Monthly Archives: January 2020

Living with — and beyond — OCD

By Bethany Bray January 24, 2020

In popular culture, obsessive-compulsive disorder (OCD) is often portrayed through characters who can’t bring themselves to step on cracks in the sidewalk, who are germaphobes, or who are obsessed with cleanliness and organization. These “hang-ups” are often played for comic effect.

“There’s a huge misconception that OCD is cute and quirky,” says Shala Nicely, a licensed professional counselor (LPC) with a practice in Marietta, Georgia, who specializes in treating OCD and related disorders. “There’s nothing further from the truth. That [stereotype] keeps people from seeking help. They think they just need to ‘get it together’ and deal with it.”

In reality, OCD can be debilitating, says Nicely, who has lived with the disorder since she was a child. Individuals with OCD are haunted by unwanted and invasive thoughts that are often self-critical, fear-inducing or disturbing. One of the classic portraits of OCD is the person who won’t touch a doorknob without a sleeve pulled over their hand out of fear of contracting germs. But that is only the tip of the iceberg when it comes to the different types of compulsions — whether external, such as repeated hand-washing, or internal, such as rumination — that individuals with OCD feel subjected to in order to keep themselves safe.

OCD can be “hell on Earth,” Nicely asserts.

“It puts people in absolute misery. It makes people’s lives smaller and smaller and smaller,” she says. “Having OCD is like living with an abuser 24/7. It’s incredibly mean, it’s very critical, and [it] can be violent. It is being yelled at by your own brain and you can’t get away from it.”

The tipping point

Justin Hughes, an LPC who owns a private practice in Dallas, specializes in treating clients with OCD, anxiety and other mental health issues. He says many of his clients seek treatment because they are overwhelmed by intrusive thoughts or because their compulsions and routines are interfering with their daily life — taking up enormous amounts of time and causing them stress or even physical pain. Other clients come to treatment because a parent, spouse or loved one noticed the toll that OCD was taking on the person and expressed concern.

Karina Dach, who specializes in treating OCD and anxiety at her private practice in Denver, says clients sometimes come to counseling knowing that “something doesn’t feel right” but without realizing that they have OCD. “They may say things like, ‘I feel stuck,’ ‘My brain won’t let me move on,’ or ‘I can’t stop thinking about this or imagining this.’ They might feel like something is wrong with them or worry that these thoughts and fears mean something bad about their character or them,” explains Dach, an LPC and licensed mental health counselor.

Clients who come to counseling with OCD may be struggling with self-criticism and intense feelings of shame, guilt, anger, worry and fear, Nicely adds. Intrusive thoughts are common with OCD, and for some people, these thoughts can involve the idea that they might somehow end up killing, injuring or sexually molesting someone, including their loved ones. As these thoughts repeat themselves over and over, the individual may begin to believe the content of these thoughts and feel a deep sense of shame or embarrassment.

In fact, clients struggling with OCD may be hesitant to share the worst of their intrusive thoughts because they can involve things that are criminal or dangerous. “Some [individuals with OCD] really do think they might be a closet murderer. They’re afraid to share that, [thinking that] they might get in trouble,” Nicely says.

Given that insight, Nicely says, counselors should not hesitate to follow up conversations about intrusive thoughts and worries in session by asking clients if there is anything else they have been too scared to share. These clients should be reassured that counseling is a safe and confidential place to share whatever they are going through, Nicely adds.

Obsessions + compulsions

The National Institute of Mental Health reports that an estimated 1.2% of U.S. adults experience OCD each year. This prevalence is higher for females (1.8%) than for males (0.5%). The lifetime prevalence of OCD in the U.S. is 2.3%.

Jeff Szymanski, a clinical psychologist and executive director of the International OCD Foundation, notes that even though the prevalence of OCD is not increasing, mental health practitioners may see more people who struggle with the disorder in their caseloads in the future because of a gradual, general increase in awareness and a reduction of stigma regarding
the disorder.

OCD is characterized by two components: 1) recurring and intrusive thoughts (obsessions) and 2) excessive urges to perform certain actions over and over again (compulsions) to prevent or counteract the recurring thoughts. The types of obsessions and compulsions that individuals with OCD can experience are wide-ranging.

Not all recurring thoughts can be categorized as OCD obsessions, Szymanski stresses. “Obsessions in OCD are also ego-dystonic, meaning that the individual doesn’t like or want them. … Some recurring thoughts people like to have,” he says. “In lay language, people say things like ‘I’m obsessed with baseball.’ This means they like baseball. They may even spend a lot of time ‘compulsively’ following baseball. But this doesn’t interfere with their life, and it is something that is invited, not something they are trying to get away from.”

OCD-related obsessions can include unwanted sexual thoughts, religious obsessions, fear of contamination (by dirt, germs, chemicals or other substances), fear of losing control of yourself, fear of being responsible for harm to oneself or others, fear of illness, and myriad other concerns. Compulsions can involve:

Washing and cleaning tasks (including personal hygiene)
Checking behaviors (such as checking news headlines over and over to ensure that nothing terrible has happened, or checking multiple times that a door is locked)
Repeated actions such as blinking or tapping
Performing certain actions multiple times (e.g., opening and closing doors, going up and down stairs)
Asking questions (possibly to include the same or similar questions over and over) to seek reassurance
Internal actions such as repeated prayers, counting rituals, and repeated mental review or replaying of past scenarios and interactions

(Get an in-depth explanation of OCD from the International OCD Foundation at iocdf.org/about-ocd.)

“If a counselor begins hearing the exact same things [from a client in session], worded or behaved in similar ways, this is a good indicator [of OCD] to watch out for,” Hughes says. “Many of my clients are good at exactly quoting themselves on what they’ve said before. Obsessions are repetitions on a theme; if you get good at catching the theme, you can usually spot an obsession miles away.”

Compulsions can also involve avoidance behaviors. For example, Dach once had a client, a new mother, who was experiencing intense thoughts and fears about harming her baby. She would avoid interacting with her child — particularly being in the bathroom with the child while he was being bathed — because she felt it was safer to be away from him.

OCD-related avoidance can spill over into the life choices that clients make, such as where they work or live, what their hobbies are or even the words they use, Dach says. Individuals with OCD sometimes exercise another form of avoidance — breaking up with a partner because they fear the doubt, uncertainty and risks involved in having a relationship. However, they soon find that ending the relationship doesn’t quell their rumination, Dach notes.

Individuals with OCD “operate on a risk-adverse level,” explains Dach, a member of the American Counseling Association. “You find them checking a lot, asking for reassurance, accommodating their fears and compulsions. … It’s terrifying and it takes over people’s lives. We see OCD as this mental bully. You are a complete prisoner to your fears. People with OCD just want to protect themselves and their loved ones.”

Obsessions are often a reflection of a person’s deeply held values, such as being a good parent, keeping their family safe, or being a good person, Dach notes. Focusing on these values can be a source of leverage when counseling clients with OCD. When working with the new mother who had intrusive thoughts about harming her child, Dach talked with the client about how her fears were based in the values she possessed of wanting to connect with her child, be a good mother and keep him safe.

“If you can find what the client’s values are, that can be very powerful,” Dach says. “Maybe you fear rejection and failure but value excelling in a career. Finding those values can make a really clear [therapeutic] path to work on and find motivation.”

Several of the counselors interviewed for this article recommend that practitioners use the Yale-Brown Obsessive Compulsive Scale to assess clients for OCD and to get a full evaluation of clients’ obsessive thoughts and compulsive behaviors. If clients identify numerous behaviors and thoughts that they experience from the assessment’s detailed checklist, counselors should work with them to “triage,” creating a plan of care to address their most pressing or concerning issues first, Nicely says. Seeing the fearful thoughts and tortuous behaviors that they’ve been experiencing included on the checklist can serve to normalize clients’ experiences and demonstrate that they aren’t alone in their struggles, she adds.

Distinguishing OCD

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders categorizes OCD under a cluster of diagnoses that also includes body dysmorphic disorder, hoarding disorder, trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder.

OCD can be complicated to identify because the disorder often co-occurs with other issues such as bipolar disorder, anxiety-related disorders, depression, eating disorders and substance abuse, notes Nicole Hill, an LPC who co-authored an ACA practice brief on OCD. Because clients with OCD often struggle with multiple presenting concerns, the disorder can be hard to pinpoint. In addition to delving into these clients’ distress, counselors should complete full biosocial assessments to get a clearer picture of their life and family history, social landscape, early childhood experiences and other contextual factors, says Hill, a professor and dean of the College of Education and Human Services at Shippensburg University in Pennsylvania.

Although there is no one particular cause of OCD, research indicates that there may be a number of contributing or correlating factors, including genetics and family-based factors, autoimmune issues, and the brain structure involved in transmission of serotonin. Being aware of the client’s full context — especially whether other family members have OCD — can provide counselors a better understanding of the person’s experience and risk factors, says Hill, an ACA member who co-authored a chapter on OCD and related disorders in the 2016 book Diagnosing and Treating Children and Adolescents: A Guide for Mental Health Professionals.

OCD is easier to pinpoint in clients who describe overt compulsive behaviors, such as checking the weather forecast repeatedly. Asking questions to probe the depth and root of clients’ fears can help uncover mental compulsions that aren’t as immediately noticeable, such as mentally reviewing the activities of their day over and over again, repeating a conversation or a word to themselves a certain number of times, or saying a certain prayer repeatedly, Dach says.

To probe clients’ experiences, Dach suggests counselors begin by asking how they deal with stress and anxiety. It is certainly normal for people to experience anxiety from time to time, and it is true that individuals with anxiety disorders may be confronted by intrusive thoughts, ruminate, and perform certain coping behaviors. With OCD, however, the worry, fear and compulsive behaviors become so all-encompassing that they impair the individual’s ability to function. For example, most people wash their hands to keep from getting sick, but individuals with OCD may wash their hands a certain number of times, for a certain length of time, or until it feels “right” to them, Dach says.

“We all have this inner voice that’s telling us what’s safe and not safe. But someone with OCD has a faulty alarm system. They’re more vigilant. A whole battle can be happening internally on what’s safe and what it takes to be safe,” Dach explains.

To uncover compulsions that are internal (and, thus, less apparent to others), Dach suggests asking clients questions along the following lines:

Are there words or statements that make you feel better or that you say to yourself? Do you do something a certain number of times in your mind until it feels right?
When you’re lying in bed, is that when your mind wanders the most? What are you thinking about? Is it about your day and what you could have done differently? What you
did wrong?
When you enter a room, what’s the first thing you do? Do you beeline straight to where you need to go, or do you scan the area first to feel safe?

From there, Dach suggests asking clients what would happen if they weren’t able to complete whatever action they felt compelled to perform. “If there is clear distress in their answer, that may indicate OCD,” she says.

Another indicator that OCD may be present is if the client doesn’t respond to methods that counselors typically use to help individuals with their negative thoughts, says Hughes, the Dallas-Fort Worth advocate for OCD Texas, a regional affiliate of the International OCD Foundation. “If a client isn’t improving from certain methods — especially things like cognitive restructuring in cognitive behavioral therapy — this is ‘Getting Stuck 101’ and needs further assessment,” Hughes says. “Most of my clients have had prior experience with a counselor who had no idea how to treat OCD from an evidence-based way and approached it the same as regular old automatic negative thoughts. This is not typically helpful.”

OCD is disruptive, not only to the individual’s ability to function but also to their family life, says Hill, whose past clinical work included treating juvenile clients with OCD via play therapy. Parents and families often restructure their routines or make accommodations to work around a loved one’s compulsive behaviors, especially if the individual with OCD is a young child. OCD behaviors can be very concerning to parents and, in some cases, embarrassing in public situations. In making accommodations, the family typically feels like they are doing what they can to help the person, but that approach is actually counterproductive, Hill says. In reality, accommodating or yielding to OCD behaviors can exacerbate the issue.

Counselors shouldn’t hesitate to involve a client’s family in OCD treatment (if applicable and with the client’s consent) or to reach out to collaborate with social workers, family counselors or other professionals who may be working with the family, Hill says. Counselors can play a vital role in educating parents and family members about what an OCD diagnosis entails and clarifying the therapy goals for their loved one. They can also offer helpful, nonaccommodating ways to intervene when the person’s OCD spikes. Hill says that in her past work with juvenile clients, she often saw the severity of OCD decrease when she used filial play therapy with children and parents. This approach served to bolster their relationship, problem-solving skills and communication patterns. It also instilled a focus on positive behavior and empowering the child, she says.

Working with other treatment providers

Research has shown that a combination of therapy and psychiatric drugs, especially exposure and response prevention (ERP) therapy and serotonin reuptake inhibitors, can be particularly helpful to people with OCD.

“Attending to clients’ socioemotional and cognitive issues [in counseling] will be helpful, in addition to medicine,” Hill says. “Research consistently shows that the both/and approach is best, with medication and therapy.”

Medicine can “turn down the volume” on clients’ OCD so that therapy can help them manage their rituals and compulsions, says Nicely, who estimates that three-quarters of her clients take medication. Eventually, if clients and their prescribers agree it is the best course of action, their medications can be tapered back as their coping skills are strengthened in counseling.

Although professional counselors cannot prescribe medications, they must always consider their clients’ use of medications — and be proactive in working with clients’ medication prescribers — when looking at the whole picture of treating OCD. With clients’ consent, counselors can check in with these other treatment providers about clients’ symptoms and progress in counseling.

“I always worked on a team with other professionals,” says Szymanski, who was previously the director of psychological services at McLean Hospital’s OCD Institute in Massachusetts. “It is important to ensure that some time is spent coordinating care and that everyone’s work is complementary and not getting in the way of each other. It is equally important to inquire from the client how the team format is working for them and to ask them for specific feedback and encourage them to give direct feedback to each of their team members.”

Coordinating care among multiple treatment providers can be challenging, but it is worth it to work toward the best outcome for the client, Hughes asserts. Even imperfect, one-way communication stands to benefit the client.

“Although seamless communication and record exchange between providers is likely ideal, it just rarely happens in real life,” Hughes says. “In complex cases, it is almost unheard of for me to not [reach out to] another provider that is connected somehow to shared treatment concerns. I think we need to be realistic about other providers’ schedules and to communicate what we can, how we can. This often looks like me leaving a psychiatrist a voicemail after release is given and not hearing back, but at least they have the information.”

In addition to professionals who prescribe them medications, clients may be seeing other practitioners for treatment of issues such as depression and substance abuse that often co-present with OCD. This offers opportunities not only to coordinate care but also to make other health care professionals who do not specialize in OCD treatment aware of the disorder’s nuances. These professionals can also be alerted to the pitfalls of inadvertently undermining the client’s work in counseling by feeding their compulsions through accommodation or reassurance, Hughes says.

Many other comorbidities in clients will often improve by treating their OCD first, Hughes adds.

Exposure and response prevention

Research has identified ERP, a type of cognitive behavior therapy, as the most helpful and effective therapeutic method for treating OCD. All of the counselors interviewed for this article recommend its use with clients who have OCD. The International OCD Foundation refers to ERP as the “gold standard” for treating OCD and more helpful than traditional talk therapy methods.

In ERP, clinicians use gradual exposure to desensitize clients to the OCD-related thoughts, compulsions, situations or objects that are invoking fear and worry in them. With each exercise, the client works to overcome a triggering thought or scenario without responding with a compulsive action. This is the “response prevention” part of ERP. Exposure work is done both in session with a counselor and outside of session as homework for clients to complete on their own.

Counselors should be aware that clients’ OCD is likely to spike as they begin ERP treatment, Nicely says, because it removes the compulsions that have given them reassurance in
the past.

Over time, ERP empowers clients to confront thoughts and situations that they often would have tried to avoid previously, Dach says. “When someone has intrusive thoughts, they tend to [try and] push them away, and it effectively boomerangs. Pushing things away and trying to avoid them only empowers [the OCD] and gives it too much value,” she explains. “This [ERP]
puts them in the driver’s seat. They are the driver, instead of the fear deciding their choices.”

With the new mother mentioned earlier in this article, Dach used incremental exposure exercises to help her overcome her fear of harming her baby. At first, the baby was left outside of the counseling room with a caretaker while the client met with Dach. They started small, exposing the client to words that were triggering, such as “baby” or “bathing.” As the client progressed, Dach asked her to bring the baby into sessions. Even taking the baby out of his car seat and putting him on her knee was triggering to the client at first, Dach recalls. Dach would talk the client through each exercise, asking her throughout to monitor her level of distress on a scale of 1 to 10.

Eventually, the client graduated to exercises that included changing the baby’s diaper in session. In time, the client was able to work toward bathing her child at home, which had been one of her most fear-inducing obsessions.

Giving clients exposure assignments to work on between sessions is a critical part of ERP, Dach says. This can include creating a “worry script” in which clients write out imagined worst-case scenarios for themselves. For example, for one client, the scenario might involve going to the mall or another public place and losing control of themselves so that they vomit or yell and cause a scene, Dach says. The client imagines everyone staring at them, the client dying of embarrassment and then being banned from the mall. The client writes out all of the details of what they are feeling, seeing and experiencing in this imagined scenario. Next, the client reads or rewrites the story script repeatedly or records themselves reading it and listens to the recording over and over, Dach explains.

“It’s like watching a scary movie 1,000 times. It might be scary when you watch it the 1,000th time, but [it’s] not as terrorizing as the first time,” she says.

Dach uses the metaphor of working at a garbage facility to explain the effectiveness of ERP: On your first day, you notice the smell of the garbage and it’s so disgusting to you that you can’t even eat your lunch. But the smell bothers you less and less as you return to work each day and, eventually, you barely notice the smell at all.

ERP is granting permission “to open the doors to your dungeon and hang out with all these skeletons that you’ve got hiding in there,” Dach says. “If you grab your sleeping bag and pillow and hang out in there, eventually you’ll be more comfortable being around them.”

Hughes recalls one client with OCD who was struggling with severely distressing thoughts about harming her children. The client had no history of harm or abuse. Over time, the client found it difficult to differentiate between reality — that she would never intentionally hurt her children — and her intrusive thoughts about having impulses to stab her children, Hughes says.

“She knew [these fears] were irrational, yet it felt so real to her,” Hughes says. “As can be very typical, the stress also took a toll on most every area of her life, [including] making work difficult.”

ERP work began with small exercises the client learned to conquer while staying present with her distress and without turning to compulsions, Hughes says. The client was able to integrate ERP assignments into her daily life with the support of her loved ones, church community and her own desire to be able to engage with her family without fear of harming them.

She soon graduated to script writing and larger exposures that involved holding knives and stating her feared thoughts aloud (appropriately and not in front of her young children), Hughes says. For example, the client would work outside in the family garden and repeat to herself the worst-case scenario she had written in her scripts: “I’m wanting to use these yard tools to kill my daughters.” Later, she added more distressing content: “I want to stab them, and I’ll get arrested and divorced and be hated by my kids.”

Other exposures involved holding a butcher knife firmly for 15 seconds at a time (and eventually longer) while repeating her scripts. Over time, the client worked toward being home alone with her children, bathing her children, and ultimately cooking for her children (including using knives) while her husband was out of town.

Now the client’s OCD symptoms score so low on the Yale-Brown Obsessive Compulsive Scale that she would be considered subclinical, Hughes says. “In relapse prevention planning, [this client] understands the chronic nature of OCD and the necessity of staying on top of her good progress, with the plan to follow up at occasional intervals for ‘booster sessions,’” Hughes says. “I gain so much joy from stories like these.”

Tolerating uncertainty

ERP is effective because it empowers clients to tolerate the uncertainty that is at the core of their fear and worry, Nicely explains. The crux of the problem is not a client’s worry over contracting HIV or stabbing their husband, she says, but tolerating the uncertainty of whether or not those fears might happen.

“The hallmark question of OCD is ‘what if’ and having doubts,” says Nicely, the author of the 2018 book Is Fred in the Refrigerator? Taming OCD and Reclaiming My Life. Treating only the content of a client’s worries without teaching the client to tolerate uncertainty will simply lead the OCD to surge (or resurge) in another area of the client’s life, Nicely notes.

For ERP to be effective, it requires commitment and trust between the client and practitioner. Nicely explains to each client that the work requires a cognitive shift — that trying to avoid anxiety and OCD triggers actually makes them worse.

In working with clients with OCD, Nicely uses the acronym JOY: Jump into anxiety, opt for greater good, and yield to the anxiety. Nicely goes into detail about this method in the 2017 book she co-authored with Jon Hershfield, Everyday Mindfulness for OCD.

She asks clients, “What if we didn’t push the anxiety away? What if we brought it toward us? Can you handle it?” Then she points out an example of how the clients are already handling uncertainty by taking the first step of coming to counseling. Bringing anxiety toward them is equal to taking away OCD’s power, she explains.

Nicely books a double session with clients for their first exposure treatment. After the exposure work, they process what happened together. Nicely asks questions such as: Was it as hard as you thought? What did you learn? Did you learn that this is something that you can do to get your life back?

“If you do [triggering things] over and over again, then the brain begins to learn that these things aren’t the problem,” Nicely says. “The reason that our brain is putting these thoughts up front is because we’re reacting to them. The brain is learning when you’re allowing it to stay at a high level of anxiety.”

“OCD is a biological issue,” she says. “Our brains [in those with OCD] are structurally and functionally different than those without OCD. You can’t think your way out of this. It’s a brain disorder, and ERP changes the way our brain functions.”

Nicely uses a concept she calls “shoulders back” with both herself and her clients. She says that squaring one’s shoulders can serve as a physical reminder that whatever a person’s OCD is telling them, it doesn’t matter, and they can act as if it’s irrelevant.

“Ultimately, we want people to hear all of this [OCD triggers] in their heads and go on and have it bother them less and less,” Nicely says. “We want them to live in a world of uncertainty and not have it bother them and act as if their intrusive thoughts don’t matter.”

It can also be helpful for clients to imagine what their OCD “monster” looks like or even to give it a name. Nicely does that herself, even speaking to her OCD when it begins to surge. Nicely thinks of her OCD as something that will always be a part of her. It’s something that, at its core, wants her to feel safe.

“It’s exceptionally important [for clients] to realize that OCD is part of them, but it is not them,” she says. “That will help them to conceptualize the process. Think of it as something that has been torturing you. Talk back to it and tell it where you want it to go.”

Reassurance

The compulsions associated with OCD often arise out of a person’s urge to find reassurance and feelings of safety, Dach says. As helping professionals, counselors’ natural reaction may be to try to comfort these clients by telling them that their worst fears will not come true. But in the case of clients with OCD, offering reassurance is actually doing harm and reinforcing behavior, Dach stresses.

“No one knows whether or not the fear will happen — not the therapist [and not] the client. But the client will search and search and search for reassurance, an illusion of security and control,” Dach says. “If a practitioner gives them reassurance, they’re making the condition worse.”

When Dach finds clients asking questions as a means of seeking reassurance in sessions, she explains that she will answer questions to provide education or information but not for the purposes of offering reassurance. “It may be a hard pill to swallow, but we [counselors] need to sit with their uncertainty together and model what it looks like to sit with distress,” Dach says.

When clients express anxiety over the possibility of vomiting in a public place or some other OCD-related fear coming true, counselors shouldn’t reassure them that it won’t happen, Dach says, because there is no way to ensure that it won’t. Instead, she says, counselors can respond with questions such as, “If you did vomit, what’s the worst thing that could happen? What would it feel like? How do you know it’s going to happen?”

“The possibility is there, but the probability is low,” Dach says. “I can’t tell [the client] whether or not something is going to happen. The best we can do is put ourselves in a situation [via exposure] to learn what’s going to happen. Then I offer to lean into that discomfort [with the client].”

On the same team

There is sometimes a misconception among mental health professionals that exposure work can traumatize clients, but that simply isn’t true, Dach stresses. Therapy with a practitioner specially trained in ERP is hard work — it’s asking a client “to walk into their worst nightmare and have a party” — but it’s also incredibly effective and rewarding, she says.

“This is an extremely collaborative intervention. We’re on the same team. It’s not forcing [clients] to do things. It is asking them to get close to the thing they’re afraid of the most. You [the counselor] are there to offer gentle pushing, but it’s all choice-based,” Dach says.

Nicely and Hughes say that clients with OCD tend to be incredibly brave and also deeply caring. It is inspiring, Nicely says, to watch clients tackle such hard things in therapy and become more resilient.

“For many reasons, I love work with clients who have OCD,” Hughes adds. “I have found that they are some of the kindest, hardest-working and most conscientious individuals on this planet. This is where I believe many of their personality strengths arise once [they move] through pathology. It is a joy every day to see recovery, growth and maturity bloom out of suffering.”

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The International OCD Foundation offers a wealth of resources and information on its website, iocdf.org, as well as training programs, an annual conference, and local affiliates around the country.

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Contact the counselors interviewed for this article:

Karina Dach: anxietyocdcounseling.com
Nicole Hill: NRHill@ship.edu
Justin Hughes: justinkhughes.com
Shala Nicely: shalanicely.com

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OCD is not an adjective

It’s not uncommon for people to describe themselves in casual conversation as “obsessed” with a television series or “OCD” about the way they organize their closet.

Professional counselors can be agents of change when it comes to casual use of the language related to obsessive-compulsive disorder (OCD), says Shala Nicely, a licensed professional counselor in Georgia who specializes in treating the disorder. She encourages counselors to be mindful of their own language and to gently correct those who misuse OCD-related terms.

One place to begin: Stop using OCD as an adjective, she says. Someone might be meticulous or detail-oriented or neat, but he or she is not “OCD.” To say “I’m so OCD” about something can discourage people who really do have OCD from seeking treatment, especially if that offhand pronouncement comes from a mental health professional, Nicely says.

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

Letters to the editor: ct@counseling.org

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

Straddling two worlds

By Lindsey Phillips January 23, 2020

Because immigrants often feel like they are straddling two worlds — their origin country and their new one — identity development is complex and critical for this population. Immigrant clients often tell Sara Stanizai, a licensed marriage and family therapist and owner of Prospect Therapy in Long Beach, California, that they have one foot in each culture and don’t fully fit into either one.

When people feel like they don’t fully belong to any one community and are constantly hiding one or more aspects of themselves to try to fit in, they question their identity and choices, Stanizai explains. She finds this is especially true for emerging adults who are figuring out their careers. Immigrants may be successful at their jobs, but they often feel like they are failing because they are hiding or ignoring a part of their identity in the process, she says.

Daniel Gutierrez, an assistant professor in the counselor education program and coordinator of the addictions emphasis for the clinical mental health counseling program at William & Mary, points out that straddling two worlds involves code switching between language and cultures: People alter their behavior and speech to accommodate different cultural norms. They may act and speak one way at home and another way when they are at school or work or out with friends. “You can’t be who you are naturally. You have to switch depending on the social context or you have to abandon your home culture to succeed, and then you feel guilty all the time,” says Gutierrez, who is also faculty director of the New Leaf Clinic at William & Mary.

Gutierrez finds that many immigrants question their identity (for example, “Am I Korean enough? Am I white enough?”). Immigrants may feel that they need to reject their home culture to fit in with their new one, so Gutierrez recommends asking clients, “How do you identify? Whom do you connect with? What does your social network look like now? How do you make sense of what’s home?”

Immigration can also cause intergenerational conflict because family members acclimate to the new country and culture at different rates. The expectation that even after immigrating, children will continue to behave as they did in their origin country can lead to conflict, says Lotes Nelson, a clinical faculty member at Southern New Hampshire University. She often hears clients say that their children are “behaving like Americans” because they are being disrespectful to them or dressing and behaving in a way that is embarrassing to the family. These clients often ask her, “What do I need to do to make sure our children follow our culture and behaviors?”

Nelson, a licensed professional counselor and approved clinical supervisor in North Carolina, acknowledges that this isn’t an easy conversation to have, but she invites families to talk through their feelings. One framework that she finds helpful is the ABCDE model (which is part of rational emotive behavior therapy) because it helps clients reflect and reframe their thinking about a certain situation or emotion.

Nelson, a member of the American Counseling Association, briefly illustrates how this model works: Take a 13-year-old child who is no longer interested in going to church (the “A” or activating event). The parents may interpret this change as a sign that coming to the United States was a mistake (the “B” or belief), Nelson says. They may feel responsible for their child no longer practicing their spiritual values, and these emotions may manifest as anger at the child (yelling or physically punishing the child; the “C” or consequence).

To help parents challenge their interpretations of the event and their emotional response to it (the “D” or disputing), Nelson may say, “Let’s explore your impression about what has occurred for your child. Tell me more about this belief that coming to America might have been a mistake for you and your family. I wonder how else you might view this new experience.”

Closely examining the situation with a new perspective often helps clients navigate their emotions and thoughts more effectively and helps them find a way to move forward, she explains. In this example, the parents may realize how living in the United States has exposed their child to different beliefs and how their child now has friends who don’t go to church. So, the parents make a new plan: They will continue discussing the significance that religion plays in their culture in the hope that the child’s rejection of church is not permanent (the “E” or effects).

Younger generations of immigrants may also feel indebted to their parents for their sacrifices, such as moving to a new country to provide them with better opportunities or paying for their education. As a result, they may choose a career path — one they don’t want — just to honor their parent’s wishes, says Gutierrez, a licensed professional counselor in North Carolina and Virginia and an ACA member.

He recalls working with a family who possessed conflicting notions of academic success and happiness. The mother thought her children were not doing well in school, but the kids said they were doing fine. Success for the mother meant her children getting straight A’s and becoming successful medical doctors. Her children resented the added pressure because they didn’t value straight A’s in the same way.

Gutierrez says his role as a counselor is not to wave his finger at family members but to teach them how to communicate with one another. In a sense, he operates as a referee, making sure each person pauses and clearly states back what they heard the other person say.

With this particular family, Gutierrez asked the son, “What do you think your mom is going to say this week?”

The son said, “She’ll scream at me about not finishing my homework or about getting a B on my last math test.”

Gutierrez asked, “What do you think she wants from you? What do you think she means by always bringing up school and grades?”

The son replied, “She only cares about grades and about me becoming a doctor. She doesn’t care about what I want out of life.”

The mother was in the room and heard her son’s perspective. Later in the session, she had the chance to share her side of the story. She expressed how yelling over her son’s grades was the way she expressed her love for him because she didn’t want him to struggle the way she had. This exchange caused the mother and son to become emotional because they both gained a deeper understanding of the other’s feelings and the underlying motivations of the mother’s actions, Gutierrez shares.

Stanizai finds that immigrants are often used to having external validation or external measures of success, so in therapy, she helps clients move to internal ones. For example, a client might be getting pressure from their family to get straight A’s and become a lawyer or doctor, and this pressure is affecting the client’s mental health. Stanizai would help the client identify the internal qualities and strengths that they possess that are not dependent on the expectations or circumstances of others. For example, she might help the client realize that they will succeed in whatever career they choose — even if it’s a different career from what the family wants — because they possess a good work ethic.

“A lot of anxiety comes from feeling overwhelmed and feeling responsible for so many people other than [themselves],” Stanizai says. “If people feel they have no other choice than to cut people or cultures out of their life, then that can make people feel disconnected and depressed.” Feeling “othered” or isolated can exacerbate symptoms of mental health issues such as depression and anxiety, she adds.

Because it is so isolating to not fully fit into any one group, Stanizai started an Adult Children of Tiger Moms support group to give immigrant children a safe space to talk about these issues and find others who have similar experiences. She has noticed that the group, which has people from various types of cultures, has become its own culture — one that is validating and healing to its members.

Groups are often more accessible for people who may not be able to commit to weekly individual counseling sessions. In addition, they tend to help people overcome any stigmas they have about therapy because when participating in a group, individuals often feel like they are taking a class, not going to counseling, she adds.

Stanizai has noticed that a common thread often emerges in her group sessions: No matter how successful the participants are, they all feel like they are letting their families down. Many group members report feeling unhappy at their jobs, yet they feel that they have to stay because of family expectations. They also note feeling guilty because their parents often assume they will move back home — either to their hometown or into their parents’ house — after they graduate.

Stanizai had one client who graduated and found a job in a city that was far away from her parents. The client felt so guilty that she went back to visit them every weekend. Stanizai asked the client, “Why do you think your parents want you to move back home? Why is that so important to them?” The client said, “My parents worry about me, and they want to stay connected.”

Stanizai worked with the client to brainstorm ways that she could connect with her parents without having to go home every weekend, such as using a video chatting app or inviting them to her apartment for dinner. The client decided to email her parents more often, and she found that doing this actually helped her and her father grow closer, Stanizai says. They would exchange long emails, and in writing each other, they were sharing more details about their lives than they did when the client went home and sat quietly watching TV with her father.

“Parents really want [their children] to be successful and happy, Stanizai says. “The framework for what that looks like might be different from [the client’s], but they can respect and honor that and also open their [parents’] eyes to what is important to them without completely turning their backs on [their family] so they can both coexist.”

This intergenerational conflict serves as a microcosm of the constant struggle between identities that immigrants often face. With counseling, these clients can come to terms with these identities and finally find their footing.

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For more on working with clients who are immigrants, read the in-depth feature article “Fostering immigrant communities of healing” in the February issue of Counseling Today.

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. 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.

Reconciling disability studies with mental health counseling

By Emily Cutler January 21, 2020

Growing up Jewish and queer in a conservative part of Birmingham, Alabama, I faced some pretty severe bullying as a child and teenager. It was a common occurrence for me to be called anti-Semitic slurs and mocked for looking and acting different. I was excluded by almost all of my classmates and had very little social support.

As a result, I struggled a great deal with my mental health. I felt depressed and anxious almost every day, and there were times when I felt sheer panic and terror about the prospect of attending school. Because I never seemed to fit in, I was convinced that I was fundamentally unlikeable and that the only positive quality I possessed was my near-perfect academic track record. So, on top of the anxiety and depression I felt as a result of being bullied, I also put enormous pressure on myself to score perfect grades. Any score less than 100 would send me into a spiral of shame and self-hate.

I cried a lot, and this worried many of the adults around me. I was sent to a number of therapists throughout my childhood. Most of them focused on figuring out ways to get me to stop crying so much. I was prescribed medication, exercise and an array of breathing techniques. Some of the therapists worked on encouraging me to act more “normal” — perhaps if I didn’t talk about my academic interests so much, or if I stopped trying to be the teacher’s pet, or if I were just less sensitive, then more of my classmates would like me.

Although some of the advice was useful, there were many times I walked out of therapy continuing to feel like something was wrong with me — that it was my fault that I was being bullied because I was just too weird and different to understand how to act like everyone else. More than anything else, I was frustrated with myself for not being able to stop crying or feeling depressed.

An empowering approach

My experiences with and perspective on therapy changed drastically when I went away to college. After struggling considerably with the transition to a new city and new environment, I reluctantly sought counseling from my university’s mental health center. I can still remember my first session. After answering some questions about my childhood during the intake, I said, “I know I must seem really messed up. Everyone hated me in high school, and now I just started college and I still don’t fit in. There’s something wrong with me. I know it. I just can’t fit in anywhere.” I could feel myself starting to tear up, so I immediately apologized for crying. “And on top of that, I am so overly emotional! I must be your worst client.”

My new counselor raised his eyebrows and looked up from his notes. “I was actually about to say that the way you’re reacting seems normal to me. It sounds like you had a pretty difficult time in school, and that was hard for you — it would be for anyone. And the transition from high school to college is hard too, which is also normal. I don’t know if I’ve met anyone who didn’t struggle to make friends in the first few months of college. I think it shows that you have a lot of resilience to get through all of that and to reach out for help.”

I was shocked. Here was a counselor who was not saying that anything was wrong with me or that I needed to change myself to fit in better. In his opinion, I was having a natural reaction to the circumstances I had been through. I’d never heard anything like it before.

Over the next several months, I went from viewing myself as an unlikeable weirdo to a person who is different (and perhaps weird in a good way!) but still deserving of acceptance and belonging. I started to see my uniqueness as a strength. Instead of encouraging me to change myself to fit in, my counselor empowered me to seek out on-campus groups and spaces where I would be accepted. As a result, I joined my campus Hillel as well as Active Minds, a student mental health organization. My counselor also encouraged me to stand up for myself in instances of bullying. Above all, he never pathologized my emotions or told me it was wrong to feel sad or depressed. I finally felt that I was being given the space to process and react to some of my experiences as a child.

Finding my path

Later on, I began to get involved with initiatives and organizations that focus on combatting prejudice and social injustice. I interned at the Anti-Defamation League of Philadelphia during my senior year of college, and I completed an honors thesis on weight-based bullying (bullying due to a child’s weight or size). Eventually, through my coursework and through my involvement in different advocacy communities, I found my way to disability studies, a discipline that centers the voices of people with disabilities and explores philosophical, cultural and sociological perspectives on the experience of disability.

Generally, the field of disability studies challenges the idea that disability is solely or primarily an individual defect in need of medical treatment. Instead, it posits that disability is the result of a multitude of factors, including societal exclusion and inaccessibility. The perspectives encompassed by disability studies greatly resonated with me as someone who cares deeply about challenging social injustices and exclusion rather than primarily changing individuals. Over the past several years, I have become intricately involved with disability studies research and advocacy.

One of my most pivotal moments has been coming to view myself and accept my identity as a person with a psychiatric disability. Embracing that identity has allowed me not only to accept myself and reduce my shame around having experienced mental health struggles, but also to become connected to a community of people with similar experiences and perspectives. I started working with the National Empowerment Center, an organization led by and for mental health consumers. With the center, I develop advocacy initiatives, educational programming and workshops that center the voices of people with lived experiences of mental health challenges and advocate for increased self-determination and acceptance of people with psychiatric disabilities.

The most meaningful and fulfilling part of my work has been spending time with people who have psychiatric disabilities, sitting with them through difficult times and empowering them to advocate for their rights and self-determination. My work has often included responding to people in crisis and providing space for them to experience strong emotions and extreme states.

A ‘fit’ for counseling?

My passion for that kind of intensely interpersonal, relational work sparked my interest in becoming a mental health counselor. As I began to explore the possibility of pursuing a graduate degree in counseling, I became increasingly certain that it was the right choice for me. There is little I care about more than supporting people with psychiatric disabilities to gain agency over their lives and experience community, connection and meaning. However, I also wondered how my disability studies background and perspective would fit with my role as a counselor. Whereas the disability studies field seeks increased acceptance and accommodation of disability in society, the counseling field often seeks to treat or prevent psychiatric disability. Would it be possible for me to reconcile both of these goals and perspectives?

I am only in my third semester of graduate school, so I do not yet fully know how I will integrate my disability studies background with my role as a mental health counselor. However, I believe it will be quite possible to do so.

In my own experience with counseling at my university’s mental health center, I felt that my counselor focused much more on encouraging me to accept myself and to find spaces where I would be accepted than on changing me or “fixing” me. I hope to take this same general approach with my clients. I believe that person-centered therapy and other humanistic approaches to counseling provide an excellent framework to accomplish this. These approaches require therapists to work with clients from a position of unconditional positive regard and to support clients in discovering their strengths rather than operating from a deficit-based model.

I also believe it is important to learn from counseling approaches developed by and for other marginalized communities. For example, while homosexuality used to be pathologized as a mental illness in the Diagnostic and Statistical Manual of Mental Disorders, many counselors now practice LGBTQ-affirming therapy. This approach supports LGBTQ clients in accepting themselves and decreasing any feelings of shame they may have related to their identities. Similarly, feminist therapy focuses on empowering women and people from other marginalized groups to advocate for themselves and to challenge injustice in their daily lives. Similar approaches could be applied to counseling clients with disabilities, including those with psychiatric disabilities.

I do not mean to suggest that psychiatric disabilities should never be treated or prevented. Many people with psychiatric disabilities want treatment such as cognitive behavior therapy, dialectal behavior therapy, and medication. Neither should exercise and breathing techniques be discounted because they are very useful for many people. However, there is no reason why the social and systemic factors affecting a person should not also be explored. In fact, professional counselors have an ethical and moral obligation to encourage people with disabilities to advocate for themselves. If clients are facing prejudice or discrimination on account of their psychiatric or other disability (or other difference), it may be helpful to explore ways of addressing that with them. Counselors can also encourage clients to request disability accommodations and link them to organizations such as peer-run wellness centers and peer support groups through which they might find acceptance and social support.

The 20/20: A Vision for the Future of Counseling initiative, sponsored by the American Counseling Association and the American Association of State Counseling Boards, reached a consensus definition of counseling as “a professional relationship that empowers diverse individuals, families and groups to accomplish mental health, wellness, education and career goals.” I believe that the disability studies field complements and enhances this goal rather than taking away from it. As a future counselor with a disability, I look forward to empowering my clients to accomplish their goals and to stand up to any injustice that stands in their way.

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Emily Cutler is a graduate student in clinical mental health counseling at Troy University in Tampa, Florida. In addition to pursuing her studies, she provides training and consultancy on the topics of disability rights, trauma-informed care, suicide prevention, peer-run mental health services, and the Health at Every Size paradigm. Contact her through her website at emilyscutler.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.

Michigan LPCs block attempt to take away their right to practice

By Laurie Meyers January 16, 2020

Your voice matters. Those who doubt the power of speaking out and advocating for the profession need only look to the counselors of Michigan. This fall, approximately 10,000 licensed professional counselors (LPCs) participated in a grassroots campaign that thwarted an attempt to take away their ability to practice.

On Friday, Sept. 13 — some would say an appropriately ominous date — Michigan’s Department of Licensing and Regulatory Affairs (LARA) released a notice of public hearing for comments on proposed changes to the state rules that define the scope of practice for LPCs. The notice served as confirmation that despite the objections of the state’s board of counseling and months of protest from local advocates, LARA was moving forward with its plan not only to change, but also to repeal, virtually all of the previous rules governing scope of practice. Most critically, the proposed changes would repeal LPCs’ practice of “counseling techniques” and ability to “diagnose and identify the problem.” In other words, LARA intended to strip away Michigan LPCs’ rights to diagnose clients and practice psychotherapy.

Absent this ability to diagnose, neither counselors nor clients would be able to seek insurance reimbursement — a devastating blow to practitioners. But the damage wouldn’t stop there. LARA’s proposed repeals would have threatened the very existence of the counseling profession in Michigan by taking away LPCs’ right to provide psychotherapy. How do counselors who can’t counsel practice? The answer: They don’t.

“The ramifications [if LARA was successful] would’ve been that 10,000 counselors would be unable to practice legally,” says Michael Joy, president of the Michigan Counseling Association (MCA). “They essentially would have lost their jobs.”

Joy, a member of the American Counseling Association and an LPC in private practice, adds that LARA’s repeal would have also left up to 150,000 clients in the lurch. With their counselors unable to practice, clients would have needed to seek treatment from other therapists. Because most of Michigan’s mental health practitioners are already carrying heavy caseloads, the search could have taken months, during which time these clients would not have been receiving help, Joy continues. This rupture in the continuity of mental health care would have been a significant therapeutic setback and could have potentially endangered clients’ well-being, he asserts. Those with more acute symptoms might even have needed hospitalization, he says.

LARA’s interest in changing the scope of practice rules for LPCs in Michigan is not new. Many veteran counselor advocates had been bracing for an official proposal for years and were working on several fronts in hopes of preventing a crisis. Although advocates attempted to work with LARA, the Michigan Mental Health Counselors Association (MMHCA) —a former division of MCA —initiated a backup line of defense by engaging a lobbyist and appealing to the state Legislature.

In March 2019, House Bill 4325 was introduced in the Michigan Legislature. Its aim was to create a statute updating the scope of practice and licensing requirements for LPCs, thus ensuring that counselors would retain their ability to diagnose and treat clients. HB 4325 would supersede LARA’s proposed changes. The bill had strong bipartisan support and was steadily making its way through the Michigan Legislature, but there were questions about whether it would pass in time.

The clock was ticking — loudly.

“Really, no one exactly knew that the trigger was going to be pulled until there was that public announcement [from LARA], and so then, the madness actually began,” explains Stephanie T. Burns, an LPC in both Michigan and Ohio and an active member of ACA, MCA and MMHCA. “LARA had made their proposals, and the Michigan Board of Counseling at that point had unanimously vetoed all the changes and, in response to that, the powers that be at LARA decided to just go ahead and put them forward anyway …”

If LARA was not swayed by the comments and testimony given at the public hearing in October, the repeal of the counselors’ scope of practice could have become effective as early as November. Michigan LPCs needed to fight hard and fast for their jobs. And they did.

A groundswell of advocacy was triggered as news of LARA’s plan spread. MCA sent out a distress signal to the American Counseling Association (ACA), whose government affairs team swung into motion. Brian Banks, ACA’s director of public policy and intergovernmental affairs, began strategizing with MCA to formulate a plan. ACA sent out a VoterVoice email alert — which guides subscribers through the process of contacting legislative representatives on federal and state issues — to its members in Michigan. The ACA government affairs team expanded the call to action by posting advocacy alerts targeting all Michigan counselors on Twitter and Facebook. ACA also reached out to the Michigan branch of the National Association of Social Workers, the Michigan Primary Care Association and the national offices of the National Alliance for Mental Illness and the American Federation of State, County and Municipal Employees. MCA began circulating a petition and lining up members who were ready to testify at the LARA hearing to the countless clients they had helped and the lives they believed they had a hand in saving. MMHCA also urged members to testify at the hearing in person if possible or, if not, to email their written testimony to LARA before Oct. 4.

In the meantime, Burns, an associate professor of counselor education at Western Michigan University, began spreading the word among alumni and colleagues about the threat to all LPCs and the urgent need to contact LARA and state legislators. In addition to engaging in her own advocacy work, Burns teaches her students how to advocate effectively, so she had already formulated action steps and language — posted as a template on MMHCA’s website — for email and letter appeals.

Thousands of counselors responded to the call to action ahead of the hearing, pelting LARA with protests and urging their representatives to move forward and approve HB 4325. And on Oct. 4, counselors bombarded the hearing. In fact, the turnout exceeded the venue’s fire code restrictions, so not everyone who showed up was able to come inside, according to Joy.

Banks attended the hearing to present ACA’s testimony, written by Chief Executive Officer Richard Yep.

“ACA wants to support our members and the profession at the highest level,” Banks says. “Being in Michigan to support the profession was a vital step in showing LARA and the Legislature how important these issues are.”

ACA’s statement emphasized the critical role that LPCs play in providing mental health and drug abuse treatment to the residents of Michigan. Preventing counselors from treating clients would greatly exacerbate the shortage of mental health providers, particularly in rural areas of the state. In addition, LARA’s actions would have created a violation of ACA’s code of ethics, which requires that counselors make a proper diagnosis before providing treatment.

Burns also focused on the ACA Code of Ethics in her written messaging and when meeting with the Michigan Senate Health Policy Committee. She specifically referenced the part of the ethics code that says professional counselors cannot abandon or neglect their clients. “I said [to the committee], ‘LARA will be responsible in that moment for causing harm — serious harm — to our clients.’”

In the end, the combined efforts of MCA, MMHCA, ACA and — most importantly — thousands of counselors from across the state paid off. In October, both houses of the Michigan Legislature voted unanimously to pass HB 4325. On Oct. 29, the bill was signed into law by Gov. Gretchen Whitmer.

Burns and Joy both praised ACA for its assistance, in particular noting its decision to send Banks to testify in person at the hearing rather than merely submitting the statement from afar. Joy adds that the knowledge he gained at ACA’s Institute for Leadership Training helped him to form an effective course of action for MCA.

“Michigan is a perfect example of how grassroots advocacy works when effectively organized,” says Banks, adding that the campaign was one of the strongest he’s seen in his 20 years in the field.

Sometimes it takes a Michigan-sized crisis to spur large-scale grassroots efforts. But Burns and Banks urge counselors not to wait. The profession is facing numerous critical issues — such as the fight for Medicare reimbursement. Lawmakers and regulatory officials will make decisions about the profession with or without counselors’ input, Banks emphasizes.

“We have to have a seat at the table.”

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Laurie Meyers is senior writer at Counseling Today. Contact her at LMeyers@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.

Hey, Siri: Did you break confidentiality, or did I?

By Nicole M. Arcuri Sanders January 14, 2020

Did you know that your tech devices have the potential to break your clients’ confidentiality just by being in the counseling setting with you? Imagine that you have worked a full day seeing an array of clients for the various concerns they are facing. Then, at the end of the day, you snuggle up on the couch and scroll through your phone’s applications. You notice numerous ads and suggestions that relate to the topics clients have shared. For instance, imagine a client sharing about a traumatic event that happened in the Catskills, and now you have Airbnb suggestions for that area, along with resources for dealing with sexual abuse.

You may be wondering, “How did that happen? Was my phone listening to our session?” The answer might be yes.

In other cases, you might not be made aware that your phone was listening, but it is important to know that it has that capability. The reason for this is the voice assistant technology on your devices. While on, these devices are constantly listening. For instance, Apple iPhone is listening for the word “Siri”; anything said after that is considered a command. The same is true with Amazon’s voice assistant Alexa and with Google Assistant. Each of these devices is waiting for its name to be called so that it can follow up with whatever assistance the person using it desires.

However, it has been found that the devices sometimes mistake certain words and are activated unintentionally.

This past July, The Guardian newspaper shared shocking reports from an Apple contractor. This whistleblower reported that Apple contractors “regularly hear confidential medical information, drug deals, and recordings of couples having sex, as part of [Apple contractors’] job providing quality control.” These workers are tasked with listening to grade the responses of the company’s Siri voice assistant. For example, the workers will grade if the response from Siri was accidental or deliberate and if Siri’s response was appropriate.

But what does this mean for professional counselors? Just think invasion of privacy and breach of confidentiality concerns.

Voice assistant concerns in the counseling setting

This next section is going to present a hypothetical counseling office to address some of the confidentiality concerns that surround the counseling experience with technological voice assistants. Consider whether you address these concerns in your informed consent with clients. Would these occurrences align with Health Insurance Portability and Accountability Act (HIPAA) regulations?

Waiting room: Counselors strive to create a warm and inviting setting to foster a comfortable feeling for clients because they are in a vulnerable situation. Perhaps some relaxing music is playing in the waiting room. Consider Alexa being programed to shuffle through various playlists of calming songs throughout the day.

As clients await their sessions or end their sessions, they may need to discuss billing with the front-desk assistant or call their insurance companies. Clients may even take a call during this time for other purposes. Alexa hears all of these conversations throughout the day. Therefore, the potential is there for the entrance to this “safe place” for clients to instead become a place where personal information is leaked to Alexa and to those who monitor Alexa or have access to Alexa’s recordings.

Additionally, clients may not even realize that while they are in your office discussing billing, diagnosis, and plans moving forward, their smartphone’s voice assistant can be eavesdropping as well. The same goes for all of the other smartphones located in the waiting room, including those being used by personnel working the front desk.

In session: When clients and counselors meet in an office, safety is a concern. Therefore, counselors may choose to keep their phones in their pocket or nearby in case they need to call for help. Some sites may even have a policy requesting that counselors have their cellphones on them at all times. However, now these phones’ voice assistants can have access to the dialogue that occurs within the room. This also means that whoever is monitoring the voice assistants have access. What was intended to be a safe place for clients to navigate and process concerns is now compromised.

Can you imagine if you, as the counselor, were facilitating a group and each client had a smartphone with a voice assistant? Consider also if you take notes on an iPad that has voice assistant technology. As counselors, we understand there are some limits to confidentiality. However, these voice assistant technologies have the capability to leak what clients and counselors once believed to be confidential information.

Disconnect: Don’t be considered liable

A number of considerations need to be taken into account by both the counselor and the client regarding confidentiality of sessions when voice assistant technologies are present. First and foremost, this issue should be addressed. Now that you are aware of the implications for your practice, you are ethically responsible for addressing these possibilities with your clients.

According to the 2014 ACA Code of Ethics, clients have the right to confidentiality and an explanation of it limits (Standard A.2.b.). Understanding these limits, clients have the right to make an informed decision regarding whether they would like to participate in counseling services with you (Standard A.2.a.).

Therefore, if you choose to utilize voice assistant technologies, you need to inform clients of the benefits and risks prior to them beginning counseling services. This explanation is not limited only to the counselor using these technologies but also acknowledging whether the counseling site allows its staff or clients to use them. If your site chooses not to utilize voice assistant technologies, you will need to address what your protocol is concerning this matter. For instance, will all cellphones be turned off? How will this be regulated?

What if your site requires cellphones for safety concerns or if clients are not willing to turn their phones off? How can you still protect client confidentiality and be in alignment with HIPAA regulations? The simple answer is to turn off your voice assistant technologies. You might consider noting the confidentiality risks in your informed consent and then sharing some of the directions noted below for how to disable these technologies.

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For iPhones and iPads, to turn off Siri, complete the following directions:

1) Open your settings.

2) Click Siri and Search.

3) Toggle OFF, listen for “Hey Siri.”

4) Toggle OFF, Press Home (or side button) for Siri.

5) Toggle OFF, allow Siri when locked.

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To turn off “Hey/OK Google,” complete the following directions:

1) Open your settings.

2) Under Google Assistant, tap Settings again.

3) Under Devices, tap Phone.

4) Turn OFF Access with Voice Match/Assistant.

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To turn off Amazon Alexa, complete the following directions:

1) Open your settings.

2) Select Alexa Privacy.

3) Tap Manage How Your Data Improves Alexa.

4) Turn “Help Improve Amazon Services and Develop New Features” OFF by tapping the switch.

5) Confirm your decision.

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These steps can provide clients with a choice while also informing them of the risks of their choices. In group counseling, however, as a safeguard to clients’ confidentiality, I would recommend not allowing any client to keep their cellphones, iPads or any other voice assistant technologies on.

Because these devices may travel with us basically everywhere we go, our conversations are being monitored for product improvements, but in the process, our confidentiality is being breached. Currently, with some simple options for turning off these technologies, clients can continue to maintain the level of confidentiality to which they originally thought they were agreeing.

As counselors, we take many safeguards to protect our clients’ confidentiality. I encourage you to toggle off your voice assistant technology options to keep your devices from being the reason you are held liable for breaking confidentiality. Moving forward, as technologies continue to transform, we as counselors need to be ready to address implications in the counseling setting.

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Nicole M. Arcuri Sanders is a licensed professional counselor, national certified counselors, approved clinical supervisor, and core faculty at Capella University within the School of Counseling and Human Services. Contact her at Nicole.ArcuriSanders@capella.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.