Monthly Archives: May 2019

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.”

 

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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

 

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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.

Respecting the faith of clients and counselors

By Laurel Shaler May 20, 2019

The Association for Spiritual, Ethical and Religious Values in Counseling (ASERVIC) describes itself as “an organization of counselors and human development professionals who believe spiritual, ethical, and religious values are essential to the overall development of the person and are committed to integrating these values into the counseling process.” Although ASERVIC is a division of the American Counseling Association, and all counselors likely would agree to the importance of ethics, not all counselors share the mission of ASERVIC in its entirety.

With some counselors and counselor educators, this is related to a lack of knowledge, in particular because few counseling programs — other than those whose own missions include the integration of faith — address spirituality and religion thoroughly. Still other counselors and counselor educators perceive a value conflict between counseling and religion or spirituality. Although other spiritual, ethical and religious values should be explored, this article pertains specifically to the Christian faith because I believe this is something that is often misunderstood and overlooked by many counselors and counselor educators.

Unfortunately, many individuals in the counseling field are not comfortable addressing issues of faith. Although the majority of Americans highly value faith, the same cannot be said of mental health professionals, according to researcher Pamela Paul. If counseling students are not being trained to assess and treat from a faith-based perspective, how can they best meet the needs of clients who are seeking this?

The lack of comfort and competency in this area is reflected across presentations, publications and even Listservs such as CESNET (the Counselor Education and Supervision Network). At best, this is because of a lack of knowledge, training or understanding. At worst, it is a brushoff of the Christian faith of clients — in particular, if those clients are conservative or evangelical. Sadly, it is not just clients’ faith that is sometimes disrespected. Often, the Christian faith of the counselor is not respected by fellow counselors either.

From a personal perspective, I have seen many professional counselors put in writing disparaging remarks about conservative and evangelical Christians — including their own clients. If these counselors are making those comments publicly, how can we ensure that they are treating their clients who hold these views with authenticity and respect? I have even read where counselors attempt to persuade clients to “explore” their biblical worldviews — with a clear agenda of trying to encourage clients to change their deeply held beliefs. Much like the serpent in the Garden of Eden asks Eve in Genesis 3:1, “Did God really say you must not eat from any tree in the garden?” there are counselors who ask their clients, “Does the Bible really say … <fill in the blank>?”

There may be a place for this — such as when a Christian counselor and a Christian client are working together, based on a common belief system, to explore the truth of God’s Word about who the client is at his or her core, for example — but there is no place to try and convince clients that they are wrong about their biblical convictions.

Simply put, the faith of the client and the faith of the counselor must be respected. It is entirely possible for clients and counselors who do not share a similar faith to work together effectively. The ACA Code of Ethics applies equally to the evangelical Christian who should not force his or her beliefs on to a client as it does to the nonevangelical (Christian or otherwise) who should not attempt to force his or her beliefs on to a client.

Instead of just lamenting over the way that this population of clients and counselors is often discounted, I would like to offer three practical tips for integrating and respecting faith. Truly, this is what is expected of all counselors as they work with clients and interact with colleagues.

1) Listen: As the saying goes, listen to hear rather than to respond. If your first instinct is to prepare a rebuttal, that is a clear indication that you need to take a step back. Understand first, respond second. This is true not only in the counseling room with our clients, but also in communication with our fellow counselors. We should be willing to hear from those who are not like us without making assumptions or jumping to conclusions.

It is not our job to change anyone else’s belief system or way of thinking. While we absolutely should ensure that students and fellow counselors are upholding ethical standards, we should also recognize that we are all different; that is not only “OK,” it is good. For example, on more than one occasion I have worked in non-faith-based settings. When a potential client would come in requesting to see a counselor who was Christian, the client was often referred to me. It wasn’t that the other counselors could not work with the client effectively. Rather, we were trying to listen to the client and meet his or her needs. Instead of going to a place of defensiveness, our team was able to see the benefit of placing clients with counselors who shared similar values with them when possible.

2) Think: Put yourself in the other person’s shoes. We often call this empathy. Ask yourself how you might feel if your deeply held beliefs were brushed off or challenged in a demeaning or disrespectful way. Think through how you would want to be treated, and then treat the other person that same way. Take some time to reflect on what you are hearing before you immediately respond.

Interact critically with what you are hearing. It is unlikely that someone will change their mind because someone has belittled or criticized them, but they may be willing to flex a bit in their thinking if given some time to process. For example, CESNET often becomes abuzz with emails flying back and forth rapidly. What if we took some more time (as some do) to really think through what is being stated before we respond? We talk about the value of silence in counseling. Perhaps it would be helpful if we put that into practice and spent more time thinking and less time speaking.

3) Ask: After taking the time to listen and to think, there is also a time and a place to ask questions. As every counselor learns in a basic counseling skills course, this can be done in a respectful manner. As we all know, open-ended questions typically produce richer responses that contain more depth and meaning. We should make sure that we are not attempting to lead the other person to what we perceive to be the “correct” answer.

Ask to learn rather than to teach. What do you want to know about the faith of the client? Don’t be afraid to ask about the client’s belief system, how they came to that belief system, how they are living out their belief system, and how they want to (or do not want to) integrate their belief system into their counseling sessions.

This does not mean that the counselor has to share the client’s belief system (although they very well may, and there is strength in that too). It does mean that as counselors, we should be able to respect our clients and meet their needs to the best of our abilities.

Evangelical Christian clients — as well as those who simply identify as traditional or conservative — deserve to be heard and treated with dignity and respect, even when the counselor does not agree with their points of views. I also identify as a Christian who is evangelical and conservative, but there are certainly times when I do not agree with all of these clients.

Years ago, I was working with an individual whose relative was dating someone of a different race. Because of my client’s deeply held beliefs, the client became distressed about this. When seeing the young couple together, my client became distraught, went home and attempted suicide.

Was there more going on with this client? Yes. Yet the reality was that this was the straw that broke the proverbial camel’s back. I consulted with a colleague about this case. In the process, I expressed my shock and disdain over someone reacting this way to a relative dating someone of a different race. I did not understand the client’s gross overreaction.

My fellow counselor reminded me of what I have shared in this article — that although I may not always understand my clients’ views, I should strive to empathize with them and that this situation had meaning for my client beyond what I could comprehend. My colleague was neither conservative nor Christian, but she was respectful of all clients — and of me.

Although I viewed my client’s beliefs as a distortion of the Bible, the client and I both identified as conservative evangelical Christians. Yet we have to be able to accept our clients where they are and take them where they desire to go — not based on our own agendas but on theirs. (There are limitations to this, of course, such as in the case of suicidal ideations.) I had to work hard to empathize with my client’s pain while also helping him work on his desired outcome of changing his thoughts and feelings about the situation as he grappled and struggled to accept what he could not change. With proper supervision, I was able to do this and supported this client during his time in counseling.

Likewise, we should be respectful of our fellow counselors. When we make disparaging remarks about people who are not like us — when I make disparaging remarks about people who are not like me — we are inevitably disparaging some of our colleagues. It is one thing for us to challenge one another, hold each other accountable, and even heartily debate. It is another thing entirely to expect that any group of people should change their entire belief system or else not be included in the field.

Conservative or evangelical Christians are not a rogue group or a small group. We constitute a substantial number in the field who share varying views and beliefs. We cannot all be lumped together. Neither can our clients. With so many clients seeking Christian counseling, perhaps the field should recognize the value of having counselor education programs that teach the ethical integration of Christian faith into counseling (while also recognizing that not all graduates from these programs will hang their shingles as Christian counselors). In fact, it may be time for more training programs to address spiritual assessments, religiously accommodated psychotherapy, and the impact of spirituality and religion on both the client and the counselor.

If you do not understand this perspective, I encourage you to get to know us for yourself. Listen. Think. Ask. Most importantly, get to know your clients. And respect them — and us — for who we are rather than for who you want us to be.

 

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There are many excellent resources for the integration of the Christian faith into counseling settings. These books, journal articles and videos provide the research behind and the details about the practice of being an ethical and effective Christian counselor. They make it clear that this type of treatment is not one-size-fits-all, and it can (and should) be provided at the highest competency level. If one wishes to be a Christian counselor, or if one desires to further understand the Christian faith of a client, the education is available and accessible through the works of individuals such as Tim Clinton, David Entwistle, Fernando Garzon, Ron Hawkins, Harold Koenig, Anita Knight Kuhnley, Mark McMinn, Jim Sells, Lisa Sosin, Siang-Yan Tan, John Thomas and many others.

 

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Laurel Shaler is a national certified counselor and licensed social worker. She is an associate professor and the director of the Master of Arts in professional counseling program at Liberty University. Contact her at doctorlaurelshaler@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.

A script for socialization to the cognitive model

By Brandon S. Ballantyne May 14, 2019

Cognitive behavior therapy (CBT) is an evidence-based treatment approach that has statistically been shown to be effective in addressing a variety of mood disorders and psychological problems. It is my belief that a key component to successful cognitive behavioral treatment is counselor-to-client socialization of theory and concept.

It is essential that clients become socialized to the cognitive model — understanding the rationale behind CBT’s effectiveness — to gain maximum benefit. For that reason, I have developed a script that counselors can use with the clients they serve. This script aims to provide a blueprint for live, in-session socialization to the cognitive model and provides a platform to transition into routine practice of cognitive behavioral technique in future sessions.

 

Script introduction

If I were to ask you to think of a palm tree, what do you think of? You probably just imagined a palm tree. If I were to ask you to think of your very first car, what do you think of? You probably just imagined yourself either in or next to that memorable first automobile. If I were to ask you to think of your favorite food, what do you think of? You probably just imagined your meal of choice.

Now, if I were to ask you to feel anxious, what do you have to do? Most people say they need to imagine a stressful scenario to feel the emotion of anxiety. The point is that we can instantaneously produce any thought. However, when it comes to producing an emotional state, we first need to think of something in order to feel something.

The formation of emotions is a biological process, meaning that it is impossible to shut off or terminate from human experience unless we suffer serious medical injury that leads to such complications. With that being said, there is a specific sequence of internal and external events that not only create, but contribute to, the emotional experiences of you, me and everyone else with whom we share this wonderful planet.

 

Situation

For an emotion to be formed, one must first encounter a situation. A situation is anything that an individual becomes aware of. It can be an external event such as a person, place, thing or activity. It can also be an internal event such as a particular thought or emotion.

Let’s say that tomorrow, I wake up, get in my car and start my drive into work. I encounter a traffic jam, which I anticipate might make me late to my destination. As I approach, I become aware of the traffic jam itself. Both the awareness of the traffic jam and the traffic jam itself become the situation at hand.

 

Thought

Our brain is like a thought warehouse. It has a job of producing thoughts throughout the day — every second, every minute, every hour.

What is a thought? A thought is a sentence that our brain produces about the situation at hand. Thoughts have sentence structure. Each thought has punctuation. It can also take the form of an image or movie that we experience in our mind.

On some occasions, we verbalize our thoughts out loud. Sometimes they stay silent. Regardless, they affect how we feel. If I am driving to work and become aware of the traffic jam, my brain might produce the thought of, “Oh no! I am going to be late. I am going to be behind all day, and I will get reprimanded by my boss. This happens all of the time!”

The first thoughts that our brain produces about a situation at hand are automatic. We don’t really have control over them. But as I mentioned earlier, these thoughts affect how we feel, so they are important to accept and to understand.

 

Emotion

Once our brain produces a thought about a situation at hand, there is the onset of some kind of emotional experience. How is an emotion different from a thought? Emotions can be categorized into mad, sad, glad and fearful. Any emotion that we have at any given time will likely fit into one of these categories of primary emotions.

There is also a subtle category that some identify as “neutral emotions.” However, we are rarely taught about what neutral emotions are. Throughout our life experiences, we are given the message that there must be a way to feel and that emotions need to be either pleasant or unpleasant. Therefore, if we aren’t particularly happy, sad, fearful or mad, we tend to say that we are feeling “nothing.”

Emotions are a biological process. And because our thoughts are automatic, we never really have an absence of emotions. So, when we are feeling “nothing,” we are actually feeling “neutral.” Descriptors such as “content” and “OK” best describe a neutral emotional state.

Now, let’s refer back to the traffic jam scenario. While sitting in the traffic jam, I am having the thought, “Oh no! I am going to be late. I am going to be behind all day, and I will get reprimanded by my boss. This happens all of the time!”

Because of this thought, I am most likely to be feeling anxious. Anxiety is most closely related to the primary emotion of fear. Some emotions occur parallel to physical symptoms as well. For example, if I am sitting in my car feeling anxious from the thought about being late to work, I may also notice that my hands have started to sweat. Physical symptoms help us to identify and label emotions.

So, it is important to pay attention to your patterns in your physical symptoms as you experience emotional states. In general, emotions give us information about the situation at hand. However, it is then our job to examine that information accordingly.

 

Behavior

Our behaviors are influenced by the emotions we experience. Behaviors can usually be observed by others. Based on the specific characteristics of the behaviors — and the specific characteristics of the reactions that the behaviors provoke in others — these behaviors can help us to get closer to our goals, push us further from our goals, or neutralize the pursuit of our goals.

What does it mean to neutralize the pursuit of our goals? Well, some behaviors neither get us closer to nor push us further from our goals. These behaviors can be referred to as “neutralizing behaviors.”

In the example of sitting in the traffic jam and feeling anxious, I may react to the intense anxiety by engaging in behaviors such as beeping my horn and yelling at other drivers.

 

Result

Results can be defined as a set of benefits or consequences that are produced by one particular behavior or set of behaviors. Results can be desirable, undesirable or neutral.

Desirable results are outcomes that take us closer to our goals. Undesirable results are outcomes that push us further from our goals. Neutral results neither take us closer to our goals nor push us further away.

In the traffic jam example, the behavior indicated was beeping the horn and yelling at other drivers. We can anticipate potential results that those behaviors may produce. As a reminder, the goal in that scenario is to get to work on time, or at least not too late, and safely.

One possible result of beeping my horn and yelling at other drivers is that other drivers may begin beeping their horns and yelling at me. This additional conflict may cause my anxiety to intensify further. At the same time, everyone beeping their horns and yelling at each other will not change the fact that I am sitting in the traffic jam itself. Therefore, this outcome can be categorized as an undesirable result.

 

Wrapping it up

The goal of this type of cognitive behavioral style work is to identify where in the process above an individual may have personal control or personal choice of changing the problematic patterns or tendencies. By examining the above scenario in that way, individuals will be able to conceptualize aspects of personal choice and change that can help them reduce intense emotional distress, engage in healthier behaviors, and achieve more desirable results — first in the above scenario and then with the real-life stressors that have brought them into treatment.

Use the following reflection questions to get started with application of this skill:

1) If you were stuck in a traffic jam similar to the one described above, what would be going through your mind? What are some of the automatic thoughts you would be having?

2) What kinds of emotions would your automatic thoughts produce? Would you be noticing any symptoms of those emotions in your body?

3) What type of automatic behaviors might you engage in based on the influence of those emotions or physical symptoms?

4) What type of outcomes or results would those behaviors likely produce? Would those results be desirable, undesirable or neutral based on your goal of getting to work on time, or not too late, and safely?

5) Is there anything else you might be able to say to yourself in the scenario about the traffic jam that would produce less intense distress? If so, what are those thoughts? Remember, thoughts come in the form of sentences or images.

6) If you were able to insert those new thoughts the next time you experience a traffic jam, what types of emotions would those thoughts likely produce? If they do not produce less intense distress or new emotions comprehensively, try identifying new thoughts (sentences) until you find one or two that either reduce the distress or produce new desirable emotions.

7) With less intense distress or new desirable emotions, what are the new behaviors that likely would be produced as a result?

8) Given the likelihood of those new behaviors, what would happen next? In other words, what would be the results of those new behaviors? Would those results be desirable, undesirable or neutral based on the goal of getting to work on time, or not too late, and safely? If those results are desirable or neutral, then you have successfully completed examination of this scenario. If the results are undesirable, repeat steps 1 through 8 until you are left with desirable or neutral results. If a neutral result does not make the situation worse, then it is desirable in itself.

9) What are some situations in your life that have caused stress?

10) What were the automatic thoughts running through your mind at the time?

11) Given those life situations, what were the undesirable results that were occurring?

12) Given those life situations, what were the behaviors that were contributing to those undesirable results?

13) Looking back, could you have said anything different to yourself in those moments to reduce the level of stress? If so, what would those coping thoughts be?

14) Given those life situations, what are examples of healthier behaviors that you want to be able to engage in?

15) Given those life situations, what emotions would be needed to make those healthier behaviors easier to achieve?

16) Given those life situations, what results would you want to be able to achieve, experience or receive?

17) With those desired results in mind, what can you say to yourself about those life situations that might help to produce healthier emotions and healthier behaviors?

18) Copy down those thoughts. Put them on an index card. This will serve as your coping cue to take with you. It will be a reminder that although we may not be able to fix a stressor at hand, we do have the opportunity to access alternative thoughts. It is those alternative thoughts that kickstart the process of reduced distress, healthier behaviors, and the satisfying experience of more desirable results. Thus, we are creating an opportunity for achievement as we assist ourselves in getting closer to our goals, even if certain stressors stay the same. With consistent practice, we teach our brains that we control our thoughts, emotions and behaviors. We give power to ourselves in knowing that we do not need situations to change in order to feel better and do better.

 

 

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Brandon S. Ballantyne has been practicing clinical counseling for 12 years. He is a licensed professional counselor and national certified counselor who specializes in the treatment of anxiety and depression. He currently practices at a variety of different agencies in eastern Pennsylvania. Find him on the web at https://thriveworks.com/bethlehem-counseling/our-counselors/, and contact him at brandon.ballantyne@childfamilyfirst.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.

One school counselor per 455 students: Nationwide average improves

By Bethany Bray May 10, 2019

Although America’s average student-to-school counselor ratio is improving, it is still higher than what is recommended by the American School Counselor Association (ASCA) and some states lag far behind the national mean.

Across the U.S., there is an average of one school counselor for every 455 public K-12 students. This is an improvement over last year’s average of 464-to-1 and the narrowest margin the ratio has been in three decades, according to ASCA.

However, the nationwide average remains far above ASCA’s recommended ratio of 250 students per school counselor. Individual state ratios also vary widely, ranging from 202-to-1 in Vermont to 905-to-1 in Arizona.

“Given the prevalence of school shootings, increasingly intensified natural disasters and rising suicide rates among youth, there has never been a more critical time to ensure that students have access to school counselors,” says American Counseling Association President Simone Lambert. “Our children deserve the opportunity to reach their academic potential to prepare for future careers, while attending to mental health concerns. School counselors play a vital role in supporting students who have mental health concerns, which challenge students’ daily life functioning and school success.”

ASCA compiles a report each year on student-to-school counselor ratios based on data from the federal government. The Virginia-based nonprofit’s latest report, released this week, included data from the 2016-2017 school year, which is the most recent information available.

 

According to the report:

  • States and territories with the lowest student-to-school counselor ratios include Vermont (202-to-1), U.S. Virgin Islands (213-to-1), New Hampshire (220-to-1), Hawaii (286-to-1), North Dakota (304-to-1), Montana (308-to-1), Maine (321-to-1) and Tennessee (335-to-1).

 

  • States and territories with the highest student-to-school counselor ratios include Arizona (905-to-1), Michigan (741-to-1), Illinois (686-to-1), California (663-to-1), Minnesota (659-to-1), Utah (648-to-1), Puerto Rico (571-to-1), Idaho (538-to-1), the District of Columbia (511-to-1), Washington (499-to-1), Oregon (498-to-1) and Indiana (497-to-1).

 

  • Alabama was the most improved state, adding 269 new school counselors and decreasing the student-to-school-counselor ratio 15% (to 417-to-1).

 

  • Wyoming lost more than 100 school counselors (76 secondary-level counselors and nearly 70 at the elementary level). As a result, the state’s student-to-school counselor ratio increased 52% from ASCA’s last report, from 225-to-1 to 343-to-1.

 

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Access the full report with a state-by-state breakdown on the ASCA website: schoolcounselor.org

 

 

The American Counseling Association’s School Counselor Connection page: counseling.org/knowledge-center/school-counselor-connection

 

From the Counseling Today archives in 2017: “U.S. student-to-school counselor ratio shows slight improvement

 

Statistics on mental health and American youth:

 

 

Bethany Bray is a senior writer for Counseling Today. Contact her at bbray@counseling.org

 

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

 

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

Remembering Martin Buber and the I–Thou in counseling

By Matthew Martin and Eric W. Cowan May 8, 2019

Counseling research designed to measure therapeutic efficacy has increasingly focused on empirically validated methods and interventions. On the other hand, counselors have long understood the therapeutic relationship to be the most powerful meta-intervention for fostering client change and transformation. Carl Rogers’ No. 1 rule — that the counselor and client must be in psychological contact — is the precondition for all therapeutic movement. As counselors, we must “be someone with” rather than “do something to” the client.

However, the interpersonal process that occurs between counselor and client is difficult to quantify because it possesses intangible qualities that slip through the fingers of measurement and scientific scrutiny. The relationship between counselor and client seems to transcend any particular intervention strategy. The maxim “it is the relationship itself that heals” is an organizing principle to which most counselors subscribe and yet still sometimes forget. In the search for empirically validated methods, are we in danger of losing touch with what matters most in counseling?

Another consideration is the cultural shift that has altered how people communicate, with interpersonal contact becoming increasingly digitized, objectified and packaged in virtual platforms. Will the next generation of counselors still give primacy to the sense of “presence” in the therapeutic relationship that is the heart of counseling? From our perspective, it seems that a counselor’s enhanced capacity for meaningful interpersonal contact is more important than ever.

Philosopher Martin Buber detailed the qualities that characterize a real “encounter,” or I–Thou meeting, between two people. His ideas remain as relevant today as when they helped to shape the humanistic movement in psychology and counseling.

The I-Thou encounter

According to Buber, an interpersonal encounter contains wonderful potential that far exceeds two separate people in conversation. This potential becomes apparent when two people actively and authentically engage each other in the here and now and truly “show up” to one another. In this encounter, a new relational dimension that Buber termed “the between” becomes manifest. When this between dimension exists, the relationship becomes greater than the individual contributions of those involved. This type of meeting is what Buber described as an I–Thou relationship.

The I–Thou relationship is characterized by mutuality, directness, presentness, intensity and ineffability. Buber described the between as a bold leap into the experience of the other while simultaneously being transparent, present and accessible. He used the term “inclusion” to describe this heightened form of empathy. It is a far cry from the now-familiar scene of a group of friends sitting around a table at a restaurant, all gazing into their smartphones.

Buber saw the meeting between I and Thou as the most important aspect of human experience because it is in relationship that we become fully human. When one meets another as Thou, the uniqueness and separateness of the other is acknowledged without obscuring the relatedness or common humanness that is shared. Buber contrasted this I–Thou relationship with an I–It relationship, in which the other person is experienced as an object to be influenced or used — a means to an end. Regrettably, the I–It relationship requires little explanation for anyone living in a cultural frame of absent-mindedness and technological materialism.

The world of I–It can be coherent and ordered — even efficient — but it lacks the essential elements of human connection and wholeness that characterize the I–Thou encounter. The I–It attitude is increasingly depersonalizing and alienating as it becomes structuralized in human institutions. When an extreme I–It attitude becomes embedded in cultural patterns and human interactions, the result is greater objectification of others, exploitation of people and resources, and forms of prejudice that obscure the common humanity that unites us.

Although Buber saw the I–It as an essential pole of human existence, he thought humanity was losing its ability to orient toward the Thou. He emphasized the important balance required between the two poles if humanity was to survive the dangers inherent in the possibility of mutual destruction.

Counselors view the client–counselor relationship as the foundation of all therapeutic growth because it is fundamentally affirming of human connection, validation and participation. In our own small sphere of influence, we are a force for promoting a more compassionate and humanized world. Counselors should keep this in mind even as we strive toward greater technical organization and efficiency within a mental health “service delivery system” that is not entirely compatible with our broader aims.

To exist is to be in relation

Buber rightly understood that human development occurs in a relational context. Human beings are highly social creatures who need love and care from others to survive through infancy and beyond. An absence of these relational needs almost always leads to psychological injury.

Buber called this deep participation with, and acceptance of, another’s essential being “confirmation.” He believed that one’s innate capacity to confirm others, and to be confirmed in one’s own uniqueness by others, is the source of our humanity. The innate subjectivity that unfolds within every human being can begin to be actualized only when it is accurately mirrored in the eyes of another. Confirmation is at the heart of the I–Thou meeting, of human flourishing and of counseling.

Confirmation is similar to the concept of not imposing “conditions of worth” in the relationship. However, confirmation goes a step further by acknowledging the person’s potentialities — what one may become. For example, a child experiences the tension between growth and fear along each step of the developmental path. The parent can either accept the child’s reluctance in the moment or encourage the child to take the leap. At all ages, human thriving is found in these continual moments of confirmation of potentiality from person to person. As a client struggles with making the “growth choice” or the “fear choice,” the counselor invites the client to greater participation, yet expects to bump into the old fears that make such participation fraught for the client.

Unfortunately, we aren’t always as mindful and present as we’d like to be with others, and we ourselves have not been affirmed in the eyes of others as often as we would like. Even the best of us can fall into an I–It orientation with the world, failing to see the other person at all. Buber believed that these “missed meetings” were the ultimate failure of human relationships and resulted in us losing a part of ourselves.

We all desire to be confirmed in our uniqueness, but when we realize that confirmation is not going to happen, we seem to sacrifice true confirmation for mere approval in hopes of preserving our attachment to others. We cultivate the ability to “seem” a certain way to others to elicit approval, but such approval does nothing to nourish our “being.” A person would rather be confirmed in that which he or she is not than chance the possibility of not being accepted at all.

Unfortunately, this “seeming” mask tends to get stuck, and as one hides one’s being in fear, the possibility of an I–Thou relationship is lost. As Buber cautioned, “To yield to seeming is man’s essential cowardice, to resist it is his essential courage.” When the I of the I–Thou relationship is sacrificed for the It orientation of abstracted relation, authentic human growth and connection are lost, and the I begins to wither away.

Healing through meeting

How can we as counselors foster and model I–Thou relationships with our clients and help them avoid the temptation of “seeming” like someone they are not? Buber thought the answer could be found in a process of active imagination that he termed “inclusion.” In this process, the barriers and constrictions that prevent one from being fully present to an I–Thou encounter indicate where the work is to be done. In what ways must the client stay hidden from others and protect his or her own inner thoughts, feelings and fantasies?

In inclusion, one imagines what another person is feeling, thinking and experiencing while standing in relation to them as a Thou. Rogers’ concept of empathy and Buber’s concept of inclusion are similar (in fact, the two of them debated about it). However, inclusion places greater emphasis on the unique subjectivity of the person attempting to understand the other.

The attempt at understanding the subjective inner world of the person is not a one-way street because the counselor must account for his or her own influence upon the client as both participants come into psychological contact. The I–Thou is a relational event that is co-created; it does not fully reside in one participant or the other. The counselor’s ability to mine the riches of the present encounter and wonder “what is happening between us in the immediate moment” expresses Buber’s notion of inclusion.

We as counselors have the ability to confirm our clients through the process of inclusion, providing them with a relationship that can heal the wounds of their past missed meetings. We must stand in relation to our clients as an I to a Thou to successfully inspire them to move from a “seeming” stance to one of greater authentic participation and “being.”

Although empirical methods and interventions are critical in guiding our understanding of best practices, we must not forget that the single most predictive variable in whether counseling is effective is the client’s experience of the counseling relationship itself. Clients deserve to be seen as a Thou. As Buber once said, “In spite of all similarities, every living situation has, like a newborn child, a new face that has never been before and will never come again. It demands of you a reaction that cannot be prepared beforehand. It demands nothing of what is past. It demands presence, responsibility; it demands you.”

Every moment is an opportunity for “healing through meeting.”

 

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Matthew Martin is a graduate of James Madison University’s clinical mental health counseling master’s program. He is currently completing his residency in counseling at the university’s counseling center. Contact him at matthewmartin.rva@gmail.com.

Eric W. Cowan is a professor in the Department of Counseling and Graduate Psychology at James Madison University. He is the author of Ariadne’s Thread: Case Studies in the Therapeutic Relationship. Contact him at cowanwe@jmu.edu.

 

Letters to the editor: ct@counseling.org

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

 

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