balancing act. “There’s a saying: You can’t work on the business when you’re working in the business. So, if I’m seeing clients, I can’t be working on marketing, billing/accounting, networking, blogging.”

In addition to seeing clients and running the business side of things, it’s essential that self-employed counselors continue to devote time to self-care, Riggs says. “I’ve discovered my magic number of clients I can see in a row and in a day,” she says. “I’ve blocked time in my calendar as I’ve gotten busier to eat, return phone calls and do administrative tasks. Occasionally, I block a mental health day for myself and spend time with non-therapist friends.” Peer consultation is also essential, Riggs adds.

Riggs doesn’t have office support staff but does outsource certain tasks. She employs an accountant and someone to manage her website and consults with a social media expert. She does her own scheduling, billing and filing of health insurance claims with a little technological assistance. Riggs uses practice management software that allows clients to schedule online, sends clients appointment reminders, bills insurance, posts payments and even provides a central place for Riggs to take progress notes and write treatment plans. “I couldn’t manage without it,” she says.

Not having the luxury of sick time or paid leave as a private practitioner can be difficult, but Riggs thinks the trade-off is worth it. “I love the freedom and I love being my own boss,” she says. “I can arrange to go to the kids’ school or doctors’ appointments or even take a recharge nap on my office couch in between clients if I need to.”

When asked what advice she would give to counselors interested in setting up their own practices, Riggs says the following:

  • “Work with your own personality strengths and weaknesses. If you procrastinate on accounting and hate it but have a talent for writing, spend your time writing and hire someone to help with the financial aspects.”
  • “If you don’t want to deal with the administrative aspects of your practice, don’t. Get with a group [that] provides that for you and willingly pay the costs involved.”
  • “Don’t feel like you have to do everything all at once. Serve the clients you have and serve them well.”
  • “Find a supportive accountability partner if needed, and engage in regular peer consultation with other counselors.”
  • “Be kind to yourself. Keep learning and growing.”
  • “Make sure you have a life outside of work.”

 

Identifying a need and growing into a group practice

Michael Stokes, an LPC and founder of Stokes Counseling Services LLC, in Naugatuck, Connecticut, set up his own practice because he wanted to develop a niche devoted to treating LGBTQ individuals and their families. “There were not agencies focused on LGBTQ services in my area, and this was a significant unmet need in my community,” he explains.

To get up and running, Stokes networked with other counselors in private practice, but he says he owes the most to a former supervisor. “Her guidance around logistics helped me develop a step-by-step process for opening my practice. The first step was finding an office location [and] community I wanted to practice in. This was not difficult since I knew exactly the town where I wanted to set up my practice. From there, I needed to find office space I could afford. Living paycheck to paycheck, I needed something extremely cheap. I cashed in my saving bonds from when I was a baby and used that $500 to secure my lease on the office space. After the office space, I finalized my paperwork [and] insurance paneling and started to let others know I [would] be open for business Oct. 1.”

Like other first-time small-business owners of all stripes, Stokes was unaware of how much business knowledge he would need to run his own practice. “I had no formal training,” he says, “so I dove straight into reading, researching and seeking out experts in the field of private practice.”

Initially, Stokes’ practice was part time, but as he grew more confident with the business side, he decided to go full time. Suddenly, his practice mushroomed.

“When I took the leap into private practice full time in April 2012, I was eager to build my caseload to a place that was comfortable,” he says. “What I found instead was that I was seeing way too many clients, and the referrals were not stopping anytime soon. I was seeing about 40 clients a week and knew I could not sustain that level of practice.” Stokes realized that without additional help, he would have to start turning clients away, which he was loath to do.

“Simultaneously, colleagues from other agencies were reaching out to understand my experiences in private practice and asked if they could start to see a few clients in my office when I was not there. Little did I know, this was my starting point of group practice development. Being able to serve more clients was an amazing experience. As I began to cultivate my group [practice], I knew it was important for me to bring clinicians on who had different styles, theoretical orientations, different niche areas and populations. This allowed us to build a cohesive practice of clinical services. We now have over 50 licensed clinicians who serve thousands of clients in our state.”

Stokes started with a mission of providing help to the underserved LGBTQ community, but he didn’t anticipate just how much private practice would reignite his passion for clinical work. “I was working in clinics and nonprofits throughout my career. Feeling very overwhelmed, overworked [and] underpaid, I was on the path for early burnout,” he says. “Having my own space was empowering because I was able to design a safe place for myself and my clients. To this day, I am a huge advocate for private practice and helping clinicians find success in this arena.”

When asked what guidance he would give counselors who are thinking of setting up their own practices, Stokes says, “My best advice … would be explore all of your opportunities. Have a good handle on who your ideal client is, where you want to serve and what supports you need [to have] in place as you go down the path of private practice work.”

 

Keeping clinical skills sharp as a counselor educator

Misty Ginicola, a professor in the counseling and school psychology department at Southern Connecticut State University, is primarily a counselor educator. She began her career teaching, but decided that she wanted to keep her clinical skills sharp.

“I wanted to be a more effective professor,” she says. “It definitely helps students to have plenty of narratives on how something might work with a client.”

Ginicola, now an LPC with a private practice in West Haven, Connecticut, decided to focus on two specific populations — LGBTQ individuals and highly sensitive people. She purchased a website and started the process of completing the business application process for her town, registering for tax purposes, applying for a National Provider Identifier number, and getting on insurance boards, all of which took longer and proved to be more complicated than she had anticipated. Ginicola says she fervently wishes she had known enough beforehand to find someone with insurance board experience to guide her through the process.

Striking a balance between teaching, consulting on and conducting research projects, doing clinical work and all of her other commitments requires a bit of juggling and a lot of self-care on Ginicola’s part.

“I put limits on the number of clients I take. I only take a maximum of five clients at a time. I also only see clients during times when it will not interfere with family time,” says Ginicola, the mother of two small children and the president-elect of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling, a division of ACA. “My self-care is vast and it really has to be. I practice pranayama — breathing practices — throughout my day and coherent breathing every night. I practice yoga every day and am a yoga teacher. I teach three times a week, and it really keeps me working on my own wellness, as I have to practice through the week and stay true to my own physical wellness. I make sure to be honest with myself and to communicate clearly with others what I need. I have learned to say no to lots of things that do not bring me happiness or speak to what I feel is my life purpose, or dharma. By really focusing in on those things, I do not feel overwhelmed. Everything I do truly feeds my soul.”

When asked what advice she would give to counselors who want to set up their own practices, Ginicola says, “Really understand that it involves being a business owner, not just a counselor. Therefore, if it is going to be your primary source of income, it takes a lot of work in setting up and retaining a thriving practice. As a part-time practice owner, the demand is not as much to make a good income at it. I can put a limit on my number of clients, I can choose what insurance boards I truly want to work with, and I can specialize in specific issues. I think establishing a specialization is an excellent way to attract clients and gain referrals.”

 

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Additional resources

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

Webinars (aca.digitellinc.com/aca/pages/events)

  • “Private Practice: The Ethics and HIPAA of Technology” with Rob Reinhardt and John P. Duggan (WEBA18007)
  • “Private Practice: Building Your Brand” with Deb Legge and John P. Duggan (WEBA17007)
  • “Private Practice: Managing Your Business” with John P. Duggan and Deb Legge (WEBA18002)
  • “Private Practice: Getting Off to a Strong Start” with Deb Legge and John P. Duggan (WEBA17005)
  • “Counselor Risk Management: Counselors and Technology — A Two-Edged Sword” with Anne Marie “Nancy” Wheeler and John P. Duggan (WEBL18005)
  • “Private Practice: Choosing a Best Fit” with Rob Reinhardt and John P. Duggan (WEBA18004)
  • “Ethics and Values in Real-Life Counseling Practice” with Stephanie F. Dailey and John P. Duggan (WEBA17006)
  • “Counselor Risk Management: What You Didn’t Learn in Grad School That Could Lead to a Lawsuit or Licensure Board Complaint” with Anne Marie “Nancy” Wheeler and John P. Duggan (WEBA18001)
  • “Does One Size Fit All? How to Successfully Get and Keep Your Clients” with Janis Manalang (CPA20695)

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • The Counselor and the Law: A Guide to Legal and Ethical Practice, eighth edition, by Anne Marie “Nancy” Wheeler & Burt Bertram
  • ACA Ethical Standards Casebook, seventh edition, by Barbara Herlihy and Gerald Corey
  • Ethics Desk Reference for Counselors, second edition, by Jeffrey E. Barnett and W. Brad Johnson
  • The Secrets of Exceptional Counselors by Jeffrey A. Kottler
  • Counselor Self-Care by Gerald Corey, Michelle Muratoni, Jude T. Austin II and Julius A. Austin
  • Cognitive Behavior Therapies: A Guidebook for Practitioners edited by Ann Vernon and Kristene A. Doyle
  • Creating Your Professional Path: Lessons From My Journey by Gerald Corey

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources/self-care-resources)

  • Self-Care

 

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

Letters to the editor: ct@counseling.org

 

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

 

Behind the Book: Wellness Counseling: A Holistic Approach to Prevention and Intervention

Compiled by Bethany Bray March 18, 2019

“Each area of an individual’s life inevitably affects other areas,” write Jonathan H. Ohrt, Philip B. Clarke and Abigail H. Conley in the preface to their new book Wellness Counseling: A Holistic Approach to Prevention and Intervention. Mental health practitioners who target a treatment plan to only one aspect of a client’s life “neglect to recognize the interplay/interconnectedness of the different components that compose the well-being of our clients.”

“When I am counseling a client and reflect on the wellness model during an intake session or goal setting, I am prompted to ask not only about the presenting concern but also about factors such as the client’s religion/spirituality; gender; and physical, emotional, social and mental well-being,” Clarke explains in the books first chapter.

With that in mind, the authors write, it is imperative that counselors are able to articulate the profession’s connection to wellness, both to their clients and to other professionals. After all, the term “wellness” is in the very definition of counseling and is “an inextricable part of our professional identity,” write Ohrt, Clarke and Conley.

 

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Ohrt is an associate professor and counselor education program coordinator at the University of South Carolina. Clarke is a licensed professional counselor and faculty member in the Department of Counseling at Wake Forest University. Conley is an assistant professor in the Department of Counseling and Special Education at Virginia Commonwealth University and an affiliate faculty member in the university’s Institute for Women’s Health.

Wellness Counseling: A Holistic Approach to Prevention and Intervention was published by the American Counseling Association in December 2018. CT Online sent the co-authors some questions via email to learn more about this resource.

 

 

Q+A: Wellness Counseling

Responses written by co-authors Jonathan H. Ohrt, Philip B. Clarke and Abigail H. Conley

 

“Wellness” is often thrown around as a buzzword in our culture. How would you define wellness as it relates to counseling?

In our book, we utilize Jane Myers, Thomas Sweeney and Melvin Witmer’s definition of wellness [from their Journal of Counseling & Development article “The Wheel of Wellness Counseling for Wellness: A Holistic Model for Treatment Planning”] to guide our approach, which is that wellness is “a way of life oriented toward optimal health and well-being, in which body, mind and spirit are integrated by the individual to live life more fully within the human and natural community.”

Building off of this definition, we conceptualize a five-domain model of wellness that connects mind, body, spirit, connection and emotion [and] that highlights the interconnectedness of these domains within the whole self. Because of this holistic approach, one small change in one area can lead to positive changes in others. Thus, a client’s strengths are just as important, if not more so, than their struggles.

Finally, a key part of a wellness counseling approach is helping a client work toward their own optimal level of harmony both within and among each domain rather than [pursue] the often elusive idea of balance.

 

In the book, you all mention that wellness goes hand in hand with prevention. What do you want counselors to know about this intersection?

Prevention models in health care (e.g., primary, secondary and tertiary prevention) and education (multitiered systems of support) start with a focus on providing preventive interventions and education to avoid problems from occurring. These models emphasize healthy behaviors, decision-making, coping strategies, and strength and resiliency building.

From a wellness perspective, counselors can focus on prevention by assessing their clients holistically and collaboratively developing goals for clients to work toward optimal physical and mental health prior to the onset of problems. Goals can include physical health goals, mental health goals and goals related to the clients’ social functioning and spirituality. Counselors who focus on wellness can also advocate for policies that help promote wellness for individuals within various systems.

 

What tips would you share to help practitioners remember to step back and take a look at the client’s whole picture and not just the presenting problem?

Wellness models are one of the most useful tools to ensure that counselors consider the whole client. Utilize wellness models for client conceptualization and during sessions with clients. This will remind you to examine the client’s presenting problem from multiple perspectives.

For example, what (if any) spiritual, physical or cognitive components factor into the presenting concern? Inviting the client to reflect in this way communicates to them the importance of viewing themselves holistically. You can then discuss client strengths across wellness areas.

Counselors can also share with clients that they utilize a wellness-based approach during the informed consent process. As a self-awareness activity to solidify the relevance of wellness, you may want to write and periodically update your own wellness plan that consists of areas for improvement, strengths and goals.

Another fun and helpful exercise for counselors is to view television shows and reflect on the multifaceted nature of the stressors and lives of the characters on the show.

 

What is a main takeaway that you would like readers to know about wellness counseling?

Readers should know that wellness counseling is an approach that can be of value to and incorporated with most any client. It is useful regardless of the type or severity of the client’s presenting concern. It can be helpful when working with children or older adults.

The challenge is to not fall into the trap of a singular view of the client. It takes effort for the counselor to delve into the various aspects of the client’s well-being. Clients might initially balk at the idea of these different components of self. But this discomfort can result in benefit to the client.

Wellness counseling is versatile because the counselor can incorporate counseling theories that are most helpful to the client while remaining within the wellness framework. Wellness counseling is client-centered [because] you are offering the client new ways of understanding and experiencing themselves and new avenues for goal achievement.

 

Would you say that wellness is a new concept in the counseling profession? How long has it been something that counselors have adopted?

Wellness has been at the core of the counseling profession throughout its history. Most counselors tend to view their clients holistically and from a developmental perspective. Melvin Witmer, Thomas Sweeney and Jane Myers developed more defined theoretical and empirical wellness models for counselors in the early 1990s and 2000s. Their models are still widely used for client assessment, conceptualization and treatment planning.

A newer trend related to wellness is the integration of behavioral health with primary care. Counselors are becoming more aware of the strong relationship between physical health and mental health. Counselors are now more likely to be part of an interdisciplinary treatment team through which physical health and mental health services are integrated and coordinated together more strategically. This model fits well with a wellness perspective because counselors can engage in interdisciplinary collaboration with other professionals to provide interventions that address the client’s holistic functioning.

 

Are there any misconceptions or misunderstandings about wellness counseling that you’d like to clear up?

The exciting thing, in our experience, is that wellness appears to be critical to the identity of most counselors we have encountered. However, we have noticed that some counselors use aspects of wellness counseling without full intentionality or struggle to describe wellness counseling.

Thankfully, counselor educators such as Jane Myers and Thomas Sweeney have developed this information. We hope to highlight and add to their work, providing counselors with skills specific to this intervention and guidelines for determining whether or not they are working within a wellness counseling approach.

 

What inspired you to collaborate and create this book? Why is it relevant and needed now?

This book came together because the three of us have had many conversations about the ways that we teach wellness counseling (both as stand-alone courses and as a component of other core counseling courses) and the need for a text that delves deeply into what a wellness-based counseling approach is conceptually and also what it looks like in practice.

We wanted to write a book that is grounded in theoretical and empirical support and also provides techniques for client assessment, case conceptualization, treatment planning and intervention.

We wholeheartedly believe that wellness is an inextricable part of our professional identities as counselors and [that it] should serve as a framework for a holistic, prevention-focused approach to clients across the life span.

 

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Wellness Counseling: A Holistic Approach to Prevention and Intervention is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-347-6647 ext. 222.

 

Hear more on this topic in a session with the co-authors at the ACA Conference & Expo in New Orleans later this month. Ohrt, Clarke and Conley will present a session on wellness counseling Friday, March 29 at 4 p.m. Find out more at counseling.org/conference

 

 

 

 

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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 Facebook at facebook.com/CounselingToday.

 

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

 

Building a kinder and braver world

By Bethany Bray March 13, 2019

When Cynthia Germanotta discusses how complicated and misunderstood mental illness can be, she speaks from a place of knowing because her family has lived the reality. Germanotta is the mother of two daughters, the oldest of which, Stefani — better known as Oscar and Grammy Award-winning artist Lady Gaga — is open about her struggles with posttraumatic stress disorder, depression and anxiety.

“My husband and I tried our best (and still do!) to be deeply loving and attentive parents, who made sure we had regular family dinners and spent hours talking with our children. But, for all of that communication, we still didn’t really understand exactly what they needed sometimes,” Germanotta wrote in a candid essay last year. “Like many parents, I didn’t know the difference between normal adolescent development and a mental health issue that needed to be addressed, not just waited out. I mistook the depression and anxiety my children were experiencing for the average, if unpleasant, moodiness we all associate with teenagers.”

Cynthia Germanotta

Together, Germanotta and Lady Gaga work to combat the stigma and misunderstanding that often surround mental health issues through the Born This Way Foundation, a nonprofit they co-founded in 2012. Germanotta will speak about mental health and the work of the foundation during her keynote address at the American Counseling Association’s 2019 Conference & Expo in New Orleans later this month.

Through research and youth-focused outreach programs, the Born This Way Foundation works to disseminate information and resources about mental health and help-seeking. Its mission is to “support the wellness of young people and empower them to create a kinder and braver world.”

Counselors, Germanotta asserts, have an important role to play in achieving that goal. She recently shared her thoughts in an email interview with CT Online.

 

Q+A: Cynthia Germanotta, president of the Born This Way Foundation

 

Part of the mission of your foundation is to empower young people to “create a kinder and braver world.” From your perspective, what part do professional counselors have to play in that mission? What do you want them to know?

Building a kinder, braver world takes everyone — including (and especially) counselors. As adults who care about and work with young people, counselors can and do help young people understand how to be kind to themselves, how to cope with the challenges that life will throw their way, and how to take care of their own well-being while they’re busy changing the world.

To us, being brave isn’t something you just have the will to do; it’s something you have to learn how to do and be taught the skills for, and counselors can help young people do that. Counselors are a vital part of the support system that we need to foster for young people so that they are able to lead healthy lives themselves and to build the communities they hope to live and thrive in.

 

What would you share with counselors — from the perspective of a nonpractitioner — about making the decision to seek help for mental health issues or helping a loved one make that decision? How can a practitioner support parents and families in making that decision easier and less associated with shame or stigma?

When you’re struggling with your mental health, asking for help is one of the toughest, bravest and kindest things you can do and, for so many, shame and stigma make these conversations even harder. If that’s going to change (and my team works every day to ensure that it does) we have to normalize discussions of mental health, turning it from something that’s only talked about in moments of crisis to just another regular topic of conversation.

Practitioners can help the people they work with, and their loved ones, learn strategies for talking about mental health, equipping them with the skills they need to communicate about an important part of their lives.

 

What motivated you to accept this speaking engagement to address thousands of professional counselors?

My daughter would be the first one to say, we can’t do this work alone. Fostering the wellness of young people takes all of us working together.

Counselors are such a crucial part of the fabric that surrounds and supports young people, so I was honored to be invited to speak to the American Counseling Association and have the opportunity to not only share our work at Born This Way Foundation, but to hear from (and learn from) this amazing group of practitioners.

 

What can American Counseling Association members expect from your keynote? What might you talk about?

I’m so looking forward to sharing a bit about Born This Way Foundation — why my daughter and I decided to found it, what our mission is and how we’re working toward our goal of building a kinder and braver world, including a couple of new programs we’ve excited to be working on this year.

I’m also excited to share what we’re hearing from young people themselves about mental health. We invest heavily in listening to youth in formal and informal situations, in person, online and through our extensive research. We’ve learned so much through this process, and we have some important insights we’re looking forward to sharing, including the results of our latest round of research where we collected data from more than 2,000 youth about how they perceive their own mental wellness [and] their access to key resources.

 

How have you seen the mental health landscape in the U.S. change since you started the Born This Way Foundation in 2012? Are things changing for the better?

Over the past seven years, we’ve seen real momentum around both the willingness to discuss mental health and the urgency of the challenges that so many young people face. We certainly have a long way to go, but I truly believe we’re starting to move the needle.

There are so many examples of the progress being made on mental health — public figures starting to talk about it, global advocates organizing around it, governments starting to invest in it, schools starting to prioritize it, and so much more.

And, as always, I’m inspired by young people who are so much further ahead on this issue than I think we sometimes give them credit for. In the research we’ve done, about 9 out of 10 young people have consistently said mental health is an important priority. There’s still work to do, but that’s a great foundation to build on.

 

After seven years of working on mental health and the foundation’s youth-focused initiatives, what gives you hope?

Young people give me hope. The youth that we have had the privilege to meet and work with throughout the years are so inspiring, demonstrating time and time again just how innovative, brave and resilient they are.

Young people already recognize mental health as a priority and have the desire and determination to change how society views and treats this fundamental part of our lives. Their bravery and enthusiasm make me excited for the future they will build, and [we are] committed to fostering their leadership and well-being.

 

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Hear Cynthia Germanotta’s keynote talk Friday, March 29, at 9 a.m. at the 2019 ACA Conference & Expo in New Orleans. Find out more at counseling.org/conference.

 

Find out more about the Born This Way Foundation at bornthisway.foundation

 

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In her own words

Read more about Germanotta’s perspective and experience through two articles she has written:

 

 

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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.

 

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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 caregiving conundrum

By Tia Amdurer March 12, 2019

The branch of therapy that deals with anticipated loss due to death is a specialization that often gets overlooked. As a counselor who works with anticipatory grief and has five years’ experience in a hospice bereavement office, I have found that primary caregivers usually need guidance and support but don’t ask for it until they are completely overwhelmed. Counseling for end-of-life caregiving is very much an area in which good therapists can make the difference. 

Current Medicare standards for hospice do not cover the cost of a bereavement specialist for family members of a dying patient. Unless the family or caregiver seeks an outside therapist, chaplains and social workers affiliated with assisted living facilities or hospices become the de facto mental health experts, juggling family dynamics, anticipatory grief, medical regulations, spiritual concerns and the patient’s care plan.

Caregivers: The unsung heroes

Whether end-of-life care is being given in a home or a facility, caregivers can grow overwhelmed by the physical and emotional toll of their responsibilities. They may start showing signs of anticipatory grief, including mourning the loss of their role and relationship and fearing the future. This can be coupled with anger at the isolation and abandonment by others, bitterness at the exhaustion, frustration at the never-ending demands, shame for wishing caregiving were over already (which would mean the patient’s demise), helplessness at being unsure about what they should be doing and sadness at the way that time is running out.

In my book Take My Hand: The Caregiver’s Journey, Chris Renaud-Cogswell offered written reflections on her emotional overload with caregiving responsibilities: “I’m so jealous of all of you who enjoy your parents’ company and treasure the time you have with them. When do I get past the ‘I can’t believe this is my life,’ regretful, resentful stage? I have never used the F-word as much as I do since my mother moved in.”

Guilt seems to be the emotion that rises to the surface most often for caregivers. Even in the most “functional” homes, the intensity of caregiving can be enormous. For example, a spouse may not be capable of doing everything but still feels responsible for the care of his or her sick partner. Conversely, partners in good health may feel weighed down by the extreme change in their role and lifestyle. Adult children who are working or raising kids themselves can feel put upon to do more and angry that their time is so limited. Those caring for an elder may find old childhood resentments bubbling up. Relatives who might like to visit don’t know how to help. Asking for help triggers additional feelings of guilt and frustration among caregivers.

As grief counselors, we listen to recitations based on a lifetime of behaviors and try to help put boundaries in place. We validate and remind clients that they are doing the best they can under trying circumstances. Caregivers may struggle with the history of a poor relationship with the patient. These interpersonal dynamics are likely to continue being problematic. For many families, a storybook resolution or a full sense of forgiveness might be difficult to achieve.

One middle-aged man paid a daily visit to his dying father, who had a long history of being abusive and battling alcoholism. Despite the visits lasting for four or five hours, the man refused to interact with his father. Instead, he sat in a chair, played games on his phone and felt guilty. A daughter who had been constantly rejected by her narcissistic mother reacted by directing her frustration at staff for any minor infractions, fearing that her mother, who was dying, would deride her for her own lack of attention. In another case, an adult daughter wanted to scream at her mom for never asking for what she needed, acting out passive-aggressive patterns and playing the “martyr.” The daughter hated the nagging person she was becoming.

Caregiving can be a long journey, so, as counselors, we must explain the necessity of self-care for the caregiver. Even among caregivers who are fully engaged with their sick loved ones and content with their position, emotional exhaustion takes a toll. Whether dealing with a loved one’s personality changes or the loss of that person’s physical abilities or mental acuity, being on call as the “responsible adult” is draining. Caregiving can run the gamut of emotions and experiences, from boring to terrifying.

Self-care for caregivers includes asking for help, making schedules, sleeping, taking time alone, exercising, seeing friends, checking out support groups, praying, laughing, journaling, connecting through social media and, of course, learning to accept help. By presenting family members, friends, faith organizations or neighbors with specific ways to help, the caregiver is actually providing a service. Rather than viewing these “asks” as a burden to others, it can be reframed as an opportunity for others to do a good deed for the person who is dying.

A caregiver’s functions will depend on many variables. For instance, if the person who is dying is in a facility, the caregiver may be tasked with doing laundry, attending functions at the facility, visiting the sick loved one daily or weekly, finding coverage for meetings with facility staff to discuss behavior changes or concerns, driving the loved one to outside medical appointments, scheduling visits from friends and relatives, and maintaining a family home.

For at-home caregivers, responsibilities might include adjusting for safety precautions around the home. This might involve installing grab bars, removing throw rugs and acquiring nonslip mats, having a working fire extinguisher, checking that the water heater thermostat is set below 120 degrees Fahrenheit and preparing for durable medical equipment (such as commodes, hospital beds and oxygen tanks/cylinders). In addition, these caregivers typically shoulder the responsibility for being available to drive the person to appointments as necessary, finding coverage when away from the home and providing meals that are dietarily different.

Counselors should remind clients who have caregiver responsibilities that friends or relatives might be able to visit or engage in crafts or music with a sick loved one, thus allowing the caregiver some time off. To ward off burnout, caregivers need respite.

Thus we arrive at the conundrum of respite: “If I go away for a few days, what if my loved one dies? How will I live with the guilt?”

There are two scenarios at the end of life: One, the loved one dies when someone is with them and, two, he or she dies when no one is there. Caregivers often worry that their loved one might be alone when they die. Some hospices can provide 11th-hour care, during which volunteers can sit at bedside if the family wishes.

My experience in hospice has been that some patients follow a definitive trajectory in their decline, whereas others follow an indeterminate timeline, making a family’s desire to be bedside at the last breath fraught with uncertainty. Although many cultures encourage “vigiling” at the deathbed, there is an unknown: Does the patient want the family there? Some individuals need to be alone when they die and will release from this life only when the family or a specific person leaves. The speculation about why this happens is endless, but it may help alleviate family guilt to use the metaphor of a group coming to a bridge together, but because only the dying individual may cross that bridge, he or she will do it alone. 

Family dynamics

As counselors, we should encourage caregivers to see that a document such as Five Wishes (fivewishes.org) is completed while the elder is mentally competent. This document serves as a directive about how the patient wishes to be cared for at the end of life. It is a binding document like a living will. In considering end-of-life protocols, all adults should be encouraged to write down their wishes so that these are known in advance.

During a crisis or major upset in a family system, different personality traits come to the fore. Family members who aren’t the primary caregiver might assume many roles at the end of life: the Swooper, the Know-It-All, the Call-Me-If-You-Need-Me sibling, the I-Don’t-Know-Anything-About-Dying-Elders family member … All the family roles are intensified. Folks who have a personal need to make amends come crashing in. The Golden Child comes back for a weekend and questions everything that’s been done.

Renaud-Cogswell shared her experience in Take My Hand: “Mom was diagnosed with lymphoma a week and a half ago. The hospice team began coming to care for her at our house shortly thereafter. Brother wants to take mom to lunch. Incredulous, I tell him she is sick, she has lymphoma, and that he could bring lunch here. He brings lunch. He doesn’t, however, bring lunch for me. Not something I should be overly surprised by, but I am hurt nonetheless. Then brother asks Mom if she would like to move into his empty townhouse. (Alone.) Then he and his girlfriend begin telling her all the positives about moving in there. I say, ‘She’s sick. She needs 24-hour care.’ Brother says, ‘Since I kicked my renters out, I need the money.’

“Loudly enough for them to hear, but soft enough so that Mom doesn’t, I hiss, ‘She’s dying!’ Then what do you suppose this brother asks our mother? ‘Can I borrow $500?’ (Who asks their dying mother for money???) And do you know what? She gives it to him! This was yesterday. I ran from the minute my feet hit the floor in the morning till my head hit the pillow at midnight last night. I need to sit down and have a good cry, but today, I’m afraid, will be just as busy.”

There are additional complications that must be addressed when “helpers” come. For caregivers, it is a frustrating and delicate struggle between wanting support and allowing helpers to make mistakes while visiting. The strain of feeling that no one else can do the caregiving correctly is immense. Caregivers should establish safety rules that are nonnegotiable — for example, the parent cannot go out without oxygen, medications must be administered on time, hospice will be called if the elder falls.

Grief counselor David Maes created a template (see below) that can be used when conflict arises between family members. The template helps ensure that during a family meeting, the identified patient remains the center of attention. Family members respond to prompts written in the appropriate boxes. Other concerns are written outside the square in list format.

Start by asking the existential questions (the upper left-hand box): What is meaningful for the patient? Before the illness, what was the person’s worldview? How did he or she move through life? What was the essence of who they were? Next, move to the upper right-hand box, which deals with patient preferences. Ask what the person likes related to music, food, art, reading, nature, hobbies, etc.

The lower left-hand box deals with the illness: How is the diagnosis and prognosis affecting the loved one’s personality, behavior, likes and worldview? What gets in the way of who they are? Finally, list the resources: How is the family going to work together? What’s the plan of care? Who is responsible for what?

Counselors might need to remind family members that past relationship dynamics should have little bearing on the here-and-now focus of the discussion. The question to ask is, “Whose death is this anyway?”

Another protocol, from Susan Silk and Barry Goldman, is called Ring Theory (see tinyurl.com/RingTheory). In this exercise, the center circle is the patient, the subsequent circle is the primary caregiver and concentric circles can identify others who are less involved with daily care. The idea is that only comfort can go inward while the difficult emotions go outward. Family members and friends can offer unconditional love to each inner circle while finding their own support and a place to vent in extending circles. Each family member may find their own rings of support.

If end-of-life care is an area you are considering as a professional counselor, begin by learning about grief and bereavement. Alan Wolfelt’s comprehensive books are available through the Center for Loss & Life Transition (centerforloss.com). The Hospice Foundation of America also offers excellent webinars and books (hospicefoundation.org). There may be local support groups for caregivers in your area, and we should also be able to direct clients to resources such as the Alzheimer’s Association (alz.org) and AARP (aarp.org).

Competency in serving caregivers and families at the end of life involves a combination of approaches. We should be able to provide psychoeducation on dying and the needs of the dying. We should be competent listeners, validating and normalizing their experiences while encouraging life review and memory making. We can offer facilitation for family discussions. We can help our clients with boundaries, rituals and support groups. Finally, we can encourage the caregiver to engage in self-care, including therapy.

 

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Tia Amdurer is a licensed professional counselor and national certified counselor with a private practice, Heartfelt Healing Counseling, in Lakewood, Colorado, that specializes in grief, loss, life transitions and trauma. She is the author of Take My Hand: The Caregiver’s Journey, which was published last year (TakeMyHandJourney.com). Contact her at tiaamdurer@gmail.com.

 

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.

The Counseling Connoisseur: Cultivating silence in a noisy world

By Cheryl Fisher March 11, 2019

Silence is about rediscovering, through pausing, the things that bring us joy –  Erling Kagge

In an attempt to reboot, my husband and I packed up our fur family and spent a week at the beach over the Christmas holiday. We got up each morning and trekked the shoreline immersing ourselves in the feel of the fresh salt air, the crash of the ocean waves and the caw of the seagulls flying overhead. We walked miles and miles each day — often in companionable silence with our cell phones off and tucked away in back pockets. Every now and then we would stop, plop down on the cool, damp sand and just be in silence.

Noise does not simply refer to sound, it includes the busyness of both internal and external environments. The constant need to “do” something and the aversion to boredom prevent the opportunity to relax the body and the mind. While technology has certainly contributed to the “skim, scan, scroll” processing of our world, it has also generated the technostress afforded by constant availability. Therefore, it is important to recognize the value of cultivating a practice of silence.

The Benefits of Silence

According to a study published in the March 2015 issue of the journal Brain Structure and Function, preliminary research on mice indicates that  as little as two hours of silence may promote brain cell growth by strengthening the hippocampus and improving memory. Additionally, some research has found that cultivating just moments of silence can lower blood pressure and heart rate, and improve relaxation and sleep even better than listening to soothing music.

Ways to Cultivate Silence

  1. Early morning moments: Invite intentional silence into your morning. Curl up in a blanket and sit in the dark allowing your eyes to focus slowly. Take a few moments to gaze at the sunrise, or inhale the fresh morning air. Ease into your day grounded and calm.
  2. Thankful mealtimes: Use the first few seconds prior to eating to close your eyes, take a deep breath and take a moment to appreciate your meal. Attending to your meal in this manner will not only provide you with a nice transition from your busy morning but welcome a more pleasant dining experience.
  3. Breathe: Throughout our busy days, we often forget about breath. We become complacent that the next breath will come without effort or thought. Take a moment to turn your attention to your breath. Are you taking full, deep cleansing breaths? Or do you inhale wisps of air? Take time to breathe.
  4. Meeting preludes: Begin your meetings at work with a five- minute practice of silence. This will allow the transition from work to the meeting agenda at hand. You and your co-workers will begin the meeting focused and ready to tackle the work.
  5. Media fast: Intentionally unplug for thirty minutes, an hour, a day. No cheating! No devices. A colleague of mine has initiated Unplugged Sundays, where she and her family members put away devices and spend time interacting as a family.
  6. Brisk walk in nature: Nature provides endless opportunities to soothe and refresh. Take a 15-minute walk around the block or on a nearby trail. When I work from home, I schedule a couple brief walks with my dogs to clear the clutter from my brain.
  7. Bedtime brain purge: Prior to bedtime, take a moment to purge all of the worries of the day. Lists of things left undone. Ruminations of concerns. Simply let them go long enough to prepare for slumber. You can use a journal to quickly write down your thoughts or just say them all out loud — quickly.
  8. Gratitude: I love to end my day with a gratitude list. I crawl into my comfy bed and immediately acknowledge the comforts of my home, my bed, my full tummy and the loving companions (my dogs and hubby) who share my life.
  9. Meditation practice: Consider beginning a meditation practice. A 20 minute practice morning, midday, or evening can promote calm focus to the day.
  10. Silent retreat: If you find that you crave longer jaunts with silence, consider participating in a silent retreat. Many retreat houses offer formal or informal retreats. Additionally, you may choose from group or individual silent retreats. I regularly schedule overnight escapes to the beach by myself to just reboot. I return ready to take on life’s challenges.

 

Modern-day living is accompanied by a cacophony of external noise and internal concerns. Our bodies and minds cannot sustain the ongoing level of stimulation without disease or disorder. Apparently, silence is golden, and it is imperative to make time for silence in our noisy lives. As counselors, we are trained to listen and sometimes we just need to unplug, retreat and refresh.

 

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Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online MA in Clinical Counseling.  Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy; and geek therapy. She may be contacted at cyfisherphd@gmail.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.