Monthly Archives: May 2019

CEO’s Message: Professional counselors lend a helping hand

Richard Yep May 31, 2019

Richard Yep, ACA CEO

June is often a bittersweet month for us here at ACA headquarters. While it means we are one month away from starting a new program year, it also means that we must say farewell to an amazing cadre of volunteer leaders who have worked so hard over the past 12 months.

Leading our volunteer efforts this year was Dr. Simone Lambert. During her tenure, she proved that she possesses great listening skills, was respectful of her counterparts in related organizations, continued to explore how ACA could help new and emerging professional counselors, and exhibited both warmth and graciousness with our staff.

Honestly, you just never know what a new president will be like. However, you truly get a sense of how the person operates during the 12 months that she (or he) serves in this office. You also get to witness the person’s true passion for the counseling profession. President Lambert has been no exception, and I have been honored to serve alongside her during the past year.

We also say goodbye to many outstanding volunteers who served on the ACA Governing Council, our committees or our task forces. In addition, there are many individuals who work tirelessly for their divisions, regions or branches every year. I do hope that all who served in a volunteer capacity will know how much ACA appreciates you.

The “sweet” part of June revolves around the excitement of bringing on many new volunteers. ACA has a vast number of slots reserved for volunteers, and we look forward to helping you in your new roles.

I also want readers to know that ACA will be organizing its 11th annual Institute for Leadership Training this year (July 15-18) in Alexandria, Virginia, and on Capitol Hill. Our plan is to provide more tools for attendees in keeping with ACA President-elect Heather Trepal’s emphasis on advocacy. I can’t think of a better area on which to focus given all that we read and hear about at the state and national levels of government.

Bringing somewhere between 125 and 150 professional counselors and counselor educators to visit with their U.S. senators and representatives should have a great impact on the policies at the heart of ACA’s legislative agenda. We also want to ensure that our public policy efforts have a strong grassroots strategy. For example, while some of your colleagues will be on Capitol Hill advocating for the profession, students and clients, perhaps you might like to organize a similar event (or some effort that shines a light on professional counselors, counselor educators and graduate students) in your own state.

This statement may seem biased since I work for ACA, but I truly believe that the work of professional counselors has rarely (if ever) been more needed. Whether we’re talking about the tragic school shootings in Colorado and North Carolina last month, the famine in South Sudan, or the global crisis involving opioid addiction, many professional counselors possess the training, experience and knowledge to make a huge difference in the lives of those impacted by human-caused and natural disasters.

I call on all of you to do what you can. You don’t necessarily have to fly off to another country for four weeks to address a humanitarian concern. Rather, just take a pen and a piece of paper and write down a list of concerns you feel are negatively affecting the lives of clients, students or others. Now, flip over that paper and “chunk down” what you think needs to be done. Mark an asterisk next to the tasks you think you might be able to help with. Finally, identify what you are willing to do over the next 12 months to address the issues on your sheet of paper. This commitment doesn’t need to take all of your time or money, but it should guide you in determining what you might be able to do.

I look forward to hearing what you will do in 2019-2020 to address the concerns you have written down. It might be something that has a direct effect on a population, or it might be something a bit more tangential yet still have a major impact on righting wrongs.

Hundreds of ACA members, led by President Simone Lambert, recognized a need and chose to participate in volunteer activities this year. This highly regarded cadre of individuals committed their time and effort to addressing various concerns. We thank each of them.

I hope you will consider participating in ACA this year as a volunteer, as a conference attendee, or simply as an informed and educated member (because that is also quite powerful).

As always, I look forward to your comments, questions and thoughts. Feel free to call me at 800-347-6647 ext. 231 or to email me at ryep@counseling.org. You can also follow me on Twitter: @Richyep.

Be well.

From the president: A game-changing tool for counselors

Simone Lambert

Simone Lambert, ACA’s 67th president

Throughout my career, my caseload has included people who had difficulty getting themselves to counseling sessions because of issues such as young age, chronic pain, social anxiety, severe mental illness, chronic illness, sensory defensiveness, or a suspended/revoked driver’s license. In addition, single parents and parents who often shouldered sole parenting responsibilities because of their partner’s work (think airplane pilots, doctors in residency, military deployments, graduate school, etc.) found it difficult to take time for themselves to obtain counseling. The fact is that many people must overcome obstacles — for any number of reasons — to physically attend counseling sessions consistently.

Technology is a game changer. For some people, technology offers a life-saving means of seeking and obtaining mental health help whenever and wherever it is needed. And for younger generations, of course, using technology to communicate seems only natural.

Our society continues to change rapidly as we adapt to technological advances. It’s true that mental health technologies monitored by nonlicensed providers could lead to some troublesome outcomes. However, technology that is appropriately implemented could have an extensive positive impact, including increasing access to mental health services. Licensed professional counselors tend to be found in major metropolitan areas; the mental health workforce shortage is often felt most by rural communities. Telecounseling can assist with those living in rural areas. Likewise, the opioid epidemic has overwhelmed the resources of many small towns. This is one crisis — where there is a high demand for services and a short supply of mental health providers — that could be addressed through the provision of distance counseling.

Given the widespread prevalence of stress, mental illness, addiction and trauma in our society, professional counselors can harness the power of technology to provide prevention, assessment, treatment and wellness maintenance services to people in any geographical setting. Many people have grown up with smartphones serving as a seemingly necessary tool to function in life. For these individuals, obtaining counseling services through their mobile devices might seem like second nature. Thus, the counseling profession has opportunities to reach and connect with clients in novel ways through technology.

Furthermore, technology will play an even more pivotal role in research. I recently attended a National Institute of Mental Health conference that focused on global mental health research without borders. There, I learned how big data is being used to analyze larger databases and platforms to identify issues related to mental health that could not be seen on a smaller scale or with limited statistical analytic software. From the continued exploration of larger sample sets, coupled with biotechnology, shifts may take place in how symptoms are clustered for diagnostic purposes and treatment.

By attending the conference, I also learned how other mental health professions use technology to share resources among researchers, disseminate cutting-edge results, and support postdoctoral students through research collaborations both nationally and internationally. The counseling profession would benefit from having larger evidence-based research studies and from building a stronger support system to advance research conducted about professional counseling that could then be used for improved services and legislative advocacy.

Technology will become more integrated into our professional development, supervision, counselor education, and delivery of direct client services. If you would like to network with other ACA members about technology in counseling or technology in training, consider joining one of the following ACA interest networks: 1) Counseling and Technology Interest Network or 2) Distance Learning on Counseling Education (see counseling.org/aca-community/aca-connect/interest-networks).

Finally, I want to strongly encourage all of us to utilize technology (such as VoterVoice — see counseling.org/government-affairs/actioncenter) to wholeheartedly advocate for professional counselors, the counseling profession, and those we serve in our communities and schools.

Stepping up to the challenge

By Lindsey Phillips May 29, 2019

Stepfamilies are complex and feature unique differences, yet on the surface, there may be little to distinguish them from “traditional” families. In fact, as Joshua Gold, a professor in the counseling education program at the University of South Carolina, points out, some counselors don’t necessarily think to ask if they are working with a stepfamily or blended family.

But perhaps they should. According to a 2010 Pew Research Center report, more than 40% of American adults have at least one step relative — a stepparent, a step- or half-sibling or a stepchild — in their family. Gold points out that of the eight most recent U.S. presidents, four (Obama, Clinton, Reagan and Ford) were part of stepfamilies.

“Often for counselors, it gets overwhelming to think about working with stepfamilies because it does look like so many moving parts,” says Jayna Haney, a licensed professional counselor (LPC) in private practice at the Wellness Collective and at Red Dun Ranch in Texas. “But what is also true is that stepfamilies [tend to] have similar problems.”

According to Institute for Stepfamily Education Director Patricia Papernow in her 2017 Family Process article “Clinical Guidelines for Working With Stepfamilies,” stepfamilies face five
major challenges:

1) Insider/outsider positions

2) Children struggling with losses, loyalty binds and change

3) Parenting issues and discipline

4) Building a new family culture while navigating previously established family cultures

5) Dealing with ex-spouses and other parents outside the household

Normalizing stepfamily dynamics

Stepfamilies often assume that something is wrong with them if the family isn’t working well, so counselors should reassure these clients that crisis and change are normal in stepfamily life, says Haney, the founder of the Bridge Across for Single Parents and Stepfamilies. She will often tell clients, “It’s not you. It’s your situation.”

One tool that Haney uses to educate clients about the challenges of stepfamily dynamics is called the stepfamily triangle. She draws a triangle, and at the top she writes in the name of the biological parent. She adds the name of the stepparent in the bottom right corner of the triangle and the name of the biological children in the bottom left corner. Then she explains how the biological parent and biological children have three bonds — emotional, biological and legal — and each bond is as old as the children are. Haney draws three lines to represent these bonds on the side of the triangle that connects the biological parent and biological children. The biological parent and stepparent have an emotional bond and a legal bond (if they are married), so Haney adds the lines connecting them. The stepparent and stepchildren have only an emotional bond (one that is only as old as their relationship) connecting them, which Haney illustrates with one line at the bottom of the triangle.

“So, when stepfamily couples are confused or frustrated because it feels like the family dynamics aren’t squaring up, it’s because they’re not,” says Haney, a member of the American Counseling Association. To illustrate her point, she’ll often put her hands together in the shape of a triangle and tip it over to the left because all of the weight is with the biological parent and child. She has found this visual helps families understand the dynamics and challenges that stepfamilies often face.

Gold, author of Stepping In, Stepping Out: Creating Stepfamily Rhythm and editor of the newly released book Intervening for Stepfamily Success: One Case, Multiple Perspectives (both published by ACA), also uses education as a means of normalizing stepfamilies’ experiences. Rather than directly asking stepfamilies whether a specific issue affects them, he provides general information about challenges that stepfamilies often face to see if anything resonates with them. He often starts counseling sessions by drawing two large circles — one for the clients’ lived experiences and the other for common stepfamily issues based on his professional knowledge. For example, in his circle, Gold may write that some stepfamilies deal with gendered expectations, such as assuming the stepmother will automatically be nurturing with the children or expecting the stepfather to be the disciplinarian. If the clients say they have experienced that issue, Gold will add it to their circle.

Both Gold and Pat Skinner, an LPC in private practice in Denver, agree that the schools offer one effective avenue for easily reaching stepfamilies and helping normalize their experiences. Gold recommends that school counselors hold stepfamily groups. These groups can be promoted in the school handbook given to parents at the beginning of the year.

Skinner, an ACA member who specializes in working with stepfamilies, thinks that holding stepfamily groups or classes at schools helps address some of the time and financial obstacles that these families might otherwise face in getting assistance. She also says that groups allow stepfamilies to hear stories similar to their own, helping them realize that they are not alone in their experiences.

Integrating multiple perspectives

Working with stepfamilies means having multiple voices and perspectives in each counseling session, which can further complicate the process. “The more complex the situation, the more flexible you need to be,” says Gold, a member of ACA and the International Association of Marriage and Family Counselors (IAMFC), a division of ACA. “If I’m dealing with one client, I’m trying to meet one client’s expectations. If I’m dealing with five, I now have five sets of expectations.”

“It takes more skill and more orientation as a clinician to figure out how to integrate all these different voices,” he continues. “Most conflict is founded in the notion that it’s an either/or situation. Either you’re right or I’m right.”

Gold, a contributing editorial board member of IAMFC’s The Family Journal, advises counselors to help stepfamilies switch to a both/and mindset so that situations won’t become win-or-lose propositions. For example, rather than focusing on how the kids from one family ate yogurt and cereal for breakfast and the other family ate eggs, the new stepfamily could include both breakfast options.

Haney, who specializes in high-conflict situations, parental alienation and stepfamilies, has developed an integrated family protocol in which she spends three to four family sessions discussing how to convert high-conflict tendencies into something productive. High conflict involves rigid thinking, unmanaged emotions, extreme behaviors and blaming others. She advises stepfamilies to do the opposite: engage in flexible thinking, manage their emotions, moderate their behaviors and own their actions.

In the first session, Haney always discusses flexible thinking. She puts eight or nine items with various textures (such as slime, play dough, Kinetic Sand, putty and therapy dough) on trays and passes them around. Each family member plays with the items and discusses how the items feel. Haney then asks what all the materials have in common. Someone typically responds that all the items can be mushed or smashed. Haney points out that no matter what the family members do to the items, the materials remain flexible. To emphasize this point, she asks the stepfamily to consider what would happen if they punched slime versus punching a wooden box. The answer: Only the wooden box would break.

Haney connects this exercise to the importance of being flexible in one’s thinking and explains that all people and situations have some good and some not so good features. With this new perspective, she asks each family member to tell her one thing that they like about their other family members.

Next, they take turns telling Haney one thing that drives them a little crazy about their family. For example, a family member may say that they don’t like it when everyone is yelling or how one of the parents is constantly asking the children how they are doing. Haney purposely uses the phrase “drives you a little crazy” because she finds it helps clients think of small problems, not big ones. She also advises counselors against asking clients what they wish were different because that is often counterproductive, she says.

When a stepfamily walks into Darrick Tovar-Murray’s office, he observes where each family member sits and how they communicate with each other. Take for example a session with Jim (the custodial parent), Jeff (the stepparent) and James (the child). Tovar-Murray will call attention to the way the family is arranged in the room: “James, why did you sit closer to Jim than to Jeff? Help me to understand what you make of the way … the family is sitting in the room right now.”

Tovar-Murray, an associate professor of counseling at DePaul University, also points out subtle verbal and nonverbal communication: “Jim, when you said James is not doing well in school, your voice went up, and at that moment, James turned his back to you. Can you tell me what James may be feeling right now?” Teaching stepfamilies effective communication skills helps them to understand one another’s experiences and emotions, says Tovar-Murray, a member of ACA.

Haney encourages clients to explore the narratives they are telling themselves about certain situations while simultaneously accepting that everyone has their own perspective on those situations. For example, if a stepmother says that her husband is always looking at his phone and waiting for his ex-wife to call, the counselor can say, “I understand that bothers you. What’s the story you are telling yourself?”

The stepmother might say she feels like the ex-wife is still more important to her husband than she is. The husband says he’s simply concerned that he’ll miss a phone call from his children. To which the stepmother responds, “I don’t want you to miss a phone call from your children. I just feel like you’re always looking at your phone when we’re out at dinner.” The couple can then make an agreement for the husband to either put his phone away for an hour or call his children before going out to dinner.

Recently, Haney had a stepmother come in by herself because her 25-year-old stepdaughter was constantly fighting with or upset with her and her husband. Haney worked with the stepmother to help her understand that she could not control the adult child’s behavior — but she could control how she reframed the situation and responded to the stepdaughter. With Haney’s guidance, the stepmother changed her perspective and learned new skills so she would no longer get surprised, upset or disappointed when the stepdaughter turned argumentative.

“The hardest part in relationships is to realize the amount of power you have or don’t have to make change,” Gold says. “You have endless power to make change in self. You have less power to make change in others. And, sometimes, part of being in a relationship means you accept things you don’t really like.”

Establishing stepfamily structure

Haney often begins counseling with the stepcouple first because she believes the partnering piece needs to be in place before other issues can be addressed effectively. “If the stepfamily couple can create the structure within their relationship and they can get on the same page with some of these issues, the kids fall into line,” she says.

Stepcouples often face challenges with establishing and maintaining clear parenting roles. In fact, a primary area of conflict for stepfamilies is the parent–child relationship, Haney notes.

The stepcouple need to agree on what they want to teach their children and what the family rules are in the home, she continues. For instance, if the stepmother thinks the children should stop using their smartphones at night and tries to enforce the rule without the biological father’s support, it will cause problems. In such situations, Haney often finds that the biological parent agrees with the overarching rule; the disagreement is in the details. Perhaps the father thinks that 8 is too early to restrict phone use and that 10 would be a better time.

“The moment that you allow the biology to divide, then the house is really two different houses,” Gold says. “So, there’s got to be a set of rules for the house.”

Haney suggests that stepfamilies establish basic rules about bedtime, homework and family dinners. Every family member should also have his or her own space in the house, she says. For example, one person shouldn’t sleep on the couch while the others have their own bed.

Haney believes that the biological parent needs to parent, and the stepparent needs to let that happen. Gold agrees. The stepcouple should figure out the household rules, and then the biological parent should present those rules to the family, he says. Then, both parents can enforce those rules.

If a couple disagree on this point, Haney draws the stepfamily triangle so they can visualize the dynamics. This can help the stepparent realize that he or she may have been overstepping. Haney then asks, “What does the family need to do to make the triangle stay upright?”

First, the partners must be on the same page and create a supportive relationship in which they respect each other’s experiences and perspectives, Haney says. Sometimes, stepparents will need to take a step back, she adds. Haney tells stepparents, “When you assert yourself as a biological parent when you are not … you’re putting a target on your chest because you will always be the bad guy. You will never win.” The biological parent’s job is to protect the stepparent by doing the parenting, she stresses.

Second, Haney says, stepparents have to strengthen their relationship with the stepchildren, but they must also accept that it will take time. One activity she uses to help with this is the emotional bank account. When stepparents marry or move in with the biological parent, they assume a parenting role, she explains. Because biological parents already have a strong emotional, legal and biological bond with their children, they can discipline, set boundaries for, and offer advice and make comments to their children, Haney says. However, stepparents don’t have this emotional connection yet, so with every negative action (e.g., punishing, yelling, making comments, rolling eyes), they make a withdrawal from the emotional bank account with the child, she continues. “It’s not one deposit and one withdrawal,” she points out. “It’s one deposit, but for every negative nonverbal or negative interaction, it’s five withdrawals.”

Haney often helps stepparents realize that they are depleting this emotional bank account faster than they recognize. In such cases, they need to stop making withdrawals and start making deposits. Recently, one of Haney’s clients, a stepfather, was having a difficult time with his 14-year-old stepdaughter. He expected a lot of her and often critiqued what she did. For example, he would point out that he often needed to remind her to take out the trash and even made comments about the way she tied the garbage bag rather than thanking her for her efforts. Haney encouraged him to start making deposits in his stepdaughter’s emotional bank account by giving her compliments, texting that he was proud of her, or saying that he noticed how hard she had been working. When he followed through, their relationship took a 180-degree turn within a week’s time, Haney says.

When a biological parent finds a new partner, the children are often expected to show love and respect for that new partner right away, Skinner says. However, it’s important to remind stepfamilies that neither children nor adults love immediately. It takes time.

In addition, the child’s developmental stage can affect the degree to which the stepfamily bonds. If children are approaching or into adolescence when the stepfamily forms, they may never feel connected to the stepfamily unit because they are focused on forming their
own separate identities at that point, Gold notes.

In her stepfamily, Haney and her husband developed a plan to handle the stresses and problems they faced. She encourages couples to follow a similar plan, which includes:

Talking to and reassuring each other that things will be OK
Creating daily habits that provide a sense of connection and support
Going out on dates
Limiting how much time they discuss children, stepchildren and exes

Haney also reminds clients to laugh. She and her husband found watching a daily episode of Seinfeld helpful during the difficult early part of their stepfamily’s life.

“A lot of times with stepfamilies, you’re sacrificing the me for the we,” Haney says. “If the couple … is willing to make these changes for each other, then it can be a really powerful experience.” In addition, the behavior of asking for help, finding solutions and making changes serves as a powerful model for the children, she says.

Focus on the solution, not the problem

“I think the big mistake that counselors make is they try to start with the problem,” Haney says about counseling stepfamilies. Often, stepfamily couples come in experiencing so much angst, frustration and confusion, they don’t know where to begin. If the counselor asks the couple to talk about their problems and feelings, the couple and the counselor all become problem saturated and risk becoming overwhelmed, she says.

To avoid this, Haney starts sessions with a basic genogram, which provides her with all the names and connections between the family members. She uses colored markers and construction paper, drawing a circle for each woman and a square for each man in the family, including the stepfamily couple, the ex-partners and the children. Haney then asks the stepcouple’s ages and living arrangements, when the couple first met and when they started dating, and she adds that information to the genogram. For those who are married, she will also ask if they lived together before they got married, when they got married and how long they have been married. Finally, she asks about the most serious relationship that each of the partners had before they got involved with each other.

Next, she draws smaller circles and squares for the ex-spouses or ex-partners and asks similar questions such as age, length of time together, when they separated and if they have children together. If they do have children together, Haney connects the ex and adds in the children’s names and ages, as well as how the parents split their time with the children and how involved each one is with the children.

Haney always ends this exercise by asking, “Is there anybody else that we’re going to be talking about today or who is creating challenges in your stepfamily life?” By asking this question, she often discovers other people, such as one of the partner’s siblings, a grandparent or even the ex-spouse’s new partner, who are adding to the stepfamily’s problems.

In addition to serving as a reference tool that counselors can use throughout their work with the stepfamily, the genogram provides structure to the session. “Structure is a big part of doing a successful stepfamily session,” Haney says. “[It’s] knowing what you’re going to do and how you’re going to do it so that you don’t allow [the session] to become problem saturated.”

Tovar-Murray uses a narrative approach to separate the family from the problem. For example, if a child feels divided between family members, he would have the family name the problem and then ask, “When did the sense of divided loyalty enter your family system? How has it caused you to think you are not a family who can be a cohesive unit? What would your future look like if divided loyalty were no longer present and you were operating as a family unit?” This approach encourages the family to fight together against the problem rather than letting it divide them, he explains.

To strengthen stepfamily cohesion, counselors can also ask family members to describe activities that might make them feel more connected and then encourage them to carve out time over the next week to engage in those activities, Tovar-Murray suggests. “We’re always looking for those unique outcomes, and those are the times in which the stepfamilies are not being saturated and influenced by whatever the problem is,” he says.

Separating the family from the problem is also helpful when there is resistance to the new family structure, such as when one of the partners resists embracing or blending two racial or ethnic identities. For example, in a household with a Latinx stepfather and an African American biological father, the biological father might say, “Maintaining my African American identity is extremely important, and I’m not giving that up. I’m going to see this as an African American family.”

“That resistance piece is just showing [the counselor] how important that identity is,” Tovar-Murray says. With this situation, the counselor could attempt to separate the family system from the resistance piece and reframe it. For example, the counselor could respond, “I can see that you have a strong sense of pride in being African American. Now, I also wonder how you can have that same sense of pride in the relationship that you just formed.”

The counselor can help the family reframe this racial pride and create pride in the new structure the family is developing. Otherwise, the stepfather may feel isolated, which makes cohesion and integration almost impossible, Tovar-Murray says.

Take a step forward

Both Gold and Skinner acknowledge that busy schedules and finances can be big issues for many stepfamilies. As a result, these families often are not looking to engage in long-term counseling.

Gold says that any counseling approach that is more “present-focused” works well with stepfamilies. He often relies on a brief therapy model — six to eight sessions — and finds that most clients will make a commitment to therapy if they know how long it will take. This model also works well with family schedules, he adds.

Counselors “need to remember that a stepfamily couple is going to be less likely to come once a week, every week, for six months,” Haney points out. “So, when [counselors] work with stepfamily couples, [they’re] really doing that solution-focused piece.”

In fact, Haney finds that when stepfamilies come to see her, they have already thought and talked a lot among themselves about the issues they are struggling with, so they want to know what to do. “They know where they are and they know where they want to be, but they do not know how to get there,” she says. Haney doesn’t direct stepfamilies on what to do, but she does help them figure out different paths for getting where they want to be.

After Haney finishes the genogram, she asks the stepcouple directly, “How can I help you today?” Some couples may get to the heart of the matter, whereas others may not have an answer. In those cases, Haney provides the stepfamily with information on the importance of partnering together, the stepfamily triangle and the emotional bank account.

Haney also asks the stepfamily, “What are the two or three things you want to accomplish or work on while you are in counseling?” The family’s answers must be something they have control over, she says. “You don’t have any control over the ex or the stepchild,” she explains. “You do have control over how you respond to the ex. … You do have control over how you respond to the stepchild, how you talk to your partner about the child, and what kind of stepparent or parent you want to be.”

In part because stepfamilies may attend only a few counseling sessions, Haney often spends a longer amount of time in the initial session getting to know the family members, figuring out why they came to counseling and making sure they leave with an action plan. In the initial session, which often lasts up to two hours, she spends approximately 15 minutes on the genogram and 15 minutes educating clients about common stepfamily issues. For the remaining time, she helps families determine two or three things that they want to accomplish.

By the time the family leaves, each family member “need[s] to have something that they’re going to do that’s doable and that they can work on,” Haney says. “Then they leave empowered because they know what to do. [They] leave … educated because you’ve shared with them some insights that help them change their perspective and reframe how it’s working. And … it helps them see their story and their family differently.”

****

Invisible stepfamilies

The concept of stepfamilies can challenge traditional assumptions of the word family, which often evokes an image of a married father and mother with their biological children. But as Darrick Tovar-Murray, an associate professor of counseling at DePaul University, points out, this image doesn’t account for the diversity found within stepfamilies. In fact, because this assumption doesn’t recognize other types of partnerships or unions, it renders them “invisible,” he says. That’s particularly the case when these families include a noncustodial and custodial parent with at least one child from a previous relationship and encompass multiple racial, ethnic and sexual orientation identities — which he refers to as invisible stepfamilies of color.

“When you look at invisible stepfamilies of color, they tend to come from cohabitating relationships where there isn’t a marriage or legal contract,” Tovar-Murray says. “That legal contract should not be what defines a family.”

As society continues to grow more diverse, counselors will encounter more invisible stepfamilies of color and thus may need to challenge their own views of what family means, Tovar-Murray argues. Counselors also shouldn’t assume that a couple is married, he continues. In addition, asking “How long have you been dating?” implies that the couple’s relationship may not be as close or as integrated as a couple who is married, and that may not match the perspective the clients have of their relationship.

Tovar-Murray also advises counselors not to make assumptions such as thinking that a stepcouple’s decision not to hold hands is related to their lack of affection for each other. Based on their experience of racial/ethnic or sexual orientation microaggressions, many of these couples may engage in this or similar displays of affection only in spaces they consider to be safe. “As counselors, we cannot assume that invisible stepfamilies of color are going to be out in all spaces that they walk in,” he says.

For this reason, Tovar-Murray, an ACA member and co-author of a chapter on blended families of color in the book Intervening for Stepfamily Success, advises counselors to be open and direct about microaggressions. He will often tell clients, “I want to talk about something I think is important. We know that racism exists and sexual orientation microaggressions exists, and I’m wondering if you as a couple or if this family has ever experienced those things.” He also suggests saying, “I know biases exist, and some of the things that may affect a family system like this may even be biases within your own cultural groups. Have you experienced any of those? How have you successfully dealt with those things?”

“The assumption that [counselors] make sometimes is that [they’re] not going to bring [these issues] up because the client didn’t bring it up,” Tovar-Murray says. “But sometimes clients, couples and families may not know that [counseling is] the space [where they] can talk about those things.”

— Lindsey Phillips

****

Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

****

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

Healing from multiple personalities

By Todd E. Pressman May 28, 2019

In April 1996, I began a course of psychotherapy with a woman named Angela. She came to the first session with vague feelings of anxiety and the need to “find a safe place.” This seemed usual enough for me after 20-some years in practice. Little did I know that our first meeting was the beginning of one of the most extraordinary therapeutic journeys I would ever encounter.

Although Angela had always suspected something was different about her, she did not realize that she had multiple personality disorder (now called dissociative identity disorder). She only knew that she was filled with fear much of the time and that there were large gaps in her memory.

Early in our work together, Angela had a dream of being in a bicycle repair shop — a wondrous place with huge escalators carrying bicycles here and there to be repaired. After watching many bicycles come in damaged and leave repaired, Angela asked the owner of the shop (me) if all bicycles could be repaired. In the dream, I answered “Yes.” When Angela showed me her own bicycle, which to her seemed hopelessly damaged, my response in the dream was, “There are no bicycles beyond repair.”

This was the message Angela needed to begin her therapeutic adventure. Through the course of her recovery, in which she integrated more than 70 personalities and opened up into one of the most spiritual people I have ever met, I deepened my own conviction that, truly, that are no “bicycles” beyond repair. In other words, there are no souls that cannot be healed and no injuries that cannot transform into a higher level of understanding and peace.

Angela’s story

The early part of our work together was simple and straightforward: Angela needed to know that there existed such a thing as “a love that didn’t hurt.” It was hard for her to trust that our therapeutic relationship could be the safe place she was looking for, that she could dare to start whispering family secrets without reprisal, that, together, we could be bigger and stronger than her fears.

Angela began her life as the victim of extreme abuses, as is true for most people with multiple personalities. From the time Angela was 4, her father, whom she trusted like any innocent child would, began sexually abusing her, while her mother stood by in passive compliance. When Angela resisted, her father threatened her, saying the devil would take her away if she did not agree to what he wanted to do and, in fact, if she did not enjoy it. At such a vulnerable age, Angela managed to do the impossible — she held in her screams and learned to say “thank you” and “I love you” in response to these abuses.

As these kinds of extreme torments continued, Angela forced her natural expression of self deeper and deeper down until, one day, she found a new solution: She would “project” herself into a certain picture that was hanging on the wall, a picture of a beautiful angel protecting a little girl and boy. Angela would make herself the little girl and her brother the little boy and bring the angel to life in her mind. She would do this so thoroughly that, for a time, she could live in that picture and escape her torture.

At a certain point in her therapy, Angela felt compelled to chronicle and perhaps publish her story. This served two purposes. First, she would be able to reach out to others — those with multiple personalities and those who simply needed to find their way through emotional struggle. She wanted to offer the help she was finding in her own recovery. Second, sharing her story would be a powerful way to take a stand against the thought that she needed to preserve the family secrets and stay victimized by them. That book, The Bicycle Repair Shop: A True Story of Recovery From Multiple Personality Disorder as Told by Patient and Therapist, became a reality.

In notes that Angela shared with me after the book was published, she provided the rarest of accounts of how the first moment of splitting off (dissociating) occurred:

One day, my father’s touches were worse than ever. His huge body pressing against mine was more than I could bear. … The pain grew greater until [the point of] what I thought was my last breath. I felt as if my arms were being yanked, pulling my body from its skin — my insides were separating from my outside to pull my body from the spot where I sat. My legs felt as if they were bolted to the ground. It was as though someone was trying to pull me from the other end out of my skin.

I was surprised to find myself standing in a picture that hung in my bedroom. A picture of a Guardian Angel watching over two children. Where was I? Who was it that was still with my father? I was not aware of what was going on. All I knew was that I was safe. The memory of what was happening before was successfully erased. That was how “four” was born, my first personality of many.

This remarkable description shows the adaptive function of multiple personalities: When one personality could no longer stand the circumstance of the moment, a new one would take over. This was the strategy Angela would use to grow her “family within” to help her navigate the abuses she was being exposed to.

Meeting Angela’s personalities

Through her therapy, Angela came to understand how each of these personalities was created to fulfill a specific role, protecting her from some unique threat that she could not handle by herself. In this way, she would simply stop “being” Angela and become someone who could better handle the situation.

First, there were “the little ones” — all children — including Four, Six, Schoolgirl and Crystal. Four was the first one I met, an absolutely adorable, sweet little girl who wanted nothing but to feel safe and loved. She was clearly terrified and felt solace only in my presence. When I would go away on vacation, for instance, her pain was so great that she could not tolerate it and would go “underground.”

Crystal, on the other hand, was immune to such pain. She was a beautiful little girl with curly blond hair and bright blue eyes (different in physical appearance than the others). Her strategy was to imagine that she was not, in fact, part of this family. She fully expected that she would be rescued by her “true” family any minute and taken away from the abuses.

Then there was Patrick. He was one of only two male personalities whom I met. In creating Patrick to be gay, Angela was imagining a model of a male who could be gentle, nurturing and safe.

The Boss was the other male personality, and his function was to “control” the children. In manner and even appearance (Angela’s face would change dramatically whenever the Boss showed up), he was like a classic Chicago mob boss. I must confess, I felt rather intimidated by him at the beginning. Later, however, I managed to convince him that I was an ally, someone who could help him find a better way to keep the children in place through understanding and meeting their needs. You can imagine his resistance, but in the end, we became a great team. (At one point, after we became “friends,” the Boss confessed to me in a hushed voice, “I’m working on getting rid of these.” He was referring to Angela’s breasts.) This was one of the rare occasions in which Angela’s external reality and the inner life of her creation did clash. Still, she was working on a “solution” that would enable her to keep her constructed world intact.

Eventually, three personalities came forth as those who would stand “out front”— those who would interact with the world — while the rest stayed inside to manage Angela’s inner experience. Angela, of course, was the primary personality, and she was the one who would take responsibility for handling the affairs of everyday life. Angie, on the other hand, was a party-loving, sexually profligate personality whose purpose was to have a good time and forget all troubles. She was especially skilled at “knowing what men wanted” and used these wiles to get men to do her bidding. At the other extreme was Angel, a spiritual personality who would remind the rest that they were safe and loved in God’s care. Angel would become a most important presence in Angela’s recovery because this spiritual aspect led the way to her final experiences of forgiveness.

At a later point in therapy, a personality was needed to “house” the others in a more neatly integrated whole. This was one of the few times in which I actually witnessed the creation of a new personality. The personality wanted to choose a name for itself that would bring it to life, so to speak, and it came up with Tang — a combination of Todd (my name) and Angela. This, she explained, was the result of my saying to the family, “I need you not to make any decisions without me because I am part of the family” — a necessary prevention against Angela trying to hurt herself or sabotage the therapy in some way.

Tang was a fascinating entity, representing the point at which Angela was 99% integrated. Angela described this sensation as if there were a body inside of her body that almost completely filled her up. There was just “1%” of space between them inside.

She also allowed the little ones at this point to create a magnificent collage. They knew they were about to “disappear” into the one personality that was Tang, and they wanted to be remembered this way. The collage showed what they felt inside: a single body with many faces, some happy, some sad, some shy and some covered with bugs who had been very afraid. Angela once told me that upon my calling Tang’s name, all the eyes of these faces opened up at the same time to look in response.

One by one the personalities came forth to express their need and tell their story. As Angela and I understood their core message, we were able to find a way to meet the need that was more adaptive. This required that Angela bravely face the fears that had been too horrible to withstand in childhood, trusting that it was safe to do so now. Borrowing my strength and trusting my words — that the people and circumstances of these memories could not stop her from standing up to them with my support — she did what she couldn’t dare do back then.

With a new and profound belief in her right to be free, she stood up to the abuses and said “Enough.” One personality even took on the name Shark to show her teeth and “devour” the fear that they represented. As Angela looked at her fears this way, always in manageable doses, she gave herself the message that she was no longer at their mercy, and one by one, the personalities that had been born to manage these fears would fulfill their purpose and integrate back into Angela.

Facing fears

With the right combination of safety and support, Angela was able to discover the great secret of all healing: When we face our fears, they lose their power over us. At worst, we find a problem that now can be managed. Often, the fear disappears completely because it can no longer scare us into running away from it. In this way, we find ourselves to be “bigger” than the fear, and so its illusion is exposed. It was but an imagination, given power by our refusal to look at it, with no actual ability to harm our true Self.

This was the freedom that gave Angela the power to forgive her abusers (there was nothing left to forgive), integrate the personalities (they no longer had a function), and live in a world she now knew to be safe, manageable and, in the end, sometimes even fun.

In writing the book, Angela wanted others to hear the message that facing our fears is the key to freedom, that nothing can rob us of our ability to choose how we respond to life and to declare our right to be who we truly are. With this, we integrate the fractured parts of our own personality and find our own sense of wholeness, completion and fulfillment.

Throughout our work, Angela would repeat to me, “I want to be one of your success stories.” Many times, she felt the way was too difficult, but as I continued to hold a safe place for her, she developed the courage to face her fears one by one, dismantling the entire structure of her constructed “personality” and reclaiming her original innocence and wholeness.

In the end, she discovered that facing her fears made it possible to forgive, not in the sense of merely accepting those who had abused her, but in the much more profound sense of realizing that they, too, were in need of love, and that holding onto her anger and pain simply kept her a perpetual victim of their abuse. Only with this realization was she free to ask for the love she had once known as a little child of 4, and in asking, find that it was, in fact, still available in the world. With this, she was able to integrate that love and become whole again, to replace the path of disintegration into many fragments that she had chosen before. This integration of love, “a love that doesn’t hurt,” awakened a profound sense of spirituality within her. She is now, in fact, one of the most peaceful, loving and spiritual people I know.

****

Todd E. Pressman has been a licensed psychologist for the past 32 years. He is the founder and director of Pressman and Associates at Logos Wellness in Voorhees, New Jersey. An author and speaker, he co-wrote The Bicycle Repair Shop: A True Story of Recovery From Multiple Personality Disorder as Told by Patient and Therapist with Angela Fisher, who, during the course of her recovery, felt the need to share her story so that it might be of help to “anyone who wants to get free.” Pressman’s forthcoming book, Deconstructing Anxiety: The Journey From Fear to Fulfillment, will be available in August. Contact him at toddpressman@comcast.net or through toddpressman.com.

****

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.

Learning to love (or at least leverage) technology

By Lindsey Phillips May 22, 2019

A client suffers from one of the oldest and most common fears: arachnophobia. The mere thought of a spider causes her anxiety, and she often has a friend check a room for spiders before she enters. She wants to get help, but she lives in a remote area without access to a clinical expert. Could the use of augmented reality help the client overcome this phobia and actually touch a tarantula?

Arash Javanbakht, an assistant professor of psychiatry and director of the Stress, Trauma & Anxiety Research Clinic (STARC) at Wayne State University in Michigan, has found that it can. At STARC, Javanbakht uses augmented reality along with telepsychiatry as a method of exposure therapy for clients with phobias.

The client with the spider phobia, for example, would put on the augmented reality device and connect with the therapist through a wireless telepsychiatry platform. The therapist, who has full control of the augmented exposure scenario, sees a map of the client’s environment on a computer monitor. At first, the therapist places a small spider across the room in front of the client. Then, the therapist adds a larger spider that crawls across the wall. The therapist notes what the client sees and asks how she is doing. By the end of the session, several types of spiders — all moving around — and spider webs surround the client. In this safe, controlled environment, the therapist and client work together to help her overcome her fear.

The impressive part is how quickly this method can help clients. For Javanbakht, the ultimate goal is to have clients touch a real-life tarantula (or a tank containing one). Comparing traditional therapy with the augmented experience, Javanbakht discovered that what would take on average six face-to-face sessions could often be accomplished in 40 minutes with the use of augmented reality. He contends that pairing technology such as this with traditional therapy approaches can significantly improve treatment efficacy for other phobias, anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder.

Despite the possibilities that new technologies offer, however, counselors are often reluctant to use them. Many prefer face-to-face counseling and question the impact that technology may have on the therapeutic relationship. Others are unsure of what technology to use or how to use it. Most counselors worry about possible ethical implications. For some, the overarching counseling principle of do no harm translates into do not use tech.

Olivia Uwamahoro Williams, an assistant professor of counselor education and college student affairs at the University of West Georgia, says this hesitancy to embrace technology is understandable because counseling is a person-centered profession. However, counselors shouldn’t think about technology as a means of removing the person completely, she argues. Instead, they can use technology to enhance mental health and counselor training outcomes, she says.

“There’s a general lack of understanding in the counseling community about high technology such as artificial intelligence [AI] and how it will impact the field,” adds Russell Fulmer, who is part of the core faculty at the Counseling@Northwestern program with the Family Institute at Northwestern University. Some counselors incorrectly assume that they have to be well-versed in the inner workings of technology or must learn how to code, and many counselors even fear losing their jobs to high technology such as AI, he says.

However, Fulmer, a licensed professional counselor (LPC) and a member of the American Counseling Association, doesn’t believe that counselors’ livelihoods are in jeopardy from technology in the short term. The jobs most in danger of becoming obsolete are ones that are repetitive, he says. Thus, occupations such as counseling that involve social and emotional intelligence are better positioned in the long term, he explains.

Holly Scott, an LPC and the owner of Uptown Dallas Counseling in Texas, used to be adamantly against using technology in counseling. Now, however, she is a technology convert, citing at least five ways that counselors can use technology in their practices:

Helping clients find mental health practitioners who are a good match for their presenting issues
Finding and disseminating evidence-based information
Improving clients’ mental health through the use of virtual or augmented reality
Encouraging clients to follow up on treatments and the skills they learn in session through the use of mental health apps
Reaching a broader range of clients through telehealth

Meeting clients where they are

Younger generations have a difficult time imagining a world in which libraries and encyclopedias were the only means of researching school projects. Today, they simply pull out a smartphone and Google it — sometimes while still sitting in class. According to the Pew Research Center, in 2018, 95% of teenagers reported having a smartphone or having access to one, and 45% said they were online on a near-constant basis.

Technology is not just for the young, however. Pew also found significant growth in tech adoption in recent years among older generations, particularly Gen Xers and baby boomers. In fact, boomers are significantly more likely to own a smartphone today than they were in 2011 (67% in 2018 versus 25% in 2011), and the majority (57%) now use social media.

James Maiden, the assistant dean of student affairs and an assistant professor of counseling at the University of the District of Columbia (UDC), finds that clients are outpacing counselors in terms of technology. Counselors need to do a better job of meeting clients where they are, he says. “Don’t think [technology] is going to replace you,” he argues. “Think of how [it] can extend the good work that you’re doing.”

In fact, Maiden, an LPC and an ACA member, views technology as “a gateway into seeking a professional [counselor].” Counselors can begin by providing peer-reviewed, factual information and tools online for people who search the internet for help, he says. Making this information readily available to the public will help lessen the stigma around mental health and open the door for more individuals to eventually take the next step of going to see a counselor, he explains.

Scott says most clients find her private practice in Dallas through her website or by Googling “anxiety” and “Dallas.” She acknowledges that this is a more “selfish” use of technology — one that helps counselors get their names out there. However, if counselors share with the public their specialties and what they offer, then it’s a win-win for both the counselor and the client, she says.

Part of the purpose of Scott’s website is to remove as many stressors for potential clients as possible. The information it provides can help address people’s fears and concerns and normalize the counseling experience, she says. For example, a counselor’s website can include pictures of the office and address common questions that first-time clients might have: Where do I sit in session? Are people going to see me in the waiting room? What do I say to people if they see me sitting there? How much does counseling cost? Where do I park?

Of course, the counseling profession has made some strides in meeting clients where they are through the use of technology. For example, distance counseling and telehealth remotely provide services to clients who may not be able to see a counselor in person because of location or limited mobility.

More widespread use of telehealth has led to a significant decrease in the number of psychiatric admissions among those residing in geographically isolated areas, according to Panagiotis Markopoulos, the clinical lab director and a faculty member in the counselor education program at the University of New Orleans. He touts several benefits to using distance counseling:

Safety (clients can express themselves more freely)
Less social stigma (clients can avoid public encounters)
Accessibility (clients can receive help regardless of their geographical location or daily schedule)
Affordability (clients can receive counseling services at a lower cost than with face-to-face counseling and save on transportation costs)

For clients who prefer or need to use distance counseling, Markopoulos, an LPC in private practice in New Orleans, recommends video- and text-based communication tools such as My Clients Plus and Zoom. In addition, Second Life, a 3D virtual game, offers an encrypted way of communicating, Markopoulos says. If clients value anonymity yet want to be present with a counselor, they can create avatars, enter the “virtual session” and talk through a headset or text-based chat, he explains.

Counseling: There’s an app for that

The high cost of some technologies prevents private practitioners from using them, but mental health apps are an affordable way for counselors to incorporate technology into practice. In addition, these apps can allow people who face barriers to traditional mental health services to access help.

According to Psycom.net, health experts predict that apps will play an important role in the future of mental health care. In particular, mobile apps for cognitive behavior therapy (CBT), relaxation and mindfulness interventions are gaining momentum as supplements to in-person therapy.

Scott, who serves on the board of the National Social Anxiety Center, personally knows the power of using CBT apps with clients. When a client comes to Scott, she offers to use either paper handouts of CBT activities or MoodKit, a CBT app developed by two clinical psychologists. She’s noticed that most clients 35 years and younger prefer to use the app. “For a certain population, [the MoodKit app] really increases the speed of the change and the efficacy of the therapy,” she adds.

Scott has also observed that when she asks clients to record their moods between sessions, those who do it manually often wait until the last minute — sometimes in the waiting room — to complete the assignment. Clients generally respond better to the app, she says, perhaps because it lets them easily chart their moods and provides them with a visual diagram.

When Scott introduces MoodKit, both she and the client open the app on their phones, and she walks the client through all the activities such as daily mood tracking, thought records and behavior activation. With thought records, the app guides users through all the important questions and helps them label the cognitive distortion with prompts such as “Is this all-or-nothing thinking?” Scott also thinks the app’s section for behavior activation is brilliant. With a client who has social anxiety, for example, the app provides a choice of therapeutic activities such as introduce yourself to a stranger. After the client selects an activity, the app prompts the individual to select a day and time to complete this activity.

Incorporating a CBT app with regular counseling also encourages clients to put the CBT skills they are learning in session to use in their everyday lives, Scott continues. The outcome is best if counselors follow up with clients about the app and the progress they are making, she notes. For example, counselors can ask: What do you like about the app? What activity did you complete this week? When you did that activity, what did it feel like? “The therapist’s input … is what will change [the app] from just something [clients] play with on their phones into a real therapeutic, mental-health-changing application,” Scott says.

Scott, who volunteers as a crisis counselor for Crisis Text Line (which provides free crisis intervention via text messaging), has also discovered that several of her clients already use the meditation/mindfulness app Headspace. If clients are using an app, counselors can see if the app works with their therapeutic goals before using it in session with them, she advises.

Before meditation apps, Scott would play a recording (such as background noise at a bar) and have clients focus on the conversation. Then she would tell clients to do the same thing outside of sessions, starting with 10 minutes a day and working up to 30 minutes. Clients often felt too busy to set up a place where they could play a recording and work on meditation, but the app creates the environment for them, increasing the likelihood they will practice the skill outside of session, she says.

Maiden, like Scott, is a technology convert. He started learning more about incorporating technology into counseling while serving as the principal investigator for UDC’s Verizon Innovative Learning program, which provides educational experiences that promote and support the involvement of ethnic minority boys in science, technology, engineering and math. The program included free summer sessions, led by counselors-in-trainings, that discussed how to maintain one’s mental health. Afterward, the boys created apps that featured information on mental health stigma, stress prevention, anxiety, depression, suicide awareness and local mental health resources (such as counseling centers). Participants also received a year of mentoring and follow-up workshops.

Through their involvement in the program, the students learned the importance of seeking help when dealing with issues such as bullying, death and violence. They grew more likely to reach out to mentors or parents or to access the local resources included in the apps, according to Maiden, who presented at the 2019 ACA Conference on using technology to increase mental health awareness.

Through his involvement, Maiden realized the potential apps have for functioning as counseling tools that supplement the face-to-face work. Tech tools such as those created in Maiden’s program also allow people to share information with others who may not be inclined to discuss their mental health, he continues. For example, when the friend of one of the boys who had participated in the program joked on the phone about killing himself, the boy quickly informed his friend that suicide was not a laughing matter and that he was going to tell his mother, who would tell his friend’s parents. The boy also provided his friend with local resources from the app. As a result of his actions, the friend’s parents sought help for their son.

Exposing clients to a virtual world

As Scott points out, exposure therapy can be time-consuming and expensive to do when using real-life props and scenarios. As Javanbakht’s impressive results demonstrate, however, virtual and augmented reality can allow therapists to remotely expose clients to feared objects or situations. This approach is more time- and cost-efficient and provides a safe, effective outcome, Scott says.

Markopoulos finds the immersive quality of virtual reality particularly helpful for clients with autism spectrum disorder (ASD). Research indicates that individuals with ASD are drawn to technology, and they often learn and understand visually, he says, so using virtual reality with this population makes sense. “The higher the immersion, the more likely the child who has been diagnosed with autism will be able to apply the social skills that he or she has been taught in a real-life situation,” Markopoulos explains.

Markopoulos, an ACA member, has received several awards, including the 2018 Graduate Student Research Award from the International Association of Marriage and Family Counselors and the 2017 Make a Difference Grant award from the Association for Humanistic Counseling, for his work with virtual reality in the treatment of children with ASD. He also presented on the topic at the 2018 ACA Conference.

Markopoulos developed a virtual mall for individuals with ASD and for those who present with social anxiety. Both Markopoulos and the client put on the head-mount display (box-shaped glasses that allow the user to see the virtual/augmented scenario) and enter the virtual mall, which is busy and noisy. The client will see and hear coins falling from the ATM and televisions playing, see flashing lights from a photo booth in the center of the mall and see avatars constantly walking past. All of these visual and auditory elements serve as checkpoints to figure out the source of anxiety for the client.

As the client passes by a large television producing a high-pitched frequency, the client pauses and stares at it, and Markopoulos takes note. Markopoulos has attached a heartbeat sensor to the client, and upon hearing the television, the client’s heart rate escalates. At this point, the client says the mall is overwhelming and removes the head-mount display.

Through the use of virtual reality, Markopoulos has identified what is causing the client’s anxiety — the high-pitched frequency he programmed into the television. With this information, he creates a new scenario with checkpoints focused on the same high-pitched frequency, and he allows the client to control the volume. Upon entering the virtual world again, the client reports the sound is loud and overwhelming, so the client lowers the volume. Slowly, with Markopoulos’ help, the client is able to cope with the sound at a low frequency. Then Markopoulos gradually increases the sound, helping the client slowly build capacity for handling more noise.

Scott and Maiden are excited about the possibilities of incorporating virtual reality into counseling practice. In fact, Maiden plans to use virtual reality in the Verizon Innovative Learning program at UDC this summer. He wants the boys who participate to create virtual safe spaces so they can process and cope with all the stressors they experience. He hopes these safe spaces will be tools the boys can use at home until they are able to make it to their next counseling sessions.

Mental health chatbots

Fulmer doesn’t think that AI will eclipse the human need for face-to-face interaction that counseling provides. Instead, he equates AI to a multivitamin — one that will serve as a supplement to counseling.

To learn more about the intersection of AI and mental health, Fulmer reached out to X2AI, an AI startup in Silicon Valley that is, according to language on its website, “building an AI that will … make the lives of people suffering from various forms of mental illness much better.” Fulmer offered his services and now serves as a consultant and on the company’s advisory board.

As Fulmer explains, Tess is X2AI’s largest and most versatile mental health chatbot. She provides psychological support for people using automated chat conversations through text-based messaging apps that are compliant with the Health Insurance Portability and Accountability Act (HIPAA). When a person talks to Tess, she not only analyzes the conversation but also remembers details and learns from what the person says.

Along with X2AI, Fulmer conducted a randomized controlled trial to test the efficacy of using Tess to reduce symptoms of depression and anxiety in college students. Depending on the group, participants received unlimited access to Tess for either two weeks with daily check-ins or four weeks with semiweekly check-ins. The college students used Facebook Messenger (a text-based communication) to interact with Tess. She provided psychoeducation and interventions to help the students cope with their depression or anxiety.

Fulmer and his colleagues found that having access to Tess resulted in a significant reduction in symptoms of anxiety and depression among the students. In addition, the participants said they felt comfortable and satisfied with the therapeutic experience. One student said it felt like talking to a real person and noted the benefits derived from the specific tips Tess provided for ways to improve mental health. Another student reported learning new ideas for making small changes.

Fulmer points out that this study and the students’ feedback suggest that chatbots can help with two of the most common counseling issues — anxiety and depression. Thus, counselors might want to explore the use of mental health chatbots such as Tess, in conjunction with traditional therapy, to see if it improves the mental health of some clients.

Mental health chatbots can also reach a wider, more diverse group of clients, Fulmer says. For example, X2AI has developed a chatbot (Karim) to help Syrian refugees and a chatbot (Sister Hope) designed for clients who are Catholic. Fulmer also notes that rural populations that don’t have much access to mental health care and older adults who often experience loneliness could benefit from mental health chatbots.

“AI is the biggest opportunity that humankind has ever had,” Fulmer says. “When there’s opportunity and the potential of power and influence, it must be monitored. It must be crafted, and it … must evolve appropriately. And counselors can play a role in … the evolution of psychological AI.”

Virtual role-play

In graduate counseling classes, students often engage in role-play, with one student playing the role of the client — including assuming the client’s mannerisms and personal history — and the other student embodying the role of the counselor. This traditional training method offers several benefits, including helping students develop empathy and experience what it takes to be vulnerable in a session, Williams points out.

However, because students would often “break” from their role-playing if they were caught off guard, Williams, an ACA member and LPC at the Healing Center for Change in Georgia, felt the immersion aspect was not as authentic as it could be. To make the experience more immersive, she started using virtual simulation to create these role-playing scenarios — a topic she presented on at the 2019 ACA Conference.

With virtual simulation, students go into a virtual lab and interact with avatars. The scenarios are limited only by counselor educators’ imaginations, she says. It could be a client with bipolar disorder or a family session with two adults and three children. She points out that a virtual space is also less stressful for students because it allows them to focus on the counseling role.

Another major benefit is that counseling instructors can easily manipulate or alter the student–avatar interactions and virtual scenarios to further challenge students and prepare them for real-world counseling sessions, Williams says. Instructors can also pause the simulations when students are feeling frustrated and process with them, she says.

For example, recently, when an avatar’s voice became low and choked, the counseling student doing the simulation did not pause to address the emotional change but just kept processing the client’s story. Williams wanted to check this, so she stepped over and asked the person managing the equipment to make the avatar cry. When the avatar started crying, the student froze, not knowing how to respond. Williams paused the session to process this issue with the student, who admitted that she didn’t handle it well when people cried. The other students who had been observing and taking notes on the virtual session acknowledged that they wouldn’t have known how to respond either.

This virtual experience made the counselors-in-training realize that they needed to work on handling clients’ emotions and led to a class discussion on strategies. Williams says she wouldn’t have been able to recreate the same scenario in a traditional role-play because she can’t easily walk over to a student and whisper, “Start crying.” That wouldn’t create the same effect, she says.

Because students know the avatar is not a real client and recognize that the virtual simulation is a safe space, they are also more willing to take risks, Williams adds. A year ago, a student went into the virtual lab and started asking the avatar close-ended questions, which every counseling textbook and instructor advises against. When the student came out 10 minutes later, Williams asked her why she had used those questions. The student replied that she had been curious about what would happen; now she understood that it resulted in the counselor and client going around in circles.

Providing a safe space to role-play often gives counselors-in-training the courage to “mess up,” Williams says. “They can get it wrong — really wrong — and that’s fine because you can stop the simulation, give them feedback, assess how they’re doing, and start it back over and give them an opportunity to practice that skill again.”

Williams still recommends blending traditional role-play with virtual role-play. She uses the traditional method when students are learning the basic counseling skills, such as listening and developing a therapeutic alliance. Then later in the class, she uses virtual simulation to have students practice those skills and experience more complex scenarios such as crisis intervention, a client with psychosis, or couple and family sessions.

Counseling students can also use avatars to learn how to talk with clients’ families and caregivers, she adds. For example, the virtual scenario could involve a school counselor discussing with a child’s parents how the child mentioned having suicidal thoughts. The counselor-in-training can practice having that conversation with the parent and figuring out how to work together to create a safety plan, she explains.

“As educators, we need to be mindful of the students that we’re teaching,” Williams says. “The millennial generation … [is] exposed to a level of technology that is beyond what any of us were exposed to over the course of our lifetime. It’s naïve to think that we can continue to teach effectively these new sets of students and keep their level of excitement and keep their level of enthusiasm without incorporating more exciting technologies in their learning experiences.”

Technologically ethical

Because technologies change so quickly, counselors may find themselves in uncharted waters when debating whether to incorporate things such as virtual reality therapy or mental health apps into their counseling practice.

The first questions Scott typically hears related to counseling and technology revolve around ethics. She acknowledges that a lot of misinformation tends to circulate about using technology within one’s counseling practice, so she advises counselors to continually check the ethics codes of counseling organizations such as ACA and state-level regulations to see if new guidance or rules have been put in place.

The ACA Code of Ethics doesn’t specifically mention chatbots or mental health apps, but as Joy Natwick, ACA’s ethics specialist, points out, the decision to make the code a general set of guidelines and principles for using technology was intentional. “If we were to write a code that specifically names types of technology, it would be out of date before we printed it,” she says.

Natwick encourages counselors to pay special attention to Section H of the ACA ethics code, which discusses distance counseling, technology and social media. “If you feel like you can’t find [an answer in that section], go to the preamble of the code because that’s where the [professional] values are, that’s where the principles [of professional ethical behavior] are,” she advises.

When counselors encounter a new technology or have ethical questions about technology, Natwick suggests they use an ethical decision-making process such as Holly Forester-Miller and Thomas Davis’ “Practitioner’s Guide to Ethical Decision Making.” (ACA members can access both an infographic and a white paper on the seven-step model at counseling.org/knowledge-center/ethics/ethical-decision-making.) ACA is also in the process of creating tip sheets to provide practical guidance regarding social media and distance counseling, she adds.

“Technology becomes more and more ingrained in everyday life and, therefore, we as counselors need to keep up,” Natwick says. “We don’t want our profession to get left behind.” She hopes the practical guidelines provided by ACA will serve dual purposes: 1) Encourage those eager to use technologies in counseling to pause and consider the ethical implications, and 2) encourage reluctant counselors to engage more with technology.

Natwick also stresses the importance of competency, privacy and confidentiality when it comes to technology in counseling. “Technology is another way we are supplementing therapy or interacting with our clients,” she says. “[As with] anything we introduce to our clients, we need to really educate them about the risks and benefits.”

Scott is well aware of privacy concerns online, so her informed consent document explicitly details her online and social media policies and lets clients know appropriate ways to contact her. For example, she will not friend clients on Facebook, but they can follow her on Twitter. Clients can also contact her through a form on her website or by posting comments on her blog (which require her approval). She also addresses these issues during her intake session
with clients.

“Tech privacy means something very different in the tech space than it does in the health care space,” Natwick warns. For this reason, she recommends that counselors use technologies created or informed by mental health professionals because these vendors should share similar values with counselors and understand the HIPAA privacy rule.

Teaming up with tech

Of course, professional counselors can also benefit from technology apart from using it with clients. Scott often turns to Twitter to find information and to get practical suggestions from fellow mental health practitioners by using hashtags such as #CBTworks and #SoMePsychs. For example, she recently saw a Tweet asking other mental health practitioners for their favorite clinical handouts for doing cognitive restructuring with clients with anxiety or depression. Several people replied with resources, including handouts, infographics and links.

Scott discovered MoodKit, the CBT app she uses with clients, through the Academy of Cognitive Therapy Listserv. A quick search on the Listserv led her to a research study on three CBT apps. The study found that MoodKit was effective in decreasing depression and increasing mood.

All of this reveals that technology is changing the way that clients and counselors communicate and form relationships. This suggests that counselors will need to be open to finding new ways to build relationships, and it may mean that some of the initial relationship building will happen in different ways than they are used to, Natwick points out.

Smartphones already have built-in sensors that record users’ movement patterns, social interactions, behaviors, and vocal tone and speed. According to the National Institute of Mental Health, apps in the future may be able to analyze the data to determine a user’s real-time state of mind and alert mental health professionals that help is needed before a crisis occurs.

In fact, AI has already made great strides in medical diagnoses. New Scientist magazine recently reported that human doctors annotated medical records (including text written by the doctors and lab results) to help train AI. This partnership resulted in AI that could diagnose children’s illnesses in unseen cases with 90% to 97% accuracy.

Fulmer believes a type of symbiotic relationship could also form between counselors and technology. He sees technology such as AI working alongside counselors in the same way that counselors often work in multidisciplinary treatment teams. For example, a chatbot could detect a person’s emotional or behavioral state and provide the counselor with the client’s data and a possible diagnosis.

“Rather than just one counselor meeting [clients] during their initial interview and having to write down a provisional diagnosis, it might be pretty helpful to also meet with an AI and get their input on the diagnosis,” Fulmer says. “That could probably enhance reliability and even validity.”

The partnership aspect is key. Technology is most likely to assist mental health professionals, not replace them. Fulmer is an optimist about the intersection of technology and counseling and believes “that if done the right way, everyone can benefit.”

****

Letters to the editor: ct@counseling.org

****

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