Monthly Archives: August 2019

Understanding the gap: Encouraging grad students to work with an aging population

By Neha Pandit August 20, 2019

It often feels like an uphill battle to be attending graduate school, working, sifting through large amounts of data about practicum (and then internship) placements, and weighing options all at the same time. As a graduate counseling student, there are recurrent moments of panic and thoughts of What am I going to do? Where should I apply? and the unavoidable, multifaceted What if … ?

As someone who has advised graduate students, supervised future counselors throughout their clinical training process, and practiced for over a decade myself, I try to break this process down into questions such as: What do you hope to achieve? What interests you? What type of work do you see yourself doing when you graduate? These questions illicit responses that span from the specific (e.g., “I want to work with kids who are struggling with an addiction”) to the more general (e.g., “I want to get experience doing actual therapy”).

Many clinical training directors will tell you that what we less frequently hear is counseling students who say they want experience working with older adults. When I suggest that this is a growing field with extremely diverse opportunities — from setting (hospital, community, private) to format (individual, family, group) — what I often get in return is a perplexed look, a head shake, and a facial expression that seems to suggest anxiety. This is accompanied by a statement to the effect of, “I’m just not comfortable counseling an old person. What could I possibly say to them that they haven’t already heard?”

 

Uncertain about the uncertainty

The reasons behind this uncertainty are not simple. First of all, what does being an “old person” or “geriatric” even mean? Society most often measures these constructs in terms of years. According to the World Health Organization, the beginning of “old age” typically hovers somewhere between 60 to 65 years old, coinciding with average retirement age in many cultures. But even this age range is slowly shifting upward as we live longer and healthier lives. According to the U.S. Census Bureau, in 2017, 15.6% of the U.S. population was 65 or older. By 2030, this number is estimated to grow to 25% of the population. The Stanford Center on Longevity estimates that 10,000 Americans turn 60 every day.

Given the many opportunities to enhance their clinical skills with such a large and diverse population, how can we understand the hesitation that counseling graduate students may show toward working in organizations that aim to provide services to those over 65? Is the hesitation connected to an internal fear of the unknown — growing older themselves or thinking about loved ones aging and not being ready to face those prospects? Or does it involve assumptions made about people based on age? In speaking with students and fellow counseling supervisors, I think it has to do with a combination of those two reasons.

We all get nervous about working with unknowns, of course. Applied to this situation, the origins of this uneasiness seem obvious: Graduate students have all experienced being children before, but few of them have experienced being old. When a shared reference point is not available, assumptions are all too often generated from stereotypes. The same holds true with words such as “old,” “geriatric” and “elderly.” The problem is that the almost automatic images associated with these descriptors — and with presumptions about fragility, sickness, and resistance to change — are not appropriately reflective of older adults in general.

Given the inevitability of aging and the astounding need for more counselors with geriatric training and experience, I often wonder what we can do to challenge such inhibitions and encourage more students to pursue opportunities to work with older adults.

 

Challenging myths

It is vital to this discussion to debunk age-related myths. This involves challenging the veracity of automatic links and images that students may generate related to the mental and physical well-being of aging adults.

One way to accomplish this is by discussing the basic statistical concept that the variability of differences within a group is much greater than the variability between groups. Said another way, it is more likely that a graduate counseling student will have more in common with an older person than it is for a group of older adults to have a lot in common with each other. This concept should already be a learning objective that is core to any multicultural counseling class. Ensuring that graduate counseling classes that focus on matters of diversity also include exploration of what aging does and does not mean could go a long way toward breaking down uncertainty that is based in incorrect automatic images and assumptions rather than in reality.

Scientific and technological breakthroughs mean that what once seemed to be inevitable byproducts of the aging process are no longer homogeneously applicable. Here are two examples of myths with associated reality checks:

 

Myth: Old people are fragile and are probably ill.

Reality: Some diseases, infections and conditions that were not understood or treatable 50 years ago are now completely preventable or treatable at any age. The National Institute on Aging states that the average age of onset of many chronic illnesses (for example, arthritis and heart disease) has increased incrementally by 10 years over the past 80 years. This means that people are staying healthier for longer and have freer will to control environmental factors that can facilitate good health.

 

Myth: Old people are set in their ways and don’t want to change.

Reality: Personality characteristics usually remain stable over time. Someone who was generally resistant to change over the course of his or her life is likely to remain resistant to change. However, the converse is also true: Someone who generally welcomed change over the course of his or her life is likely to continue to welcome change.

 

Getting personal

Normalizing the fear of the unknown, identifying experiences that may affect this, challenging the rationality of assumptions around aging, and having frank discussions about the universality of “experience” are all pivotal to encouraging graduate students to work with an aging population.

By “universality,” we are not just referring to the inevitability that, with luck, we will all get older. Rather, it refers to the reality that we are all subject to similar challenges and emotions that can arise at any point in our lives. For example, relationship difficulties, depression, anxiety, trauma, illness and loss are life challenges that a 5-, 25- or 75-year-old can face. Therefore, a 5-, 25- or 75-year-old could benefit from treatment.

Erik Erikson recognized this lifelong process of continuous development, growth and reflection through the “integrity versus despair” stage in his theory of psychosocial development. According to Erikson, around age 65, individuals begin to profoundly reflect on the meaning in their life thus far. Someone who is able to find this meaning and look back on life with few regrets moves toward integrity. If, on the other hand, individuals feel they have wasted their time and are full of regret, they will be more prone to despair. Meeting the developmental needs of older adults as they negotiate this critical phase elucidates a common clinical issue that both current and future counselors will always face: perception of meaning in life.

We want our counselors-in-training to mature in their reflective capacity skills and to strive to understand internal variables that they may bring into sessions. By the time they are in the classroom with us, most graduate students have had the experience of seeing loved ones age, and those who have not could be anxious about the certain reality of having this experience at some point in the future. This gives counselor educators and supervisors the opportunity to explore with students how their reactions to these inevitable realities are collective in nature and how they are shared by many people, regardless of age. A counselor-in-training with good reflective capacity can harness the associated emotions and funnel them into an invaluable therapeutic tool: empathy.

 

Recommendations and tips

As mentioned earlier, the diverse options for working with older adults better enables us to match student interests with appropriate placements. I had a student who was interested in getting clinical experience with family therapy and older adults in hospital settings. The student was able to find a placement in a hospital working with families in which one of its members had been newly diagnosed with Alzheimer’s disease. Another student had strong interest in getting experience working with addictions. The student was able to find a placement at a methadone clinic and was assigned a good caseload of older clients who were in recovery. My point is to communicate to students that the variety of placements available for working with older adults mirrors the diversity of today’s older adult population.

The passage of time inevitably brings change and, with that, different challenges and fluctuations. As counselor educators and supervisors of future practitioners, it is our responsibility to challenge and prepare graduate students to tackle these issues. Whether it’s a student seeking guidance or a person seeking counseling, assisting in increasing their reflective capacity, adaptation or coping with these challenges and changes is core to what we do as educators and practitioners. Regardless of how old the person sitting in our office or classroom is, engaged learning can happen in countless forms, as can growth through stepping out of one’s comfort zone.

 

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Neha Pandit is an assistant professor at Robert Morris University, working mainly in the master’s counseling psychology program. She also has more than 15 years of clinical experience and is currently working at a practice in Wexford, Pennsylvania. Contact her at pandit@rmu.edu.

 

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

Looking back, looking forward

Compiled by Jonathan Rollins August 15, 2019

Simone Lambert recently completed her term as the American Counseling Association’s 67th president, handing over the reins to new ACA President Heather Trepal on July 1. Shortly before leaving office, Lambert agreed to answer a series of questions from Counseling Today reflecting on her experience as ACA’s top elected leader. Her answers give context to some of the major happenings and challenges within the association and the counseling profession as a whole and provide insights into possible future directions.

 

When you look back on your past year as president of the American Counseling Association, what are you most proud of?

Without any hesitation, the single area I am most proud of is our advancement toward national portability. The ACA Governing Council prioritized the strategic initiative of “1.1 Working to advance and ensure that licensed professional counselors enjoy seamless portability of their licenses when: moving to other states; practicing across state lines; and engaging in tele-counseling” for this year and next.

In October 2018, after careful deliberation, Governing Council unanimously approved funding for the development of a professional occupational interstate compact for professional counselors. We thoroughly vetted and contracted with the National Center for Interstate Compacts, an arm of the Council of State Governments. The ACA Portability Task Force provided invaluable expertise and asked critical questions. ACA leaders and staff do not spend membership dues lightly. Thus, the contract was meticulously reviewed and revised to ensure optimal outcome.

While national portability will be a multiyear process, ACA is making a massive investment that likely will improve counselor workforce retention, including for military spouses, and increase access to mental health services. The interstate compact is a policy vehicle that furthers the work that began years ago with the Building Blocks to Portability Project of the 20/20: A Vision for the Future of Counseling initiative and the adoption of the ACA licensure portability model. 

In which specific areas do you feel like the association as a whole is gaining positive momentum?

Under the guidance of CEO Rich Yep and the executive team, the association has been transforming into a modern association looking ahead at how best to meet the needs of current and future ACA members. The internal, behind-the-scenes transformation has been extensive. We, as members, see snippets of this with such activities as being able to access the Journal of Counseling & Development and Counseling Today on our phones and being able to readily search and find clinical resources on our website.

As leaders, we see the revolutionary impact of our robust strategic framework that Governing Council approved in April 2018. Implementation of the strategic framework has had widespread impact on the association, including how staff workplans are developed, what staff and leaders prioritize across the association, and how we evaluate the organizational performance. Leaders also revamped our Governing Council agenda to include time for generative, strategic and operational discussions. The combination of the revised agenda format and the strategic framework has allowed Governing Council to move forward in collective thought leadership.

What issues took up most of your time or received a substantial amount of focus from you this year? Why were these issues so important?

The ACA president is a spokesperson for the association. I wholeheartedly jumped into this role as a way to advocate for the counseling profession and those we serve. Another priority initiative this year and next is “3.2 Raising awareness among the public and consumers about the benefits provided by the counseling profession.” In addition to providing keynotes and attending ACA branch and division conferences, I presented at the Mental Health America and the Time to Thrive conferences. I also had the privilege of advocating and interfacing with staff from the National Institute of Mental Health (NIMH), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Disease Control and Prevention’s Division of Adolescent and School Health, the Department of Education, and national and state legislators. These efforts were important to increase knowledge of our profession among decision-makers.

Often this year, I found myself to be the only licensed professional counselor in the room. I gleaned a few things from that experience. First, Shirley Chisholm’s guidance of “If they don’t give you a seat at the table, bring a folding chair” resonates more than ever. If we want clients and students to receive psychoeducational materials that are developed from a strength-based wellness perspective, we need to be at the table. If we want to be included in federal grants and Medicare reimbursements, we need to invite ourselves to the table.

Second, just like the Whos in Horton Hears a Who! we need a megaphone to collectively say, “We are here!” The American Counseling Association, including staff, leaders and members, is that megaphone. To raise awareness with the public and policymakers, we proactively need to state that we are part of the solution to the mental health workforce shortage. To obtain parity of status with other professions, we need to increase our visibility among federal and community partners.

In addition to meeting with our sister counseling organizations throughout the year, I met with representatives from the American Psychological Association (Division 17), the American Art Therapy Association, the World Health Organization, the United Nations (U.N.) Department of Public Information and nongovernmental organizations, as well as the Human Rights Campaign, the Born This Way Foundation and many other community agencies.

In addition to Skyping into doctoral counselor education classes and attending a residency with master’s-level interns from all over the world, I was honored to speak on behalf of the profession to those in the media, including venues such as NPR, Brit + Co, Time magazine, The Deseret News, USA Today and MEA Worldwide. I was interviewed on the Sirius XM Radio station Doctor Radio with host Dr. Michael Aronoff. With the guidance of the Promoting Mental Health and Averting Addiction Through Prevention Strategies Task Force and the expertise of ACA staff, I even did a video for ACA’s Instagram and a Twitter chat during National Prevention Week of Mental Health Awareness Month.

Seizing on opportunities to say “we are here!” in ways that promote the counseling profession as a resource is critical to not only increase awareness, but also to join with partners to decrease stigma and increase access to counseling services. 

Were there any issues that you developed a new appreciation for or that you gained a substantial amount of new knowledge about throughout the year?

In addition to trauma-informed care, I have a whole new appreciation for intersectionality. People are complicated and multifaceted. Attending events like the launching of Project Thrive and the SAMHSA Voice Awards, I heard amazing stories of resiliency related to people who had a mental health or substance use disorder, physical health issues or were from marginalized communities. Approaching counseling practice and advocacy with lenses of trauma-informed care and intersectionality within this sociocultural political climate is challenging and requires strong coalitions of professional associations, community agencies and government partnerships where possible. To assist our champion legislators, we as a profession need to produce more large-scale research studies that demonstrate the effectiveness of professional counselors.

Internally, we need to follow other professions in setting safeguards to assist counselors who have relapsed with their own substance use disorders or who are having mental health challenges. The ACA Code of Ethics discusses gatekeeping and counselor impairment, but we as an association have just begun to have conversations about policies related to member impairment as a larger issue. Other professional associations have resources to monitor members who are unwell or whose behavior is harming the profession. Counselors are not immune to mental health struggles, and we can actively address the issue for the betterment of our members and profession.

As ACA president, you spent a significant amount of time traveling and meeting with other counseling professionals and counselors-in-training. What did you learn from those conversations? Did a particular concern or question get voiced repeatedly?

Counselors have a strong professional identity, yet we still struggle with recognition of our profession within the mental health workforce. Beyond raising awareness, the third strategic initiative priority for this year and next is “1.2 Working to ensure equitable, consistent and adequate reimbursement for appropriately educated, trained and licensed professional counselors in all practice settings.”

After navigating undergraduate and graduate degrees, undergoing extensive post-master’s degree supervision, and passing credentialing exams, professional counselors across settings want to make a livable wage. They worry about competing with life coaches, who have less training but charge more. The Counselor Compensation Task Force found much variability in reimbursement rates, and counselors hope to have parity of status with other mental health professionals to have comparable reimbursement rates. Counselors also want to work in interdisciplinary teams, but they need other professions such as medical doctors, psychiatrists and clinical psychologist to recognize the value added when including professional counselors across settings to the treatment team.

Another huge challenge for counselors is student loan debt, which impacts counselors’ ability to afford to stay in the profession, especially through those prelicensure years. Engaging in professional association membership and participating in professional development on top of licensure application fees, supervision expenses and liability insurance coverage is challenging for those with higher student loan debt, which is often women, a large percentage of our counseling profession. 

How did your own perspective change in the year you served as president? Is there anything that surprised you?

Having met with all of our sister organizations, my bird’s-eye view of the profession has informed my perspective about how our profession is in the midst of a major transition. Over the past few years, we have seen turnover of long-serving staff at the helm of Chi Sigma Iota (CSI), NBCC, CACREP and the Association for Counselor Education and Supervision. Even our own David Kaplan, ACA’s chief professional officer, retired this spring after 15 years.

We have seen CACREP and the Council on Rehabilitation Education merge and alternative accreditation proposed by other associations. The American Association of State Counseling Boards has transitioned from an independent organization to being managed by the Center for Credentialing & Education, an affiliate of NBCC. In addition, two large ACA divisions, the American School Counselor Association and the American Mental Health Counselors Association, decided to disaffiliate from ACA. Change is difficult for all of us, yet with change comes opportunity. For instance, ACA can now fully serve and strongly advocate for professional counselors who work in schools and community agencies. ACA continues to maintain collaborative relationships with our sister organizations. The concerted wraparound response to the closure of Argosy University is an excellent example of how ACA, CACREP, CSI and NBCC each addressed the part of the crisis within their purview. 

This year, I attended two International Association for Counselling (IAC) conferences. I was incredibly surprised to learn how many countries look up to ACA as a model professional association. We are leaders in the international community. Likewise, there is much to learn from other counseling professional organizations that have dealt with similar issues. Interestingly, there seems to be a developmental curve for counseling organizations whereby we are one of the older counseling organizations. Then there are countries such as Uruguay, which is developing its first counseling degree program. None of the countries I met with had as complicated of a licensure situation as we do. We are unique with our unique licensure laws in 50 states plus U.S. territories.

After attending global conferences of the U.N., IAC and NIMH, a few startling themes stood out. First, there are not enough of us. There is a national and international mental health workforce shortage. We need to work to reduce barriers and obstacles to “scale up.” Second, there are forces beyond our control, such as climate change, that will increase the need for counselors to assist with issues related to migration and loss of livelihood as lands, resources and industries are subsumed. Third, there will be dramatic shifts in the workplace as technological advances and artificial intelligence necessitate retraining many people. School and career counselors will play an instrumental role in readying the next generation for jobs that have not yet been created. Finally, we will see increased telehealth and integrative approaches to mental health.

Where do you see things heading with ACA and with the counseling profession as a whole? What are some of the major issues or challenges that the association and profession will need to address in the coming years?

A major challenge of the profession is diversification of our workforce. Another item in our strategic framework is “3.1 Building a diverse, inclusive and engaged pipeline of counselors who will serve well into the 21st century.”

I attended a screening of Personal Statement, which followed three high school students who were from marginalized and underrepresented populations. The additional obstacles that these students faced were seemingly insurmountable. If we are going to have a more diversified counseling profession, we need to start advocating for people of color and diverse cultural backgrounds much earlier in their academic career paths. As these students make it to counseling graduate programs and leadership positions, we need to provide mentoring and support to increase retention and ensure that their voices are at the table when policies are being made. The message of “nothing for us without us” was mentioned to me in multiple venues this year, and I strongly believe that those with privilege need to listen to and advocate with those from diverse backgrounds.

Having diversity within the counseling profession is critical so that clients have the option to see counselors who are representative of their own backgrounds. In addition, there are societal stressors impacting clients that may impede on therapeutic progress. For instance, poverty, income inequality, education and other systemic issues could be barriers to accessing services. While counselors have the ethical responsibility to advocate, we cannot solve all of the world’s problems on our own. We need to work with other professions and stakeholders, including those outside of mental health, to tackle issues that prevent clients from seeking counseling services.

To further the ideas of breaking down silos, viewing the client from an intersectional perspective, and working across specialty areas, the structure of ACA in some ways restricts such collaboration. There are many entities within the ACA structure, including regions, divisions, branches, task forces, committees, interest networks and ACA Connect communities. Some of these entities are autonomous, such as divisions and most state branches. Other entities fully consist of ACA members, yet members may not know how their entities’ charges are related to another entity. Thus, the structure of ACA could become streamlined to increase efficiency in operational costs and content development. We have had many conversations, and I anticipate there will be many conversations to come.

Ultimately, we need some guidance from an association architect to reconfigure our professional house built in 1952. It’s time for serious structural renovations to help us be more productive as a whole. Imagine a professional home where subject matter experts have a structure to pool together best practices and evidence-based strategies for ACA members to address intersectionality in session and advocate on related legislation.

Looking back with all of the experience and information that you have now, is there anything you might do or approach differently if given a second chance?

If I had a do-over, I would have spent more time with our ACA committees, which are the workhorses of our association. In every meeting I attended and every email I read, it was apparent that our committees and task forces consist of incredibly dedicated and passionate volunteer leaders. For instance, the Human Rights Committee has recently developed advocacy statements about gun violence, climate change, transgender and nonbinary issues, indigenous people’s rights and concerns, and judicial and punitive disparity.

In hindsight, there could have been additional bridging and connecting of the committees with other committees/task forces and other ACA entities. One example was the leadership campaign that took place at the ACA Conference in New Orleans, whereby the Branch Development Committee and the region chairs worked to identify potential counseling leaders. Special thanks goes to the region leaders, CSI and the Association for Multicultural Counseling and Development for allowing recruitment of potential volunteers to take place at their venues.

Any words of advice or guidance for new ACA President Heather Trepal?

My hope is that President Trepal stays focused on our mission: “Promote the professional development of counselors, advocate for the profession, and ensure ethical, culturally inclusive practices that protect those using counseling services.”

Our counseling association is unique from all others. We include 18 divisions that represent specialties and settings across the profession. When ACA makes decisions, we do so understanding our responsibilities to all of our members. President Trepal is well-supported by an incredibly talented staff and deeply committed group of leaders. She is not in this by herself. Based on my lessons learned, I encourage her to ask and accept help as needed, listen and learn, share her expertise, and strengthen ACA by collaborating with internal entities of ACA and external partners.  

In what ways will your time as ACA president influence your work as a counselor educator or clinician moving forward?

The amount of hardship and pain that I heard about throughout the year could be very disheartening, especially in our polarized times. However, I am optimistic from seeing the work of so many counselors, allies, researchers, advocates, policymakers, staff and leaders who are working in the trenches to promote mental health.

As a counselor educator and mentor, I want to assist learners and emerging leaders to identify tables where their voices need to be heard. As a professional counselor, I want to focus my energies on decreasing stigma, increasing access to care, encouraging wellness, and helping clients and policymakers hear us say, “We are here!”

 

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Jonathan Rollins is the editor-in-chief of Counseling Today. Contact him at jrollins@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.

From Combat to Counseling: Characteristics of the military affiliated population

By Duane France August 13, 2019

When we talk about serving the military population as counselors, it would be easy to think that we’re talking about a group of clients who are similar and homogenous. It’s true that there are many common factors among those who serve in or are affiliated with the military, but there are a large number of differences too. Age, ethnicity, gender, period of service, full time or part time, combat or not — all of these factors have their own impact on the experiences of military-affiliated clients.

Because my goal is to help my fellow counselors understand how to address the unique needs of this population, it might be helpful to expand a bit on what I term SMVF: service members, veterans and their families.

 

Service members

This segment of the SMVF population seems easy to define: It includes anyone who is currently serving in the military. That broad definition is accurate, as far as it goes, but it is also deceptively simple.

When talking about a service member, it is important to understand a number of different things, including which branch of service they are in. Whether a client is currently serving in the Army, Air Force, Navy, Marine Corps or Coast Guard is an important distinction. Each branch of the service has its own sub-culture, a different rank structure, and vastly different experiences.

And even in each branch of service, there are subcultures within the subculture. Does the client serve in the Air Wing of the Marine Corps? Which occupational specialty does the client hold in the Army: Infantry? Military intelligence? Logistics and supply? Each of these sub-branches has its own unique outlook and experiences.

Even the current location of service helps to further define service members. For instance, there is a difference between the experiences of a Marine stationed at Twentynine Palms, California (not so great), and one stationed at Marine Corps Base, Hawaii (pretty great). Or the experiences of a soldier stationed at Fort Polk, Louisiana (one of the least desired duty locations), compared with a solider stationed at Fort Carson, Colorado (among the top five most desirable duty locations).

Currently serving military clients also include those drilling in the National Guard and Reserve. Each branch of the service has a Reserve force, and each state has a National Guard and Air National Guard unit. Typically, currently drilling service members in the National Guard and Reserve attend a weekend drill of anywhere from two to four days once per month and participate in a two- to four-week annual training each year.

Not all currently serving military members have equal access to mental health care. National Guard and Reserve service members, for example, have access to Department of Defense mental health professionals while they are on weekend drill or annual training, but not for the rest of the time. And the availability of mental health services, both on base and off base, differs with each duty location.

 

Veterans

Similar to the term “service member,” the term “veteran” is also deceptively broad. Title 38 of the Code of Federal Regulations defines a veteran as “a person who served in the active military, naval, or air service and who was discharged or released under conditions other than dishonorable.”

Although that may seem fairly straightforward, one glaring omission is former National Guard or Reserve service members who were never activated for full-time military service. This exclusion means that someone who enlisted in the military and, at minimum, participated in basic and advanced military training but did not serve on active duty is not considered a veteran.

The veteran community is further subdivided depending on whether the individual served in combat. There are currently four broad categories of combat veterans. The first is World War II and Korean War veterans, many of whom are in their 80s and 90s today. The next generation, the Vietnam veterans, are over age 65. The youngest veterans of the Gulf War (Operation Desert Storm) are in their 40s. Where things get complicated is with the fourth category of veterans. The senior leaders of the global war on terror, who are considered post-9/11 veterans, served in Vietnam, whereas the youngest members of the post-9/11 generation weren’t even born before Sept. 11, 2001.

Of course, that leaves a large number of individuals who served in the military but did not deploy to combat. They are identified as veterans, of course, but in the eyes of some (including, in some cases, their own view), they are not considered “real” veterans. These include people who served in the post-Vietnam era in the 1970s, Cold War veterans who served in the 1980s, and the post-Gulf War veterans who served in the 1990s. Regardless of whether people deployed to combat, however, the military is an inherently dangerous place.

According to a 2015 Congressional Research Service report, 2,392 active-duty service members died in 1980. Compare that figure to the total number of active-duty deaths in 2010: 1,485. There were two major conflicts in 2010, Operation Iraqi Freedom (Iraq) and Operation Enduring Freedom (Afghanistan). There were no conflicts in 1980. The reasons for this higher active-duty mortality rate in 1980 are speculative, but they likely have to do with advances in safety protocols and medical treatment that have increased the survivability of catastrophic injuries. Of course, if more members of the military population are surviving catastrophic injuries, then it means there are likely more individuals dealing with the psychological impacts of those injuries — which is another area where we can help as counselors.

The veteran population is further segmented by the military subcultures mentioned earlier, which are influenced by factors such as time, location and branch of service. This goes to show that while we consider the word “veteran” to be a descriptive term, it covers a very wide area.

 

Military family members

The designation for the final portion of the SMVF population, military family members, can also be deceptively broad. My wife and I married after my deployment to Bosnia, and she was with me for more than three-quarters of my career. She and my children experienced four of my five deployments in a very different way than I did. They also endured hardships that were significantly different from mine, yet no less challenging.

Being a military spouse is not easy. My wife and I lived in eight different houses in our first nine years of marriage. Three of those years were overseas, and all of them were away from where we both grew up. The stress of constant movement, of nights alone and nights together, can be considerable.

On top of that, you have military brats — the children of those who served. I once had a conversation with my son about where he thought he was “from.” Children of service members, especially those who served significant time in the military, aren’t really “from” anywhere. Many people have roots in a place where they have family; they can point to a childhood home when they go back to visit. For instance, I am from St. Louis, and my wife is from Knoxville, Tennessee. But my kids were born in Germany, started school in Maryland, and have lived in Colorado for most of their lives — but they don’t consider themselves “from” any of those locations.

What further complicates the designation of military spouses and children is that it is used only to describe those who were with the service member while they were serving. My father was a veteran of the Vietnam War, but I wasn’t born until three or four years after he returned home. I never knew what he was like before combat. I certainly know the impact that combat had on him, however, because I saw it for 40 years.

Many veterans — and I’m using the term in its most broad and inclusive form — marry and start families after their military service has concluded. A spouse who was not with the veteran when that person was in the military has little to no understanding of the unique aspects of military life and culture. That spouse certainly experiences the aftermath, however, as does the veteran’s children. My wife was with me while I was serving in the military, so she lived it too. Thus, when I retired, she already had a frame of reference about military life. By the grace of God and my wife’s immense patience, we remained married after I retired.

Finally, when we consider the military family, we should also include parents and siblings. My mother and sisters experienced my military service — and that of my brother, who is also a combat veteran of both Iraq and Afghanistan — in a very different way. And that circumstance brings up an entirely different dynamic: When I left Iraq, my brother was enlisting in the military. Eight months later, he was stationed in the same combat zone I had just left. Less than two years later, he and I were in the same combat zone at the same time, in different locations.

Picture two brothers, one coming in from out of town, who decide to grab some breakfast together. They catch up on what’s happening, and then the in-town brother introduces his out-of-town brother to some of the folks he works with. Only, the out-of-town brother arrived on a Blackhawk helicopter, and the breakfast was at the dining facility on Forward Operating Base Shank, Afghanistan.

To further expand the concept of the military family population, we need to consider those family members who have lost their service member. Parents, siblings, spouses and children of service members who died in combat are called Gold Star families. Those family members of veterans who have died by different means aren’t called anything, but their loss is just as great.

 

Understanding the diverse SMVF population

As this article probably makes evident, talking about someone who is serving or has served in the military, or that person’s family, is not as easy as it might seem at first. The differences between this generationally, geographically, culturally and experientially diverse population may seem large. It is important to understand, however, that a common thread — military service in its many forms — still binds them together.

 

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Read the first From Combat to Counseling column.

 

Duane France, LPC

Duane France is a retired U.S. Army noncommissioned officer and combat veteran who practices as a licensed professional counselor in Colorado Springs, Colorado. He is the director of veteran service for the Family Care Center, a private outpatient mental health clinic specializing in service members, veterans and their families. He is also the executive director of the Colorado Veterans Health and Wellness Agency, a 501(c)3 nonprofit that is professionally affiliated with the Family Care Center. In addition to his clinical work, he writes and speaks about veteran mental health on his blog and podcast at veteranmentalhealth.com. Contact him at duane@veteranmentalhealth.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.

Client suggestibility: A beginner’s guide for mental health professionals

By Jerrod Brown, Amanda Fenrich, Jeffrey Haun and Megan N. Carter August 12, 2019

In the context of mental health treatment, suggestibility refers to a client’s vulnerability to accepting information provided by a third party as true, regardless of its veracity. This can result in the client providing inaccurate guesses or statements in a verbal, nonverbal or narrative format. Influenced by a range of individual, psychosocial and contextual factors, the client may be convinced that events unfolded differently than they actually did or that events that never took place actually occurred.

Such behavior is often encountered when clients are uncertain about what happened or what is true, lack confidence in their own memories or ability to understand, or are unable to discriminate between what is real and what is not. As such, suggestibility can profoundly limit a client’s capacity to navigate the various stages of the mental health system.

Suggestibility is a complex and multifaceted phenomenon that mental health treatment specialists rarely take into consideration, largely because of the lack of research on it and the limited availability of training opportunities on the topic specifically tailored for these professionals. The research that has been conducted is largely circumscribed to the fields of criminal justice, forensics and the law, where it is well-established that clients who are more suggestible are more likely to provide unreliable eyewitness accounts, spurious alibis or even false confessions to crimes.

Across mental health treatment settings, suggestibility may result in inaccurate diagnoses and ineffective or problematic goal and treatment plans. Given the importance of this topic, we aim to briefly describe the phenomenon of suggestibility within the context of clinical interviewing, assessment and treatment planning. We will also suggest future directions that may assist mental health professionals in addressing this threat to effective clinical decision-making.

Minimizing suggestibility risk in clinical interviews

Certain forms of questioning can increase the likelihood of suggestibility. A suggestive question is one that implies a certain answer, regardless of the client’s actual perspective. Such questions intentionally or unintentionally seek to be persuasive, often by using wording that excludes other possible answers. For example, asking “Where did your father hit you?” instead of “What happened with your father when you got home?” is leading. It promotes a response that would affirm the interviewer’s hypothesis that a physical assault took place and largely excludes the possibility that no altercation occurred.

Questions framed in a negative manner also can have a suggestible impact and are confusing to the client. For example, asking “Didn’t you want to run away?” rather than “Did you want to run away?” is biased in that it may make the client feel guilty for not saying that he or she wanted to run away.

To avoid asking suggestive questions and to lessen the likelihood of receiving false responses from clients, consider using the following strategies:

1) Use open-ended questions while avoiding or minimizing the use of forced-choice and either-or questions.

2) Allow the client to speak in his or her own words, and avoid interrupting the client.

3) Do not assume that you know what the client is trying to say when he or she is unable to fully convey his or her ideas.

4) Accept “I don’t know” responses as potentially valid.

To further illustrate this point of decreasing suggestibility within the context of clinical interviewing, mental health professionals should try to avoid the following approaches when questioning clients:

  • Use of closed-ended questions
  • Giving an impression that implies the client is providing the wrong answer
  • Implying that a certain answer is needed or required
  • Leading questions
  • Misleading questions
  • Negatively worded statements
  • Persuading the client to change his or her response
  • Pressing the client for a response
  • Rapid-fire questioning
  • Repeated lines of questioning
  • Biased statements
  • Subtle prompts

How often questions are asked may also have a suggestive impact. Clients may perceive repeated questioning as a sign that they have not responded in a manner that the counselor deems “correct” or acceptable. Indeed, repetitive lines of questioning in which the client is asked about details of events that either did not happen or that the client does not remember well may result in the unintentional formation of false memories or confabulation (i.e., filling in memory gaps with fabricated memories or experiences).

Asking more general questions about an incident (e.g., “Tell me about what happened at the park”) and then later following up with related questions (e.g., “How often do you go to the park?”) has been found to be a useful method for verifying or clarifying information that might appear to be inconsistent or illogical. Regardless of the questioning style, however, it is advisable to allow clients as much time as they need to respond to questions and to verbally reinforce that they can take their time when answering questions.

In addition to questioning style, the counselor’s nonverbal behaviors, including facial affect, gestural affect and intonation, both before and during the interview, may increase the likelihood of suggestibility and threaten the validity of the information elicited. An example of facial affect could be smiling when a client is providing certain answers but not others. A gestural affect might include leaning forward when a client is providing certain answers but not others. Intonation as a means of nonverbal communication could be providing feedback using upward inflection when a client provides certain answers but downward inflection when he or she provides others. These nonverbal, and often unintended, means of communication are forms of both positive and negative feedback that can shape a person’s responses and increase the risk of suggestibility.

The context of the interview can also affect the likelihood of suggestibility. For example, false reports are more likely if an interview is conducted in a stressful situation (e.g., having an appointment with a therapist immediately following a family conflict). Environmental factors (e.g., a small room without windows or air conditioning on a hot summer afternoon) can also be influential. Providing clients with frequent breaks and avoiding very long clinical interviews is encouraged, when possible. The time between the occurrence of an event and the interview that focuses on the event can also influence suggestibility because clients can become more confident in the accuracy of their false accounts over time. Context within the realm of a clinical interview can include any of the following either prior to and during the actual interviewing process:

  • Body language of the counselor
  • Duration of eye contact from the counselor
  • Environmental distractions (lighting, noise, temperature, etc.)
  • Length of the interview
  • Pace of the interview
  • Tone of the counselor’s voice

Mental health professionals should also take into consideration personality and social characteristics that can influence suggestibility. These may include tendencies toward confabulation, acquiescence, memory distrust, low confidence, desire to please, extreme shyness and social anxiety, avoidant-based coping strategies, fear of negative evaluation, lack of assertiveness, attachment disruptions, fantasy proneness, and psychosocial immaturity (e.g., irresponsibility and temperament). Professionals should also consider cognitive factors, including executive function and memory-related problems (e.g., short-term, long-term and working memory), intellectual limitations, diminished language abilities, and deficits in theory of mind (the ability to understand mental states in oneself and in others).

Preparing for and debriefing from the interview

Understandably, many of these characteristics initially present as invisible, meaning that clients who are highly suggestible may not overtly appear as impaired or vulnerable. Clinicians would benefit from screening for such traits in the initial interview with new clients to determine the prevalence of traits that are likely to contribute to suggestibility. Specific screening tools for suggestibility, such as the Gudjonsson Suggestibility Scale, can help clinicians in determining a person’s level of suggestibility. This will also assist clinicians in understanding how best to proceed as it relates to interviewing techniques and treatment planning to account for an individual’s level of suggestibility.

False or misleading information can have a negative impact on diagnostic accuracy and treatment outcomes. Accordingly, it is important that mental health professionals not only conduct interviews properly but also prepare for and debrief from them properly. Prior to beginning an interview, counselors are encouraged to review client records (psychological testing, mental health records, criminal justice records, etc.) that may reveal a behavioral pattern of suggestibility and provide a resource for corroborating a client’s statements. Cross-referencing this information with information obtained from collateral informants is also recommended when appropriate. The importance of awareness of one’s self throughout the interview is an important factor for reducing the risk of suggestibility. This includes monitoring one’s verbal and nonverbal communication that could provide feedback to the client regarding potentially desirable versus undesirable responses.

It’s worth noting that some special situations may require clinicians to be more aware of their questioning style and require adaptations and flexibility on the part of the clinician to minimize suggestibility. For instance, those working in correctional and jail settings should consider how suggestibility presents among incarcerated populations, to include those with mental health needs and low intellectual functioning. Substance use is another variable that can have adverse effects on the accuracy of the information obtained during a clinical interview. Furthermore, when interviewing children or adults with neurocognitive and neurodevelopmental disorders, extra precautions may be necessary to reduce the risk of suggestibility. Finally, it is important to note that individuals with exposure to negative life events (e.g., the death of a parent or sibling, exposure to physical violence) may be more susceptible to suggestibility.

Conclusion

Given the importance of collecting accurate information, it is essential that mental health professionals acquaint themselves with the phenomenon of suggestibility. Unfortunately, many mental health providers lack the necessary awareness and training related to the detection and screening of suggestibility among clients.

Mental health professionals should seek to establish routine procedures to better identify clients who are at an increased risk of susceptibility to suggestibility before proceeding with the interviewing process. Such a procedure could include a validated suggestibility screening tool and a checklist of variables that research has found to increase risk of suggestibility among certain mental health treatment populations. We encourage mental health professionals to be aware of the various personality, social and cognitive factors that may influence some clients to be suggestible.

Suggestibility can have a negative impact on the various components of mental health treatment, including intake, screening, assessment, psychological testing, treatment planning, medication compliance, perceived understanding of treatment concepts, and discharge planning. For this reason, we urge mental health professionals to gain an increased awareness and understanding of this complex and multifaceted phenomenon.

One suggested step for moving the field forward is for mental health professionals to engage in self-study and continuing education via in-person and online training courses that focus on the evidence-based assessment and management of suggestibility. It is also important for mental health professionals interested in understanding suggestibility and its implications to review key research findings on at least a quarterly basis and to consult with recognized subject matter experts. Clinical interviews should be conducted through developmentally sensitive and suggestibility-informed approaches that consider the client’s psychiatric, neurocognitive, social and trauma history. By taking such steps, the potential negative impact of suggestibility can be minimized, thus paving the way for positive outcomes.

 

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Jerrod Brown is an assistant professor, program director and lead developer for the master’s degree in human services with an emphasis in forensic behavioral health for Concordia University in St. Paul, Minnesota. He has also been employed with Pathways Counseling Center for the past 15 years and is the founder and CEO of the American Institute for the Advancement of Forensic Studies. Contact him at jerrod01234brown@live.com.

Amanda Fenrich obtained her master’s degree in human services with an emphasis in forensic mental health from Concordia University. She is currently completing her doctoral degree in the advanced studies of human behavior from Capella University and is employed as a psychology associate for the Washington State Department of Corrections Sex Offender Treatment and Assessment Program.

Jeffrey Haun is employed as a forensic psychologist for the Minnesota Department of Human Services, where he conducts a variety of forensic evaluations and offers consultation, supervision and training in forensic psychology. He is an adjunct assistant professor in the Department of Psychiatry at the University of Minnesota and an adjunct instructor at Concordia University. He is board certified in forensic psychology.

Megan N. Carter is board certified in forensic psychology and has received the designation of fellow from the Association for the Treatment of Sexual Abusers. She has worked as a forensic evaluator at the Special Commitment Center, Washington state’s sexually violent predator facility, since 2008. She also maintains a small private practice focusing on forensic evaluations and child welfare issues.

 

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.

Counseling in the land of religious liberty

By Cebrail Karayigit and Jason Kushner August 7, 2019

The MerriamWebster online dictionary defines minority as “a part of a population differing from others in some characteristics and often subjected to differential treatment.” The United States is perhaps the most religiously pluralistic country in the world and one of the few to integrate religious freedom into its Constitution. Christianity is far and away the largest religion in the United States, however, and is in some ways the baseline faith that guides — simply as a matter of familiarity — how many counselors approach working with religious traditions that are different from their own.

According to the 2014 Pew Research Center Religious Landscape Study, Christians represent 70.6% of the U.S. population. Meanwhile, religious minorities in the U.S., such as Jews (1.9% of the population), Muslims (0.9%), Hindus (0.7%) and Buddhists (0.7%), are frequently viewed through the context of media and other popular portrayals. These portrayals often perpetuate stereotyped perceptions and promote the notion that religious minorities and Western traditions are in conflict with one another. Counselors, like all humans, have biases that inform our perceptions of self relative to some “other.” Given misunderstandings about religious minorities in the United States, this topic is particularly relevant for counselors because we are part of an inclusive profession that is oriented toward social justice.

Rethinking multiculturalism

In an era in which many people get to know about “others” via social media, an unfortunate side effect is that stereotypes can be easily formed or solidified because we usually see what we want to see. Therefore, counselors have an ethical obligation to cautiously evaluate their sources of information relative to news coverage and social media mentions about religious minority groups in the U.S. As is the case when working with people who are different from us in other characteristics such as gender, race, ethnicity, sexual orientation and degree of ability, there is no substitute for direct contact with religious minority groups to promote counselor competency. According to a report released by Pew in 2017, knowing someone from a particular religious group was associated with warmer feelings for that group. So, direct interaction with people of a faith tradition different from our own (or the absence of a faith tradition altogether) is key to reducing or eliminating our biases — conscious or otherwise — toward religious minorities.

Within and outside the counseling profession, the terms multiculturalism and cultural diversity tend to focus on racial and ethnic minority groups, a practice promoted at least in part because of the categories used by the U.S. Census Bureau and data collected on applicants by American employers. Religious minorities are not so highly visible and are not generally regarded as “important” by mainstream American society because of this relatively hidden status. As counselors, we are in a unique position to interact with people from diverse backgrounds, and in this way, we have a meaningful role to play in ensuring that minority groups’ values are incorporated into American society. Standard A.1.d. of the 2014 ACA Code of Ethics states, “Counselors recognize that support networks hold various meanings in the lives of clients and consider enlisting the support, understanding, and involvement of others (e.g., religious/spiritual/community leaders, family members, friends) as positive resources, when appropriate, with client consent.”

Misconceptions about religious minorities in Western societies are not new, but there remains an opportunity for counselors to lead the discussion and practice of widening the tent to welcome those of minority faiths. To do this, we must be uniquely competent as a collective profession at addressing the needs of this relatively small but growing population.

The relative absence of competence and knowledge about a plurality of traditions, beliefs and spiritual practices is perhaps one reason that counselors may not actively seek opportunities to engage with religious minorities. Within the counseling literature, few studies address the unique experiences of religious minorities. Therefore, engaging more research on this topic is an important step in increasing the visibility of religious minorities within the counseling profession. That larger research base would then inform practice as it does in the cases of other kinds of minority populations with whom counselors practice.

Do’s and don’ts

Perhaps the most important step is to examine our own attitudes and behaviors as counselors toward religious minorities. To that end, in their seminal cultural diversity book Counseling the Culturally Diverse: Theory and Practice, Derald Wing Sue and David Sue focused on the importance of examining our own attitudes by asking the following questions: Have you been influenced by the negative stereotypes regarding individuals of these groups? What would your reaction be if a client came in wearing traditional clothing?

One of the most common mistakes made by counselors is failing to recognize clients’ social and cultural identities and focusing only on visible manifestations of those identities, such as wearing a kippah or hijab. For example, when white American clients come to counseling, we do not typically refer to them as “Catholic clients” or “Protestant clients” and thereby put them in a categorical box. On the other hand, when a client wearing an orange robe comes to counseling, we are more likely inclined to refer to that person as a “Buddhist client.” Such labeling should not be considered the best practice of our profession.

It is necessary to challenge our stereotypical notions of the phenotypical appearance of minority groups to overcome the prejudiced messages that may be sent. Counselors must also be cautious in assuming that clients’ religious identity is the same as their social and cultural identity. Understanding clients’ behavior as a social-cultural concept, especially in today’s American society, is necessary to avoid a fixed and prejudicial view of their identity.

Religious minorities have typically been exposed to a history of oppression, so trust and empathy may be particularly important to them in a counseling relationship. Building rapport and developing a relationship with these clients is crucial to developing effective communication. Counselors should also understand that some religious minorities may be reluctant to seek counseling for a variety of reasons. Therefore, when working with these clients, counselors are encouraged to be active in and affirming of their help-seeking behavior and to assist them in processing resistance if any exists without forcing any particular religious or faith perspective.

In most cases and with most faiths, the individual expression of that faith is a uniquely personal experience. To that end, counselors should explore what it means to their clients without making assumptions based on the counselor’s own perceptions of various faith traditions. It is also important to note that people usually overestimate their openness to minority groups. As suggested in a 2014 study by David Amodio, individuals are typically unaware of their implicit biases. These biases can be particularly difficult to change in an era of news and social media that often reinforces prejudicial or stereotyped thinking rather than calling it into question.

Counselors are also encouraged to examine their use of theories in their practices because many widely used theoretical orientations (e.g., cognitive behavioral, person-centered) are rooted in Western value traditions that may ignore the unique needs of some minority groups. Some approaches focus on inward problems and view the individual as “problematic” outside of the context in which the individual lives. For example, some religious minorities experience a significant amount of tension and stress because of societal pressure and reminders of their differences. For this reason, a theoretical orientation that emphasizes knowledge of the effects of societal pressure and that has a social justice perspective ensures greater likelihood of a therapeutic alliance that will lead to more satisfying outcomes for the client and counselor alike.

As Derald Wing Sue suggested in Counseling the Culturally Diverse, to be multiculturally competent, counselors must also be knowledgeable about discrimination policies. If counselors learn about anti-discrimination policies, they will be able to raise clients’ awareness of their legal rights so that they can challenge discrimination and take appropriate actions when faced with discrimination. To be most effective, counselors need to educate themselves about laws, practices, policies, history and situations in a global context. No one expects counselors to be living encyclopedias, but to be competent healers, we have to be comfortable enough to ask religious minority clients about their faith traditions. In doing this, the counseling profession will expand its reach, make a difference and continue to uphold the value of diversity for which it is known.

Religious competencies

Religious competencies are important for all counselors to have, in particular when working with clients with religious and spiritual issues. Consistent with the 2014 ACA Code of Ethics, the Association for Spiritual, Ethical and Religious Values in Counseling (ASERVIC) provides a set of competencies for integrating knowledge of spiritual and religious issues into counseling practice. The purpose of the ASERVIC competencies is to “recognize diversity and embrace a cross-cultural approach in support of the worth, dignity, potential and uniqueness of people within their social and cultural contexts.”

The following competencies shed light on how to improve our ability to serve members of religious minority groups:

  • The professional counselor recognizes that the client’s beliefs (or absence of beliefs) about spirituality and/or religion are central to his or her worldview and can influence psychosocial functioning. Counselors cannot effectively assess their clients’ problems and formulate strategies without first understanding their clients’ worldviews.
  • The professional counselor actively explores his or her own attitudes, beliefs and values about spirituality and/or religion. It is important for counselors to seek self-knowledge through an active practice of self-awareness and self-reflection. For example, counselors can examine their attitudes about religion by asking themselves the following questions: When did I last push the boundaries of my comfort zone to learn about religious topics that are different from my own perspectives?
  • The professional counselor continuously evaluates the influence of his or her own spiritual and/or religious beliefs and values on the client and the counseling process. It is necessary and essential to assess any possibilities of countertransference to prevent the development of a negative relationship with clients. For example, counselors who are very involved with religious organizations should not impose such practices on their clients. Many members of religious minorities have a paradoxical relationship to religion. Although they may have firm religious convictions, attending religious services can be a less frequent activity for them.
  • The professional counselor can identify the limits of his or her understanding of the client’s spiritual and/or religious perspective and is acquainted with religious and spiritual resources and leaders who can be avenues for consultation and to whom the counselor can refer. The fear of not knowing should not keep us from learning from our clients. Our clients are our best teachers. Although we strive to understand clients’ religious perspectives, it is important to allow our clients to educate us about their religious beliefs.
  • The professional counselor responds to client communications about spirituality and/or religion with acceptance and sensitivity. Counseling is a profession based on understanding, which goes well beyond simply showing tolerance for those who are different from us. Seeking understanding and respecting our clients’ religion is key to accepting clients for who they are.
  • The professional counselor can therapeutically apply theory and current research supporting the inclusion of a client’s spiritual and/or religious perspectives and practices. It is important that counselors are flexible enough to modify their treatment perspectives to best match the unique needs of clients. Perceiving psychological functioning as an internalizing problem or an inward-directed form of distress can be problematic when serving some religious minority populations. The most well-known therapeutic techniques do not emphasize a religious perspective; it is important that counselors strive to use techniques that will reduce clients’ symptoms, even if that includes learning about faith-affirming interventions that would be most helpful. One example could include using the egalitarian and empowerment principles of feminist therapy. From that perspective, clients could be encouraged to recognize the many aspects of their religious identity, increase their awareness of the origins of their presenting problems, and enhance their well-being.

Hypothetical case study

To further illustrate the highlighted competencies, we offer a hypothetical case study as an example of how specific strategies could be integrated into counseling practice.

Mary, a 19-year-old college student, was initially referred to counseling because she was experiencing social isolation and increased levels of stress. During the initial interview, Mary, a native-born U.S. citizen, described herself as an American Muslim feminist woman. She reported having never felt treated differently in the past by her friends, teachers or peer groups, perhaps because she was fair skinned, spoke English without an accent, and came from a family of high socioeconomic status. She also changed her original name, Mariam, to the English translation, Mary, while in high school. When Mary was asked about her motivation for doing this, she stated that she wanted to be well-integrated and active in larger American society.

After Mary began college, she decided that she wanted to learn more about her faith tradition, which eventually led her to choose to wear a hijab (headscarf). She realized that the hijab had a large impact on her relationship with her friends and with people in general. She even stated that she started getting fewer likes on her Instagram photos. Although Mary has never questioned her choice, she no longer feels like she fits in with her peer group.

Because building rapport and developing a relationship with a client is crucial in any counseling relationship, the counselor shows genuine interest in Mary’s story and demonstrates an openness to discussing her attitudes toward Mary’s religious beliefs. It is important to closely examine Mary’s own feelings and values regarding the hijab. By having an open dialogue with Mary, the counselor attempts to explore the meaning that Mary ascribes to the hijab. Mary states, “A lot of my friends are asking if I was forced to wear the hijab because a headscarf can be seen as a symbol of oppression. I think that my hijab gives me the freedom to set my own standards in a land of religious liberty, but I cannot convince people about that.”

The counselor acknowledges Mary’s emotional experience by stating, “You value your hijab and see it as a symbol of freedom. While you are also frustrated by your friends’ comments, you are aware that you do not have control over what your friends or society think of your decision.” The counselor further explores Mary’s experience by asking another question: “A friend you haven’t seen for a while sees you after you choose to wear the hijab. What would be different?” Such questions help Mary to reflect changes within herself and her environment.

The counselor knows that understanding Mary’s worldview and experiences is a crucial step toward effectively assessing her presenting problems and then formulating strategies to address them. From here, the counselor will connect on a deeper level the literal and metaphorical symbolism of the hijab. The counselor also examines her own attitudes by asking herself some questions: “What was my initial reaction when this client came in wearing a hijab? Have I been influenced by the negative stereotypes regarding individuals of groups who wear symbols?”

While exploring Mary’s religious values, the counselor avoids responding in a stereotypical manner by asking to be educated by Mary about her background and beliefs. The counselor encourages Mary to do this by saying, “Tell me more about your experiences of being treated differently.”

Mary states, “I do not understand why people focus only on my hijab. My hijab is an important part of my life, but I was born and raised in American culture, and that has always been the most important thing in my life.”

The counselor reflects, “You feel it is unfair that people ignore your core identity, which is your social and cultural identity. You want them to see you as an American Muslim feminist woman, not as an oppressed person who wears a hijab.” The counselor acknowledges Mary’s cultural background as a salient aspect of her identity. This could be an important step toward achieving a positive outcome. If the counselor focused mainly or exclusively on Mary’s religious identity, the counselor might fail to recognize Mary’s social and cultural identity.

The counselor will also help Mary recognize how her religious identity, even if it is not her core identity, may have caused her some disadvantages. The counselor will help Mary examine whether she has suffered from oppression as a member of a subordinate group, both as a woman and as a Muslim. It is important to note that Mary’s overall experiences make her an excellent candidate to benefit from a feminist counseling orientation, especially because of Mary’s stated identity as a feminist. Therefore, the counselor acknowledges the societal impact on Mary’s life.

Because Mary describes herself as a Muslim feminist woman, encouraging her to engage in an action can be an important step toward a commitment to social change. The counselor asks, “Do you like to do tasks between sessions? What is one powerful thing you could do for yourself between now and the next session?” By asking such questions, the counselor empowers Mary to take action and promotes an egalitarian relationship.

Mary answers, “One thing I would like to do is to share my personal story about why I decided to wear a hijab. I hope that this will lead to an open dialogue with my friends, and they will be more comfortable asking questions.”

The counselor asks, “What have you done toward this goal? How will you go about doing this? What difficulty might you have?” The counselor helps Mary to specify her direction and organize small steps toward desired behaviors.

The counselor also encourages Mary to be active in the therapeutic relationship by inviting her to direct the conversation. The counselor might ask, “Are there topics you talked about or discovered that you would like to pick up on next time?”

Finally, for the purpose of achieving better and longer lasting outcomes, it is important to help Mary build her own support system. The counselor says, “I wonder if there are any particular groups that could make you feel more connected and involved in the community?” This is important so that Mary can recognize she is not alone and that there are other women who are experiencing similar experiences. By engaging with other women, Mary can find support and become more assertive in promoting social justice.

Conclusion

In thinking about ways to work with clients from minority religions in the United States, counselors can pick from any number of similar cases in which they counsel people who are different from them in some aspect. It is important to remember that more often than not, a client’s religion, the client’s perspective on that religion, the client’s perspective of others, and what the client wants from a counselor will vary quite a bit. A client’s expression of faith is completely subjective and unique to that person. These hypothetical case studies should not be used to describe the basis of a faith’s visual aspects. Counselors should not make judgments or use phrases that may alienate clients over issues of religion, faith or spirituality. That is why it is important to have a discussion, or at least include a question, about the subject.

There are universal elements to most faith traditions (or the absence thereof) that transcend counselors’ observations about a client’s observable characteristics. The task for counselors is to understand our own perspectives and what they mean to us, and to obtain a general knowledge of many religious/spiritual traditions and how those traditions intersect with the experiences of our clients and the help they are seeking from us.

 

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Cebrail Karayigit is an assistant professor in the Department of Psychology and Counseling at Pittsburg State University in Kansas. Since coming to the United States in 2010, he has gained a reputation as an expert in multicultural counseling and school counseling, which are his areas of research and practice focus. Contact him at ckarayigit@pittstate.edu.

Jason Kushner is a professor of counselor education at the University of Arkansas at Little Rock. He is a licensed professional counselor with experience in school counseling, college counseling and mental health counseling. Contact him at jdkushner@ualr.edu.

 

Letters to the editor: ct@counseling.org

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

 

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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.