Monthly Archives: August 2020

Grappling with compassion fatigue

By Lindsey Phillips August 31, 2020

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Compassion fatigue presents a paradox for counselors and others in the helping professions. As Alyson Carr, a licensed mental health counselor and supervisor in Florida, points out, it compromises their ability to do the very thing that motivated many of them to enter the field in the first place — empathically support those in pain.

Empathy and compassion are attributes those in the helping professions are particularly proud to possess and cultivate. Yet those same characteristics may leave some professionals more susceptible to becoming traumatized themselves as they regularly observe and work with those who are suffering.

Jennifer Blough provides counseling services to other helping professionals as owner of the private practice Deepwater Counseling in Ypsilanti, Michigan. She says many of her clients experience compassion fatigue. One of her former clients, an emergency room nurse, witnessed trauma daily. One day, the nurse treated a child who had suffered horrendous physical abuse, and the child died shortly after arriving at the hospital.

This incident haunted the nurse. She had nightmares and intrusive thoughts about the child’s death and abuse. She started to isolate to the point that she had to step away from her job because she refused to leave her house. She couldn’t even bring herself to call Blough. She just sent a text asking for help instead.

Blough, a licensed professional counselor (LPC) and certified compassion fatigue therapist, asked the nurse to come to her office, but the nurse said she was comfortable leaving her home only when accompanied by her dog. So, Blough told her to bring her dog with her to the session. That got the nurse in the door.

From there, Blough and the nurse worked together to help the client process her trauma. Blough also taught the client to recognize the warning signs of compassion fatigue so that she could use resiliency, grounding skills, relaxation, boundary setting, gratitude and self-compassion to help keep her empathy from becoming unmanageable again.

Defining compassion fatigue

“One of the most important ways to help clients who might be struggling with compassion or empathy fatigue is to provide psychoeducation,” Blough says. “A lot of people don’t even realize there’s a name for what they’re going through or that others are going through the same thing.”

Blough, author of To Save a Starfish: A Compassion-Fatigue Workbook for the Animal-Welfare Warrior, didn’t understand that she was experiencing compassion fatigue when she worked at an animal shelter and as an animal control officer before becoming a counselor. After she started feeling depressed, she decided that she was weak and unfit for her job and ultimately left the field entirely. It wasn’t until she was in graduate school for counseling that she learned there was a name for what she had experienced — compassion fatigue.

According to the American Institute of Stress, compassion fatigue is “the emotional residue or strain of exposure to working with those suffering from consequences of traumatic events.” This differs from burnout, which is a “cumulative process marked by emotional exhaustion and withdrawal associated with workload and institutional stress, not trauma-related.”

Although compassion fatigue is the more well-known and widely used term, there is some debate about whether it is the most accurate one. Some mental health professionals argue that people can never be too compassionate. Instead, they say, what people experience is empathy fatigue.

In an interview with CT Online in 2013, Mark Stebnicki described empathy fatigue as resulting from “a state of psychological, emotional, mental, physical, spiritual and occupational exhaustion that occurs as the counselors’ own wounds are continually revisited by their clients’ life stories of chronic illness, disability, trauma, grief and loss.”

April McAnally, an LPC in private practice in Austin, Texas, is among those who believe that people can’t have too much compassion. Compassion involves having empathy and feeling what the other person does, but we have a screen — an internal boundary — that protects us, McAnally says. “Empathy, however, can be boundaryless,” she continues. “We can find ourselves overwhelmed with what the other person is experiencing. … So, what we actually become fatigued by is empathy without the internal boundary that is present with compassion.”

As Blough puts it, “Empathy is the ability to identify with, or experience, another’s emotions, whereas compassion is the desire to help alleviate suffering. In other words, compassion is empathy in action.”

McAnally, a certified compassion fatigue professional, also suggests using the term secondary trauma. She finds that it more accurately describes the emotional stress and nervous system dysregulation that her clients experience when they are indirectly exposed to the trauma and suffering of another person or animal.

Symptoms and risk factors

Anyone can be susceptible to burnout, but compassion fatigue most often affects caregivers and those working in the helping professions, such as counselors, nurses, social workers, veterinarians, teachers and clergy.

Working in a job with a high frequency of trauma exposure may increase the likelihood of developing compassion fatigue, McAnally adds. For example, a nurse working in an OBGYN office may have a lower risk of developing compassion fatigue than would an emergency room nurse. Even though they both share the same job title, the impact and frequency of trauma is going to be higher in the ER, McAnally explains.

Counselors should also consider race/ethnicity and contextual factors when assessing for compassion fatigue. Racial injustices that members of marginalized populations regularly experience are sources of pervasive and ongoing trauma, McAnally notes. And unresolved trauma increases the likelihood of someone experiencing empathy fatigue, she adds.

Carr, an American Counseling Association member who specializes in complex trauma and anxiety, and Blough both believe the collective trauma resulting from the COVID-19 pandemic and exposure to repeated acts of racial violence and injustice could lead to collective compassion fatigue for all helping professionals (if it hasn’t already).

McAnally, a member of the Texas Counseling Association, a branch of ACA, says the current sociopolitical climate has also affected the types of clients she is seeing, with more individuals who identify as activists and concerned citizens seeking counseling of late. She has found that these clients are experiencing the same compassion fatigue symptoms that those in the helping professions do.

Blough and Victoria Camacho, an LPC and owner of Mind Menders Counseling in Lake Hopatcong, New Jersey, say symptoms of compassion fatigue can include the following:

  • Feelings of sadness or depression
  • Anxiety
  • Sleep problems
  • Changes in appetite
  • Anger or irritability
  • Nightmares or intrusive thoughts
  • Feelings of being isolated
  • Problems at work
  • A compulsion to work hard and long hours 
  • Relationship conflicts
  • Difficulty separating work from personal life
  • Reactivity and hypervigilance
  • Increased negative arousal
  • Lower frustration tolerance
  • Decreased feelings of confidence
  • A diminished sense of purpose or enjoyment
  • Lack of motivation
  • Issues with time management
  • Unhealthy coping skills such as substance use
  • Suicidal thoughts

There are also individual risk factors. According to Camacho, a certified compassion fatigue professional, individuals with large caseloads, those with limited or no support networks, those with personal histories of trauma or loss, and those working in unsupportive environments are at higher risk of developing compassion fatigue.

In fact, research shows a correlation between a lack of training and the likelihood of developing compassion fatigue. So, someone at the beginning of their career who feels overwhelmed by their job and lacks adequate training and support could be at higher risk for experiencing compassion fatigue, McAnally says.

One assessment tool that both Blough and Camacho use with clients is the Professional Quality of Life Scale, a free tool that measures the negative and positive effects of helping others who experience suffering and trauma. Blough says this assessment helps her better understand her clients’ levels of trauma exposure, burnout, compassion fatigue and job satisfaction.

Regulating the body and mind

“Having an awareness of our emotions and experiences, especially in a mindful way, can serve as a barometer to help protect us against developing full-blown compassion fatigue,” says Blough, a member of ACA and Counselors for Social Justice, a division of ACA.

Part of this awareness includes being mindful of one’s nervous system and the physical changes occurring within one’s body. When someone experiences compassion fatigue, their amygdala, the part of the brain involved in the fight-or-flight response, gets tripped a little too quickly, McAnally explains. So, their body may react as if they are in physical danger (e.g., heart racing, sweating, feeling panicky) even though they aren’t.

If clients get dysregulated, McAnally advises them to use grounding techniques to remind themselves that they are safe. She will often ask clients to look all over the room, including turning around in their chairs, so they can realize there is nothing to fear at that moment. She also uses the 5-4-3-2-1 technique, in which clients use their senses to notice things around them — five things they see, four things they hear, three things they feel, two things they taste and one thing they smell.

Research has shown that practicing mindfulness for even a few minutes a day can increase the size of the prefrontal cortex — the part of the brain responsible for emotional regulation, McAnally adds.

Blough often uses the square breathing technique to ground clients and get them to slow down. She will ask clients to breathe deeply while simultaneously adding a visual component of making a square with their eyes. They breathe in for four seconds while their eyes scan left to right. They hold their breath for four seconds while their eyes scan up to down. They breathe out for four seconds while their eyes scan right to left. And they hold their breath for four seconds while their eyes move down to up.

Counselors can also teach clients to do a full body scan to regulate themselves, Blough and Camacho suggest. This technique involves feeling for tension throughout the body while visualizing moving from the head down to the feet. If the person notices tension in any area, then they stop and slowly release it.

Camacho once had a client lean forward and grab the armrest of the chair they were sitting in while talking. She stopped the client and asked, “Do you notice you are gripping the armrest? Why do you think you are doing that?”

The client responded, “I wasn’t aware of it, but I find it comfortable. I feel like I’m grounding myself.”

Camacho, an ACA member who specializes in posttraumatic stress disorder, trauma, and compassion fatigue in professionals who serve others, used this as a teachable moment to show the client how to ground themselves while also having relaxed muscles. She asked the client to release their grip on the chair and instead to lightly run their fingers across it and focus on its texture.

Carr finds dancing to be another useful intervention. “Engaging in dancing and moving communicates to our brains that we are not in danger. [It] allows us to develop and strengthen affect regulation skills as well as have a nonverbal, integrated body-mind experience,” she explains.

Creating emotional boundaries

Setting boundaries can be another challenge for helping professionals. Blough says many of her clients report feeling guilty if they say “no” to a request. They often feel they have to take on one more client or take in one more animal. But she asks them, at whose expense?

Blough reminds clients that saying “no” or setting a boundary just means saying “yes” to another possibility. For example, if a client wants to schedule an appointment on Thursday night at the same time that the therapist’s child has a soccer game, then telling the client “no” just means that the therapist is saying “yes” to their family and to their own mental health.

Blough and McAnally recommend that people create routines to help themselves separate work from home. For example, clients and counselors alike could listen to an audiobook or podcast during their commute home, or they could meditate, take a walk or even take a shower to signify the end of the workday, Blough suggests. “Anything that helps them clear their head and allows them to be fully present for themselves or their families,” she adds.

People can also establish what Carr calls an “off switch” to help them realize that work is over. That action might involve simply shutting the office door, washing one’s hands or doing a stretch. At the end of the workday, Carr likes to put her computer in a different room or in a drawer so that it is out of sight and mind. Then, she takes 10 deep breaths and leaves work in that space.

Exercising self-compassion

“Because a lot of helping professionals are highly driven and dedicated, they tend to have unrealistic expectations and demand a lot from themselves, even to the point of depletion,” Blough says. “Having low levels of self-compassion can lead to compassion fatigue, particularly symptoms associated with depression, anxiety and posttraumatic stress disorder.”

In other words, self-compassion is integral to helping people manage compassion fatigue. “Self-criticism keeps our systems in a state of arousal that prevents our brains from optimal functioning,” Carr notes, “whereas self-compassion allows us to be in a state of loving, connected presence. Therefore, it is considered to be one of the most effective coping mechanisms. It can provide us with the emotional resources we need to care for others, help us maintain an optimal state of mind, and enhance immune function.”

According to Kristin Neff, an expert on self-compassion, caregivers should generate enough compassion for themselves and the person they are helping that they can remain in the presence of suffering without being overwhelmed. In fact, she claims that caregivers often need to focus the bulk of their attention on giving themselves compassion so that they will have enough emotional stability to be there for others.

People in the helping professions can become so focused on caring for others that they forget to give themselves compassion and neglect to engage in their own self-care. Blough often asks clients to tell her about activities that they enjoy — ones that take their mind off work, help them relax and allow them to feel a sense of accomplishment. Then she asks how often they engage in those activities. Clients often tell her, “I used to do it all the time before I became a professional caregiver.”

She reminds them that they can help others only if they are also taking care of themselves. That means they need to take time to engage in activities that relax and recharge them; it isn’t a choice they should feel guilty making.

Self-regulating in session

As helpers, counselors are likely to experience symptoms of compassion fatigue at some point. This is especially true for clinicians who frequently see clients who are dealing with trauma, loss and grief.

For McAnally, that experience came early in her career. During practicum, she had a client with a complex trauma history who couldn’t sleep at night. In turn, McAnally found herself waking up in the middle of the night, worrying about the client. She knew this was a warning sign, so she reached out to her supervisor, who helped her develop a plan to mitigate the risk of compassion fatigue.

It almost goes without saying that counselors should take the advice they give to their own clients: They should establish a self-care routine. They should seek their own counseling and support. They should set boundaries and find ways to recharge outside of work. And they should exercise self-compassion.

But counselors also need to find ways to self-regulate during sessions. “If you are tense and you’re hearing all of these heavy stories, you’re at a much greater risk of being vicariously traumatized,” Blough says. Self-regulation can provide a level of protection from that occurring, she notes.

Blough often uses the body scan technique while she is in session. Doing this, she can quietly relax her body without it drawing the attention of her clients. In addition, as she teaches relaxation skills to her clients, she does the skills with them. For example, she slows her own breathing while teaching clients guided breath work. That way, she is relaxing along with them.

Likewise, McAnally has learned to be self-aware and regulate her nervous system when she is in session. If she notices her heart rate accelerating and her stomach clinching when a client is describing a painful or traumatic event, then she grounds herself. She orients herself by wiggling her toes and noticing what it feels like for her feet to be touching the ground. She also looks around the room to remind her brain that she is safe.

McAnally also uses internal self-talk. She will think, “I’m OK right now.” As with the body scan, this is a subtle action that clinicians can take to ground themselves without the client even being aware that they are doing it.

Helping the helpers during COVID-19

Recently, Carr received a text from a counseling mentor who has been practicing for 40 years that said, “I am falling apart. I am lost. I don’t know what to do, but sending a text to someone I trust felt right. Write or call when you can.”

Carr quickly reached out, and her colleague said he was experiencing a sense of hopelessness that he hadn’t in many years. He worried about his clients and feared he wasn’t doing everything he could for them. He was also anxious about finances; several of his clients had become unemployed because of the COVID-19 pandemic, so he started seeing them pro bono. All of this was taking a toll on him personally and professionally.

Before the pandemic, McAnally managed her compassion fatigue symptoms in part by checking in with other therapists who worked down the hall from her office and by participating in in-person consultation groups. Now that she is working from home full time because of the pandemic, she says that she has to be more intentional about practicing self-care and accessing support. She calls her colleagues to check in, practices mindfulness, and schedules breaks to go outside and play with her dog.

Even when counselors recognize that they need help, they can encounter barriers similar to those their clients face. For instance, they may not be able to find in-network providers, and only a small portion of the hourly rate may be covered by their insurance. This problem made Carr pose some questions: “Who is helping the helpers right now? How can we take care of others if we aren’t able to more easily take care of ourselves?”

Then she decided to take action. She created Counseling for Counselors, a nonprofit organization dedicated to raising awareness about the emotional and psychological impact on mental health providers during a time of collective trauma. The organization’s aim is to generate funding that would allow self-employed licensed mental health professionals in need of treatment to more easily access those services.

“Although the heightened state of anxiety around the pandemic may have exposed this critical need, the demand for quality, affordable mental health care for counselors is ongoing,” Carr says. “Counselors are not immune to trauma and, now more than ever, licensed mental health professionals need access to mental health services in order to effectively treat the populations we serve and to continue to play an instrumental part in contributing to the well-being of society at large.”

Fostering compassion satisfaction

People in the helping professions often feel guilty or ashamed about struggling with compassion fatigue. They sometimes believe they should be immune or should be able to find a way to push through despite their symptoms. But that isn’t the case.

“I think the biggest takeaway when it comes to compassion fatigue is that it’s a normal, almost inevitable consequence of caring for and helping others. It’s not a character flaw or a sign of weakness. It’s not a mental illness. It affects the best and brightest and those who care the most,” Blough says.

For that matter, compassion fatigue isn’t something you “have” or “don’t have,” she adds. Instead, it operates on a spectrum, which is why it is so important for helping professionals to be aware of its warning signs and symptoms.

Blough acknowledges that compassion fatigue is always present in some form for her personally. She often manages it well, so it just simmers in the background. But sometimes it boils over. When that happens, she knows to regulate herself, to increase her self-care and to get support.

It is easy for a negative experience to overshadow a helping professional’s entire day and push aside any positive aspects. That’s why Blough and McAnally both recommend setting aside time daily to list three positive things that happened at work. A counselor or other helping professional could focus on the joy they felt when they witnessed an improvement in their client that day or when they witnessed the “aha!” moment on their client’s face.

Blough often advises clients to journal or otherwise reflect on these positive experiences before they go to bed because it can help prevent rumination and intrusive thoughts that may disrupt sleep. Celebrating these “little victories” will help renew their passion for their job, she adds.

As Blough points out, “Empathy can definitely lead to compassion fatigue, but if properly managed, it can also foster compassion satisfaction, which is the antithesis of compassion fatigue. It’s the joy you get from your work.”

 

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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.

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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.

Revisiting 20/20: A Vision for the Future of Counseling

By Bethany Bray August 28, 2020

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In the world of ophthalmology, having 20/20 vision means that a person can see the letters on an eye chart clearly and sharply while standing 20 feet away. It is estimated that just 35% of adults have 20/20 vision without the help of glasses or other corrective aids.

Fifteen years ago, leaders from a wide range of counseling organizations embarked on an initiative to bring the profession and its future into sharper focus. Those leaders, representing 31 counseling organizations, met regularly between 2005 and 2013 to identify and forge a vision for the direction the profession of counseling should be heading — into the year 2020 and beyond. The initiative, co-sponsored by the American Counseling Association and the American Association of State Counseling Boards (AASCB), was ultimately named 20/20: A Vision for the Future of Counseling.

What organizers initially intended to be a two-year endeavor stretched into eight years. Not surprisingly, the participants weren’t always in agreement, but simply having delegates from 30-plus counseling organizations — representing a broad range of specialty focuses and passions — in the same room was a watershed moment for the profession.

“The adage about herding cats applies here, but these cats were all dedicated professionals passionate about consensus building; seemingly disparate cats whose visions would contribute immeasurably to the establishment of a unified profession,” says Kurt L. Kraus, who facilitated 20/20 in the latter years of the initiative, succeeding Samuel T. Gladding, a past president of ACA.

“Prior to the work of the 20/20 [initiative], I believe that all of our partner organizations had worked tirelessly to establish themselves as free-standing and supporting pillars in a warehouse of counseling and related fields. But the project asked delegates and their organizations to look at the house as a whole,” Kraus says. “It was time in our evolution to answer the question of are we a profession? And the answer was a resounding ‘yes.’”

Steps toward unity

The 20/20 initiative was born out of a conversation focused on the future of the counseling profession that leaders from ACA and AASCB had over breakfast at ACA’s 2005 Conference & Expo in Atlanta. The group, which included the presidents, presidents-elect and presidents-elect-elect of both ACA and AASCB, in addition to David Kaplan, then ACA’s chief professional officer, eventually was established as the oversight committee for the initiative.

Kaplan recalls Gladding and Kraus as “world-class” facilitators who “knew just when to comfort the afflicted and afflict the comfortable.” Kaplan also gives credit to Gladding for coming up with the 20/20 title for the initiative.

The initiative got into full swing at the ACA 2006 Conference & Expo in Montréal. Gladding brought the first full meeting to order with delegates attending from each of the participating organizations. Lynn Linde, who is today ACA’s chief knowledge and learning officer, remembers the energy and buzz that filled the room as delegates took their seats.

“There was a sense of excitement that we were doing something historic — and confusion on how we were going to get there. … It was overwhelming but also exciting. The counseling profession had needed this, [had] talked about this, for a long time,” recalls Linde, who initially served as a 20/20 delegate for ACA’s Southern Region before joining the oversight committee as ACA president-elect and ACA president (2009-2010).

Across years of work and countless hours of discussion, the 20/20 initiative yielded several major accomplishments, the first of which was a document titled Principles for Unifying and Strengthening the Profession.

Created and unanimously approved by the delegates as the project’s first milestone, the principles document identified seven critical areas that needed attention from the counseling profession:

  • Strengthening identity
  • Presenting ourselves as one profession
  • Improving public perception/recognition and advocating for professional issues
  • Creating licensure portability
  • Expanding and promoting the research base of professional counseling
  • Focusing on students and prospective students
  • Promoting client welfare and advocacy

When the delegates took the document back to their respective organizations, just one declined to endorse it: the American School Counselor Association (ASCA).

The creation and ratification of the principles document was historic, Kaplan says, because it marked the first time nearly all of the major stakeholders in the field recognized and acknowledged that they were part of one unified profession: the profession of counseling.

“Counseling organizations have tended to operate as a loose federation, with each tending to their specific focus. The Principles for Unifying and Strengthening the Profession was the first time in history that professional counseling’s membership, training and certification organizations put in writing that they shared a common professional identity and are all part of a single profession,” explains Kaplan, an ACA past president (2002-2003) who retired in 2019 after 15 years on staff at the association. “The Principles for Unifying and Strengthening the Profession acted as a catalyst for the change of status from ACA division to independent organization for both the American School Counselor Association and the American Mental Health Counselors Association (AMHCA). While the ASCA and AMHCA affiliation status change caused disruption … it was a healthy development for both the organizations and the counseling profession, as this was an acknowledgment of an evolution that had been occurring for many years.”

Adds ACA President-Elect S. Kent Butler, who served as a 20/20 delegate for the Association for Multicultural Counseling and Development (AMCD), “It was important to go through [the 20/20 process] so that counselors could unify and find one voice that we all could champion and use to successfully push our profession forward. The takeaway for me is the bonding that occurred, though contentious at times, because we were in this mission together. Across the 31 organizations involved, I was also able to build strong professional relationships with many of the delegates.”

Finding consensus

After participating organizations endorsed the 20/20 principles document, focused effort was put toward addressing two of the critical areas identified in the document: solidifying professional identity and forging a path toward licensure portability, or the ability for counselors to transfer their professional license when moving from one state to another.

One of the primary ways the delegates sought to strengthen professional identity was by developing a unified definition of counseling. The definition was meant to be an “elevator pitch,” something succinct that would easily explain what counselors do to the public and to other helping professionals. Ultimately, the 20/20 delegates reached consensus in 2010 on a one-sentence statement: “Counseling is a professional relationship that empowers diverse individuals, families and groups to accomplish mental health, wellness, education and career goals.”

“It was important that we define counseling and the principles on which it is built and not have outside groups try to define it for us,” Gladding says. “It was also crucial to establish that although counseling is diverse, there is a common core. As Maya Angelou writes in her poem ‘Human Family,’ ‘We are more alike, my friends, than we are unalike.’”

ACA Past President Bradley T. Erford counts creation of a consensus definition of counseling as being among the initiative’s most meaningful achievements. “I am fond of saying that it took 31 counseling professionals 24 months to agree on a 21-word definition of counseling. But we did,” he says. “20/20 was a coming-of-age event in the counseling profession. We needed consensus on some of the most pressing issues of the day, including licensure requirements and professional identity.”

Erford initially served for six years as a 20/20 delegate for the Association for Assessment and Research in Counseling (AARC) before moving onto the oversight committee when he became ACA president-elect and president (2012-2013).

Lack of portability has been a long-standing problem in the counseling profession, in large part because license requirements vary widely. License requirements for counselors were set up state by state over a period of decades — beginning with Virginia in 1976 and ending with California in 2009 — as the profession matured and pushed to establish itself. But in the process, significant disparities arose between counselor licenses across the United States, from the number of supervision hours required to obtain a license to the license titles themselves.

The 20/20 delegates hoped to spark movement toward license portability by developing and gaining support for a single overarching scope of practice for the profession and a single preferred license title. Both ideas emerged out of a subinitiative of 20/20 called the Building Blocks to Portability Project.

“We wanted to get to the heart of who are we as a profession, our professional identity. We spent hours locked in that room talking about this,” Linde recalls. “Everyone was amazed that we got there, that we trusted the process and were actually able to [reach consensus].”

The 20/20 delegates finalized the consensus licensure title — choosing licensed professional counselor (LPC) — and scope of practice in March 2013. (See the full text of the 20/20 scope of practice, a five-paragraph job description that defines the work of professional counselors, below.) Both items were recommended for use to state licensing boards across the United States in a letter co-written by the leadership of ACA and AASCB and sent in the summer of 2015.

The 20/20 delegates also debated but ultimately weren’t able to reach consensus on a third piece of the Building Blocks to Portability Project: uniform education requirements for licensure. Even so, as a whole, the 20/20 initiative stands as a large-scale success that moved the counseling profession forward and made it much better prepared to meet subsequent challenges.

“Until 20/20: A Vision for the Future of Counseling, we allowed external forces to define what we could do,” Kaplan says. “Apart from the Council for Accreditation of Counseling and Related Educational Programs (CACREP) and the Council on Rehabilitation Education (CORE) training standards, this was the first time in history that the counseling profession told the world what our skill set is. As with the consensus licensure title, having one scope of practice promoted by professional counseling to licensure boards helps solidify counselor identity, leads to licensure portability, reduces confusion among the public, and facilitates needed legislation. [This initiative] was the mark of a profession that had reached maturity. Until 20/20, the counseling profession had focused on being reactive and responding to how others defined us — particularly psychology. … [The 20/20 initiative] was the first time in history that all of the two-dozen-plus stakeholders within counseling worked together for a sustained period of time to develop a road map for the advancement of our profession.”

A lasting legacy

In January 2019, ACA signed a contract with the Council of State Governments’ National Center for Interstate Compacts, embarking on a multiyear project to develop an interstate compact focused on counselor licensure portability. The project is still in the early stages, but its ultimate goal is to create a compact that states could adopt to accept the credentials of professional counselors who are licensed in another state. Individual state licensing boards would be allowed to impose additional requirements such as a jurisprudence exam or an FBI background check, but the compact could keep counselors from having to apply for a new license — in some cases, starting over virtually from scratch — when they move across state lines.

Getting this project off the ground has been made easier by the foundation built by the 20/20 initiative, says Linde, who serves as ACA’s staff liaison to the interstate compact for portability project. She notes that the cohort is using LPC, the 20/20 consensus licensure title, in its work.

“The 20/20 project made it much easier for the compact project to come to an agreement on who we are and what we do. We didn’t have to rehash years of work. It made it easier to get started and look at other issues around portability,” Linde says.

Kaplan agrees, saying that the 20/20 initiative “provided both background and energy for ACA’s national interstate compact project. Many ACA Governing Council members referenced 20/20 when they approved the substantial amount of money needed to fund this project. If all goes as planned, the interstate compact will go a long way toward solving both our long-standing licensure portability and cybercounseling [telebehavioral health] problems.”

(For more details about the compact project, search for the article “Interstate compact plan provides hope for licensure portability” at ct.counseling.org.)

20/20: In their own words

Counseling Today reached out to some of those who participated in 20/20: A Vision for the Future of Counseling to reflect on the lasting impact of the initiative.

 

Now that the 20/20 initiative is in the rearview mirror, what reflections would you like to share?

“The elegant premise that change begets change is so visible when we look back at where we were to where we now are. … I remember approaching my role as facilitator — not to mention how daunting that role felt following Sam Gladding and being asked by the oversight committee to bring this ‘two-year project’ to conclusion before we actually reached 2020 — as that of an orchestra conductor. The 30-plus people gathered together were each soloists, and my task was to help them coalesce into an ensemble — an apt analogy for the mission of the project actually.

“The delegates had to see themselves as a cohesive group who could practice together only briefly before the individual members would travel back to their home symphonies to play. Home, they then had to present this vision for the future of counseling to their organizations/affiliations in order to garner 90% agreement [the majority needed for consensus approval during 20/20] and adoption. Conducting was an honor for me.” — Kurt L. Kraus, LPC, 20/20 facilitator and professor and director of the doctoral program in the Department of Counseling at Shippensburg University of Pennsylvania

“I’d like to emphasize that everybody — all 31 organizations — had the ability to be heard, and every voice carried weight. No one voice was more important than somebody else’s.

“Sometimes I see the [20/20] definition of counseling on someone’s email signature, and it makes me feel that we really did make an impact. It’s in textbooks, and we have a whole group of counselors out there who were trained using this definition. I have had those elevator speeches with people. It’s nice to have some prepackaged words to be able to answer the question, ‘What do you do?’” — Lynn Linde, past president of ACA and current chief knowledge and learning officer

 

Why was it important to go through the process of 20/20?

“In some instances, our profession was being left out of important legislative initiatives, insurance reimbursements and recognition of the efficacy of counseling due to our fragmentation as a profession. Bringing together all the players [the 31 participating organizations] allowed us to begin to speak with one voice to the public and government. More than this, it allowed us to break down fences between us and make the connections necessary to value each other’s contributions to the profession.” — Perry C. Francis, LPC, 20/20 delegate for the American College Counseling Association and professor and counseling training clinic coordinator at Eastern Michigan University

 

Now that we’re in the year 2020, do you feel the project hit the mark?

“Yes and no. Yes: We are seeing the fruits of our labor begin to take root as licensure laws are rewritten, cooperation between organizations increases, and the counseling profession is expanding into previously denied territory. CACREP and CORE eventually merged in part due to the 20/20 process.

“No: What I hoped would be quicker progress and greater unity has not come to fruition. For example, we are still fighting for reimbursement with Medicare, and the process of getting counselors hired into the U.S. Department of Veterans Affairs systems is painfully slow. By the time we got to the end of the 20/20 process, many of the leaders moved on to other issues, and the momentum lessened.” — Perry C. Francis

“We completed the tasks that were possible to complete at the time. I was proud of our decision to end the project when we did because the work truly didn’t end then. Like a therapeutic goal that can’t fully be assessed as met, or unmet, from in the office, we had to let go, be patient and watch to see how the vision of the profession of counseling would be operationalized, to fully emerge in real time. In 2020, I have smiled every time I read some reference to the work done by everyone involved in the project. It was a cast of hundreds.

“The results are visible, the references to our work are plentiful, and the process resulted in a host of next steps. Inherent in the evolution of a profession is change — the work left undone arises from the work accomplished. As our profession is rooted in humanity and all of its complexities, it is probably safe to say our work will always be undone.”
— Kurt L. Kraus

 

What do you feel was accomplished by the 20/20: A Vision for the Future of Counseling initiative?

“We have had several positive things happen during the last few years. First and foremost, all 50 states now have [counselor] licensure, the last one being California. Another advancement was the communication between states. There were times when states did not communicate with each other. Some states were more exclusive rather than inclusive. Now, there seems to be more acceptance between states.

“Another accomplishment is the uniformity of state requirements. More states are complying with the stricter requirements, such as requiring 60 hours in a degree program. … As one person put it, [prior to 20/20,] going from state to state was more like going from one country to another.” — Charles Gagnon, an LPC and supervisor, member of the 20/20 Oversight Committee and AASCB past president

“The project brought counseling groups together in a way that was nonpolitical and altruistic. We were all working for the good of the profession in what it could be. There were some disagreements, but there was [also] a lot of harmony, and when delegates were not together on a point, they worked constructively to reach consensus. I have never been in a better group in my life. It was a lot of hard work, but it was worth it.

“I wish we could have accomplished more, but given that we met in person only once a year, we did well, and the profession of counseling is better and stronger, I believe, for 20/20.

“20/20 was a proactive project. Too often, counseling has been reactive. 20/20 changed the mindset and made efficacy even more important professionally. I think the spillover from 20/20 continues.” — Samuel T. Gladding, 20/20 facilitator, ACA past president and a professor of counseling at Wake Forest University

“The project has yielded many things. For one, the consensus definition for counseling, which has helped in our quest to unify our profession. I believe that the project was also a slowly evolving start to conversations surrounding inclusion. This may have been undergirded in our conversations about unifying the profession.

“While it is many years later, [it is] funny how in 2020 we are able to engage in conversations that actually matter as they relate to unity. I stated in the past that there was quite possibly a breakthrough in which it seemed we ‘gave ourselves permission to engage in enriching conversations that will further unify our counseling community.’ I was able to chair a task force a couple of years back that provided a template for engaging in difficult dialogues. Amazingly, the current pandemic has forced our hand, and we are courageously engaging in that process now.

“Lastly, while we are not where we want to be in the battle for portability, we are strategically making progress in bringing this concept to fruition with our pursuance of an interstate compact. The vision gave us flexibility perhaps to find alternative ways to support counselors seeking to move or start a practice in another state.” — S. Kent Butler, ACA president-elect, 20/20 delegate for AMCD, and interim chief equity, inclusion and diversity officer and a professor of counselor education at the University of Central Florida

 

What work is left undone?

“The only thing on which 90% consensus was not reached [during 20/20] was educational requirements because CACREP and CORE had not yet merged. If we had extended the task force two more years, I believe adoption of the CACREP standards would have passed by consensus.

“There are many additional counseling issues that have been percolating under the surface for a number of years that a new multiorganizational task force should tackle. And many of these issues are international in scope. I suggested creation of a multinational task group [while I was ACA president] to address international counseling issues and priorities, [but it] never got prioritized.” — Bradley T. Erford, ACA past president, 20/20 delegate for AARC and member of the 20/20 Oversight Committee; director and professor in the counseling program at Peabody College at Vanderbilt University

“The profession of counseling is always changing, and so there is more to be done. Certainly, getting counselors to be considered core mental health providers and reimbursed by the military, the government and insurance companies is a next and continuous major step.” — Samuel T. Gladding

 

What’s next? Do you think the counseling profession should begin some kind of new strategic planning project to continue this work?

“One idea that has been tossed around for future strategic planning is in the area of focusing on prospective students [one of the seven points in the Principles for Unifying and Strengthening the Profession]: developing an undergraduate major in counseling. Unlike other helping professions such as psychology and social work, professional counseling does not have any feeder programs. As a result, our students find us by happenstance. Many undergraduates who would thoroughly enjoy a career in professional counseling and would greatly benefit the clients they serve never hear about our programs. Exactly what an undergraduate major in counseling looks like and how it is implemented is for a future planning process that focuses on the counseling profession in 2030 and beyond.” — David Kaplan, 20/20 administrative coordinator and retired ACA chief professional officer

“I believe the profession needs to really embrace the momentum that has begun around dismantling systemic racism. To be true to our code of ethics, we must consciously and consistently make sure that professional counselors do no harm. A very important addition to our next go-around at strategic planning needs to be deliberate attempts to make our profession more inclusive, especially within every level of leadership across every ACA entity.

“Each of us is accountable and should be beacons for our students and colleagues, ensuring that they are adequately trained and/or held accountable for the work that they do with their clients. … We also must be accountable to society and work to break down barriers that prevent equity for all.” — S. Kent Butler

Thirty-one counseling organizations participated in the 20/20 initiative. This photo, courtesy of Samuel T. Gladding (kneeling at center), shows some of the delegates and other stakeholders who took part in the first full meeting in 2006 in Montréal during the ACA Conference.

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Find out more

Additional details about the 20/20 initiative, its participants and accomplishments are available on the ACA website at tinyurl.com/2020InitiativeACA.

In addition, the project generated three Journal of Counseling & Development articles:

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20/20 Scope of Practice for Professional Counseling

The independent practice of counseling encompasses the provision of professional counseling services to individuals, groups, families, couples and organizations through the application of accepted and established mental health counseling principles, methods, procedures and ethics.

Counseling promotes mental health wellness, which includes the achievement of social, career and emotional development across the life span, as well as preventing and treating mental disorders and providing crisis intervention.

Counseling includes, but is not limited to, psychotherapy, diagnosis, evaluation; administration of assessments, tests and appraisals; referral; and the establishment of counseling plans for the treatment of individuals, couples, groups and families with emotional, mental, addiction and physical disorders.

Counseling encompasses consultation and program evaluation, program administration within and to schools and organizations, and training and supervision of interns, trainees and pre-licensed professional counselors through accepted and established principles, methods, procedures and ethics of counselor supervision.

The practice of counseling does not include functions or practices that are not within the professional’s training or education.

 

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Remembering J. Barry Mascari

Any mention of the 20/20 initiative would be remiss without acknowledging the important contributions of J. Barry Mascari, who passed away in May at age 71. Mascari was a part of the initiative from its start in 2005, participating in initial discussions and planning sessions as AASCB president-elect-elect. He remained closely involved throughout the entirety of the 20/20 initiative.

“Barry will always be known as the father of 20/20: A Vision for the Future of Counseling,” says David Kaplan, ACA staff administrative coordinator for 20/20. “It was his brainchild, and he willed it into existence. Barry is greatly missed, but his legacy in catalyzing the growth of the counseling profession continues on.”

At the time of Mascari’s passing, ACA CEO Richard Yep acknowledged how instrumental he had been to the 20/20 project, as well as to numerous other advances in the profession, including co-authoring the counselor licensure law in New Jersey.

“His [Mascari’s] tireless work to advance licensure portability, mentor his students, and advocate on behalf of the profession was in part what led to his 2019 selection as an ACA Fellow,” Yep said.

Mascari, a licensed professional counselor and counselor educator at Kean University in Union, New Jersey, was co-author with his wife, Jane M. Webber, of the book Disaster Mental Health Counseling: A Guide to Preparing and Responding, published by the ACA Foundation.

Read more about Mascari’s life and legacy at counseling.org/aca-community/in-memoriam

 

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

Climate in crisis: Counselors needed

By Laurie Meyers August 25, 2020

5 Comments

On a warming planet, some of the most rapid increases in temperature are being experienced in the Circumpolar North — the area within and, in some cases, just below the Arctic Circle. Overall, the average global temperature has increased by 1 degree Celsius (1.8 degrees Fahrenheit) since 1880.  Two-thirds of that rise has occurred since 1975.

Since the 1990s, warming in the Arctic, in particular, has been accelerating. Researchers say the region is warming two to three times more quickly than the rest of the planet. In some areas such as Canada’s Labrador coast, the annual average temperature has increased as much as 3 degrees Celsius (5.4 degrees Fahrenheit), causing drastic changes in the weather, terrain and wildlife.

This coastal region is home to the Labrador Inuit people, who live in Nunatsiavut, a self-governing Indigenous territory with five communities — Nain, Hopedale, Postville, Makkovik and Rigolet — accessible only by airplane. The communities are not connected by roads. Instead, navigation is via paths over increasingly unstable ice, which is now prone to sudden thaws and pitted with holes. Unpredictable seasons and severe storms have also made it more difficult for the Inuit to get out on the land that has sustained them physically and spiritually for generations. Like other Indigenous peoples, the Labrador Inuit have faced displacement and forced assimilation. Traditional activities such as fishing, trapping, hunting and foraging are not just for subsistence; they are essential practices that undergird the Inuits’ culture and identity. Climate change has disrupted all of this, not only through changes in the ice, but through changes in the wildlife and plants.

But it goes even beyond that. Climate change is affecting the mental health of this region’s residents.

In 2012, the leaders of the communities of Nunatsiavut asked Inuit and non-Inuit researchers to conduct a regional study of the effects of climate change on mental health. More than 100 residents were interviewed as part of a multiyear study. The resulting report shed light on the strong emotions and reactions of the interviewees, who expressed fear, sadness, anger, anxiety, distress, depression, grief and a profound sense of loss.

One of the interviewees attempted to convey what the land represents to the Inuit: “For us, going out on the land is a form of spirituality, and if you can’t get there, then you almost feel like your spirit is dying.”

A community leader expressed an existential fear: “Inuit are people of the sea ice. If there is no more sea ice, how can we be people of the sea ice?”

Ashlee Cunsolo, a public health and environmental expert who was one of the lead non-Inuit researchers, believes that grief — ecological grief, as she and other researchers have dubbed it — is inextricably linked with climate change. She defines it as “the grief felt in relation to experienced or anticipated ecological losses, including the loss of species, ecosystems and meaningful landscapes due to acute or chronic environmental change.”

A clear and present concern

The story of the Labrador Inuit is undeniably heart-rending. Even so, most people probably feel that scenario is pretty far removed from their own lives and losses. After all, as global citizens of the 21st century, our lives are increasingly virtual, and even if we enjoy the great outdoors, the idea of everything we are being bound to a particular land or place may seem alien.

Think about it a little more though. Whether our settings are urban, suburban or rural, most of us have geographic preferences, be they coastal, mountain, bayou, prairie, desert, forest or canyon. It might be where you live now or where you grew up, but it calls to you. And it has changed. That pond where you spent your childhood winters ice-skating no longer freezes hard enough to handle your gliding blades. Your favorite beach keeps losing feet of sand to the ocean. Ski season is now short on both time and fresh powder. Fire is prohibited at your favorite campsite. The city where you live has endured a summer string of 90-plus-degree days, leaving you longing for fall, but that season of cool, crisp air is increasingly elusive. The heat lasts well into September and October, as trees in your neighborhood stubbornly stay green — until they turn brown.

Austrian environmental philosopher Glenn Albrecht calls that feeling — a sense of missing a place that you never left because it has been altered by climate change — solastalgia.

“I think place can be really underestimated, but place attachment is such a part of who we are,” says Debbie Sturm, an American Counseling Association member who serves on the organization’s Climate Change Task Force. “If there’s harm in a place or threat to a place or loss of place, it is a significant loss.”

As an example, the diaspora caused by Hurricane Katrina in 2005 was extremely traumatic, says ACA member Lennis Echterling, a disaster, trauma and resilience expert who provided mental health support in New Orleans in the wake of the storm. In some cases, people desperately fleeing the floodwaters and destruction were barely aware of where they were headed. Many of those who evacuated have never returned.

“There is still a population who have been separated from their homes — their sacred ground,” says Echterling, a professor at James Madison University in Harrisonburg, Virginia. Although that phrase, sacred ground, is most often associated with tribal populations, Echterling believes it is true for all of us — that we all have an intrinsic attachment to place. And climate change will continue to separate people from their homes, he says, citing researchers who forecast that by the year 2050, an estimated 1 billion people worldwide will be climate refugees.

Even those who haven’t been displaced or experienced climate catastrophe may find it hard to avoid a creeping sense of existential dread — or ecoanxiety — as they witness or hear about extreme weather event after extreme weather event. On June 20, the temperature in the Siberian town of Verkhoyansk reached 100 degrees Fahrenheit, the hottest temperature ever recorded north of the Arctic Circle. Researchers say such an occurrence would be almost impossible (a once-in-80,000-years happening) without climate change caused by human activity. In recent years, wildfires have reduced entire California communities to ash, with citizens up and down the coast donning masks to protect themselves from a lingering pall of smoke. In 2018, Hurricane Florence turned Interstate 40 in North Carolina into a river. Hurricane Harvey struck Houston repeatedly over six days in 2017, leaving one-third of the city underwater at its peak. Approximately 40,000 Houston residents had settled in the city permanently after evacuating from Katrina more than a decade earlier.

Every year, the signs of a climate crisis grow more alarming, and the psychic toll can be traumatic. Psychiatrist Lise Van Susteren, an expert on the mental health effects of climate change, coined the phrase “pretraumatic stress disorder” to describe the fear that many individuals are experiencing about disasters yet to come.

Since 2008, the Yale Program on Climate Change Communication and the Center for Climate Change Communication at George Mason University have been conducting national surveys biannually to track public understanding of climate change. The latest survey results, from November 2019, indicated that 2 in 3 Americans were at least “somewhat worried” about global warming, whereas 3 in 10 were “very worried” about it. A majority of those surveyed were worried about the potential for harm from extreme events in their local areas. 

The mental health effects related to climate change extend beyond disasters such as hurricanes and wildfires. Research has indicated a link between rising temperatures and the increased use of emergency mental health services, not just in places that regularly experience hot weather, but in relatively cool areas as well. Higher temperatures have also been tied to increased levels of suicide.

As the ACA Climate Change Task Force reports in its fact sheet (currently under review), experts predict a sharp rise in mental health issues such as depression and anxiety, posttraumatic stress disorder, substance abuse and suicide, in addition to outbreaks of violence, resulting from coming climate crises. The task force views the counseling profession’s strengths-based approach and focus on resilience as essential to responding to those affected by climate crisis.

However, as part of a study that has not yet gone to press, Sturm, fellow ACA and task force member Ryan Reese, and ACA member Jacqueline Swank surveyed a group of counselors, social workers and psychologists about their personal and professional perceptions of climate change. Although Sturm, Reese and Swank found that these helping professionals were more likely than the average person to believe that climate change is real, very few felt the issue was relevant to their professional lives. Many respondents also said that they didn’t feel confident addressing issues related to climate change in their practice.

Climate change in the counseling office

Reese, a licensed professional counselor practicing in Bend, Oregon, believes that not knowing how to define — and, thus, recognize — climate concerns is part of counselors’ discomfort.

“What is climate change?” he asks. “Is it when you live in California and no longer have a home? … Is it a climate issue when a client is just talking about the general state of affairs and worrying about the world for their kids?”

Of course, there is also the matter of climate change being a polarizing topic, says Reese, an assistant professor of counseling and director of the EcoWellness Lab at Oregon State University-Cascades. When he is talking with clients about broader health and wellness and the topic of climate change comes up, sometimes they will tell him they think it is fake news. “What am I going to do?” Reese asks. “Am I going to impose my view? How do we find ways to introduce our wellness perspective without imposing?”

Reese’s practice is based on ecowellness, a model he co-developed with Jane Myers that revolves around a neurobiological relationship with nature. “The bridge here is, ‘Tell me about your relationship with nature,’” he says.

Reese says he does see a significant amount of ecoanxiety and fear of the unknown, especially among his adolescent clients. But they typically come in talking about depression.

Reese’s intake process includes questions about spirituality and life’s meaning and purpose. He asks clients about their outlook on the future, which is where their anxiety sometimes emerges. Questions about their relationship with nature often reveal the connection between that anxiety and their concerns about the climate.

If clients mention any angst about the environment, Reese asks whether they can unpack that a little more. He’ll follow up by asking questions about how a client spends their time outdoors, what their everyday access is to nature, where and how they feel most effective in nature, and whether they have any hobbies involving nature. He also encourages them to think about what role they can take on: “You mentioned being fearful about what your future is going to hold. What, if anything, can you do right now to address your concern about environmental crisis? … What is within your immediate grasp and control that you can do?”

Reese’s approach involves seeing what the individual’s broader landscape looks like and what their interests, passions and resources are. He urges his clients to get creative and often suggests that his adolescent clients take some kind of action at school, such as starting a recycling program. One of his adult clients took the action step of buying an electric bike and not driving his car as frequently to lessen his impact on the environment.

Reese also helps clients connect their hobbies with environmental action. For instance, if they like skateboarding, he’ll ask them what kind of impact they think that has on the environment. That may lead them to taking the action step of picking up trash around the skate park.

“It’s looking at what is the way we can increase self-efficacy in response to the environment so that it’s not abstract,” he says. “This is something I can engage in and learn and sustain this particular activity for myself and other people.”

Reese also asks clients to educate him about their activities. “For example, mountain biking is huge in Bend, but I don’t know anything about it. … What is the environmental impact? Oh, you don’t know either? Where can we find out?”

Climate change as social justice

ACA’s Climate Change Task Force notes that the resulting trauma from climate change has been and will continue to be experienced disproportionately. Black, Indigenous and people of color (and their communities), children, pregnant women, older adults, immigrants, individuals with limited English proficiency, those with disabilities, and those with preexisting and chronic medical conditions are all more likely to be affected by climate crisis and to have fewer resources to cope with its impact.

In September, the Gulf Coast will mark the 15th anniversary of Hurricane Katrina, one of the most powerful Atlantic storms on record. It wrought widespread devastation and flooding, including the overflow and eventual break of the levee system around New Orleans. As a result, 80 percent of the city was submerged underwater.

New Orleans and Katrina are important to the discussion of climate change as a social justice issue for a number of reasons, says Cirecie West-Olatunji, a past president of ACA who now lives and works in New Orleans. “Katrina was our first uber-disaster related to climate change,” she says. “It informed the world and was a global example of what was to come.”

West-Olatunji provided disaster mental health assistance in the aftermath of Katrina. “I could see the gaps,” she says. “The normal [disaster] response was not going to be sufficient.” Specifically, she recognized that the recovery period would be lengthy, the trauma and mental health challenges extensive, and the reconstruction resources unequally distributed.

Foreshadowing the 2017 tragedy of Hurricane Maria in Puerto Rico, the federal government’s response to Katrina was inadequate. It highlighted an essential barrier to recovery, namely that “whatever disparities exist prior to a disaster will be exacerbated post-disaster,” says West-Olatunji, an associate professor and director of the Center for Traumatic Stress Research at Xavier University of Louisiana.

Racial injustice, economic instability, and government funding for economic development that was distributed to certain communities and not to others were among the factors that magnified the physical and mental damage left behind by Katrina. And those factors continue to hinder recovery today. “Fifteen years later, and New Orleans is still in trauma mode,” West-Olatunji asserts.

There were multiple levee breaches, but only one adjacent neighborhood — the historically Black Lower Ninth Ward — was all but written off from the beginning of the recovery period, West-Olatunji says. Many of the residents owned their homes but faced multiple barriers to rebuilding. One of the most significant factors was discrimination in the distribution of Louisiana’s “Road Home” rebuilding funds. According to the Greater New Orleans Fair Housing Action Center (one of multiple plaintiffs in a lawsuit against the U.S. Department of Housing and Urban Development and the state of Louisiana), the program’s own data showed that Black residents were more likely than White residents to have their grants based on the much lower prestorm market value of their homes rather than on the actual cost of repair. Other displaced residents were unable to return and now cannot afford to pay their homeowners taxes, West-Olatunji says.

In the Lower Ninth, what’s left is an economic and food desert, with virtually no stores beyond a few mom and pops and only one school, she says. Developers have bought up properties, and instead of properly renovating them by gutting and bleaching the houses, in many cases they have simply repainted, leaving renters exposed to toxic mold.

In addition, much of what has been done to “rebuild” New Orleans has rendered it unlivable for those with low and modest incomes, West-Olatunji says. The city bulldozed public housing, and rent has skyrocketed. All of the city’s schools are now charter schools, which essentially makes them private schools that don’t answer to anyone other than their shareholders, she explains. “Kids are bussed all over the place … having to come out —unaccompanied — before daylight to find their way to school.”

New Orleans’ primary industry of tourism afforded a modest living to a significant number of residents for many years, West-Olatunji says. Pre-Katrina, that income could purchase a moderately priced house and even allow families to send children to state schools for higher education. Today, she says, the city is “assailed by outsiders and carpetbaggers who buy up properties. … We went from majority home ownership to rentals and Airbnbs.”

New Orleans is also a much whiter city now. Although most of the White residents who fled the city due to Katrina have returned, approximately 100,000 fewer Black people currently live in New Orleans than did before late August 2005.

West-Olatunji says there is a frequent refrain from the Black citizens who remained or returned: “I survived Katrina only to deal with the coronavirus and with the latest police brutality.”

“The trauma of Katrina was an overlay to existing and continuing stress and racial events,” she says. “It makes it really difficult to recover. … People are emotionally exhausted.”

Climate change should be of great importance to counselor practitioners, West-Olatunji says. “It’s influencing people’s behaviors and their possibility of choices. It narrows choices and creates barriers for living. Our job is to assist people in living abundantly. Climate change isn’t making that easy,” she says.

ACA member Edil Torres Rivera, a professor of Latinx studies and counseling at Wichita State University in Kansas, believes that climate change is still too frequently dismissed as a hoax. “Climate change is something that is real and … has implications for mental health,” he says, “particularly for populations like poor people, Indigenous people and people of color.”

Anyone who doubts that need only visit Rivera’s home island of Puerto Rico, where, three years after Hurricane Maria, people are still trying to recover. He says the urgent nature of the climate crisis is a primary reason that he joined ACA’s Climate Change Task Force.

In line with what happened in New Orleans after Hurricane Katrina, Hurricane Maria drove many people out of Puerto Rico, and those who remained faced multiple challenges, particularly around securing federal relief assistance and dealing with severe infrastructure deficits. Most critically, the island’s electrical grid was decimated, and it took approximately 11 months for power to be restored to everyone who lost it. But even now, Rivera says, it is still common for people to lose power for several hours whenever it rains. And this past January, a major earthquake left most of the island without power again for several days.

The trauma of Maria was compounded by the stress of the earthquake, which has been magnified even further by the coronavirus pandemic. “People are desperate,” Rivera says.

Many children in Puerto Rico are still terrified when it rains heavily and the wind rises, he continues. And since the earthquake, people are often hesitant about sleeping in their houses, so they stay in tents. This scenario will pose a major problem when a hurricane comes, Rivera says.

This past summer in Puerto Rico has been particularly hot, with some days reaching 103 degrees Fahrenheit. Rivera says this is higher than the norm when he was growing up and asserts that it again points to the effects of climate change. Typically, on hot days, people go to the beach to cool off. But the need to physically distance because of the pandemic has largely eliminated that option. Still, there are thos who, given the oppressive heat, would rather take their chances with possibly being exposed to the coronavirus. Another way that people cool off when it is hot is by having a beer, Rivera points out. He says that climate change has had a hand in sending both drinking and domestic violence rates through the roof for several years. The forced proximity of the pandemic is only exacerbating those trends, he adds.

Building resilience

Professional counselors “need to be involved and aware,” West-Olatunji says. “We can’t sit back and say that [climate change] has nothing to do with counseling.”

In fact, the counseling profession uses a holistic, ecosystemic perspective that looks at all the factors that influence behavior, she emphasizes. To take on climate change, counselors must broaden that model and consider structural interventions that target groups of people and focus on prevention. “Our discipline has always thought that prevention was at the core of wellness,” she points out.

West-Olatunji sees a great need for climate change literacy, noting that the people who most need knowledge about the climate crisis — because it is most likely to affect them either directly or indirectly — are also the least likely to have it. Vulnerable communities need to be given more information about how they can mitigate their risk and protect the health and safety of their citizens, she says.

Counselors can assist communities in building climate resilience by using their skills as facilitators to bring people together and help them work effectively as a group, says Mark Stauffer, a member of the ACA Climate Change Task Force. These groups don’t necessarily have to be focused specifically on climate change, he says. They could be formed to advocate for community needs, such as the right to clean water, or something more fun, such as establishing neighborhood gardens.

The essential aspect is to do the group work and to keep bringing people together, he says. “People coming together in times of need — we need to start practicing that now,” emphasizes Stauffer, the immediate past president of the Association for Humanistic Counseling, a division of ACA.

If counselors are personally concerned because their communities are not focused on climate change, Stauffer suggests they host a meeting of people who are interested in the topic. “See what people are thinking and where they want to go,” says Stauffer, a member of the core faculty in Walden University’s mental health counseling program. “It’s a process, but that’s the good part — connecting and building ongoing relationships. … People in the community need to get used to working together. The dialogue is just as important, if not more important, than the work.”

Stauffer thinks that counselors can play a key role in facilitating a new way of being in communities together. He believes that Western society has been living in a kind of empire culture, focused on what can be extracted. The mindset that started with Rome extracting treasures for itself from Europe and then Europe extracting treasures from its colonies has evolved into this sense that survival is about grasping and eking out a living by oneself, he says.

Stauffer says that our collective disaster survivor visual seems to be someone holding an AR-15 rifle in the air, surrounded by their supplies. “That’s not where we find joy,” he says. “Other cultures have found that surviving and being sustainable is something that we can do together.”

We need to find a way to be a part of the Earth in a generative way, Stauffer emphasizes. “The wild is not something to dominate and be afraid of,” he says.

Sturm, an associate professor and the director of counseling programs at James Madison University, urges counselors to get involved by finding out if their communities have climate resilience groups. Counselors who are unsure of where to start can bring themselves up to speed by using the U.S. Climate Resilience Toolkit (toolkit.climate.gov), a comprehensive resource that explores community vulnerabilities and climate resilience efforts.

Mental Health and Our Changing Climate: Impacts, Implications and Guidance, a 2017 report published by the American Psychological Association, Climate for Health and ecoAmerica, suggests several strategies for mental health professionals interested in promoting community well-being and helping to mitigate climate-related mental health distress. Among the strategies recommended:

  • Assess and expand community mental health infrastructure.
  • Reduce disparities, and pay attention to populations of concern.
  • Engage and train community members on how to respond.
  • Ensure distribution of resources, and augment with external supplies.
  • Have clear and frequent climate-mental health communication.

“Find out who is doing this in your area. Our voice has to be at the table to talk about trauma,” stresses Sturm, who is also currently earning her master’s degree in environmental advocacy. “Counselors think this is important, but they’re not doing it. … We’re not reaching out in our communities as a profession to be part of the discussion.”

 

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ACA members: ACA’s free CE of the month for September is a video session titled “Climate Change and Mental Health: The Role of the Counselor.” See more here: https://imis.counseling.org/store/catalog.aspx#

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Additional resources

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

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • Coping Skills for a Stressful World: A Workbook for Counselors and Clients by Michelle Muratori and Robert Haynes 
  • Disaster Mental Health Counseling: A Guide to Preparing and Responding, Fourth Edition, edited by Jane M. Webber and J. Barry Mascari
  • Introduction to Crisis and Trauma Counseling, edited by Thelma Duffey and Shane Haberstroh

Continuing Professional Development: Multicultural Products (https://imis.counseling.org/store/catalog.aspx#category=multiculturalism-diversity)

  • “Counseling Refugees: Addressing Trauma, Stress and Resilience” with Rachael D. Goodman
  • “Addressing Clients’ Experiences of Racism: A Model for Clinical Practice” with Scott Schaefle and Krista M. Malott

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

  • Trauma and disaster
  • Family separation
  • Grief and loss

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Laurie Meyers is a senior writer for 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.

Utilizing evidence-based practices in telehealth

By Krystal Vaughn, Kellie Giorgio Camelford and George W. Hebert August 23, 2020

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The field of mental health is undergoing unprecedented challenges during the COVID-19 pandemic. Professional counselors who worked with children and adolescents before the pandemic have found that some traditional in-person techniques are not appropriate via virtual platforms.

These circumstances are requiring counselors to consider the selection of treatment approaches and interventions that are adaptable to or created for the provision of telemental health. Today, counselors must determine how to select and implement evidence-based practices (EBPs) when working with child and adolescent clients via telemental health during times of crisis.

History of EBPs

In 1996, David L. Sackett and colleagues stated that evidence-based medicine was “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Additionally, Leslie Greenberg and Frederick Newman recognized in 1996 that there were different types of study designs that lead to the evidence base, each suited to answer specific types of research questions. For example, according to a 2005 American Psychological Association task force, one may use any of the following to build evidence: clinical observation, qualitative, systematic case studies, single case design, ethnographic, process-outcome, random control trails or meta-analysis.

EBPs and the terminology associated with them have gained popularity over the past few decades in all health care fields. However, their exact origins are mixed. Parts of the nursing profession, for example, posit that EBP originated with Florence Nightingale, whereas the mental health field argues that Lightner Witmer used a similar approach with his creation of the first psychological clinic in 1896.

Regardless, the concept of EBP marked a paradigm shift among health care professionals to consider data-based research rather than relying on the opinions of authorities to guide clinical practice.

Evidence levels

The rigor, or degree, of scientific evidence is often presented in the form of an evidence pyramid analogous to Benjamin Bloom’s taxonomy of educational objectives.

This evidence pyramid traditionally moves from expert opinions at the base to case series/case reports to case control studies to randomized control trials to systematic reviews and, finally, to meta-analyses at the pinnacle.

 

Expert opinions

These sources of evidence range in forms from editorials to book chapters. They are good resources for an early understanding of clinical areas because they discuss definition, assessments and treatments. However, these sources lack statistical inferences to reach scientific conclusions.

An expert opinion might come in the form of a textbook chapter in which a person who is generally very knowledgeable in the field opines on the subject matter without referencing a specific compilations of facts. While expert opinions can be very informative and insightful, they should be regarded only as a minimal form of scientific evidence. Few of these expert opinions speak to our current predominant practice of telemental health.

Case series/case reports

These are descriptive studies that may be from a single clinical case or from a series of clients with similar presentations. While traditionally missing inferential statistics, single-case experimental designs will often be implemented. However, control groups or conditions are clearly lacking. Despite these limitations, case series/case reports are often heralded for illuminating novel concerns that generate additional research.

Classic examples of case studies in the mental health field seemed to begin with Anna O., who received psychoanalysis for what was termed “hysteria.” Sigmund Freud wrote about her case and how the “talking cure” led her symptoms to fade. Biopsychologists often cite the case of Phineas Gage, who demonstrated personality changes after a large iron rod was driven through his head in a railroad accident. Then there is the behaviorist report on Little Albert (by John Watson), in which fear was actually instilled into a baby through conditioning.

Case control studies

Case control studies are generally retrospective in nature and investigate the risk of exposure to an event with an eventual negative outcome — usually a disease or disorder. Comparison or control groups are then utilized with people who did not have the initial experience or the disease/disorder. However, these studies are able to declare only relationships, not cause-and-effect relationships. Despite this limitation, evidence for a cause and an effect begin with a correlation.

A typical case control study in the field of mental health might investigate the relationship between physical activity and depressive traits. To that end, the investigators would harvest information from a previously administered questionnaire to patients receiving services at a mental health facility. Additionally, these investigators would use a matched control group of participants without mental health concerns who also completed the questionnaire. Although a control group or comparison group is part of the study, it lacks the characteristic that makes it a true experiment: randomization.

Randomized controlled trials 

It has often been stated that randomization is what brings an investigation from quasi-experimental to truly experimental. Randomized controlled trials assign patients with similar presentations to either the treatment group or the control group based on chance alone. This allows for other mitigating factors to balance themselves between the groups and for the “treatment” itself to cause the scale to tilt. This strategy allows a treatment to be compared with no treatment, an alternative treatment or a waitlist controlled treatment.

A typical randomized controlled trial investigation for a new treatment for depression would involve randomly assigning half of the participants to the new treatment, while the remaining half would be assigned to an existing treatment. Then pretests and post-tests for each group would be compared to evaluate the efficacy of the new protocol.

Although regarded as the gold standard for clinical research trials, randomly assigning patients to treatments may not reflect the best ethical practice without consideration of other mitigating factors.

Systematic reviews 

Systematic reviews evaluate and synthesize the results of similar studies to reach a higher-order conclusion than could be achieved by any one study by itself. Usually, the authors will select a priori factors or themes for which the studies are to be rated. Then, all of the factors or themes are considered and tabulated to reach this conclusion.

Frequently, systematic reviews will limit themselves to only studies that used randomized controlled trials. This way, the results from the group of similar randomized controlled trials can be integrated for a truly convergent conclusion.

In building upon our previous examples of possible depression studies, a systematic review might be used to identify the best treatment protocol for adolescent depression that involves psychopharmacology, individual therapy or both. Additionally, the investigators might restrict the investigation to include only those studies that utilized random assignment. Then, rubrics might be created to gauge the treatments along themes such as symptom reduction, satisfaction of the approach and time commitments. Generally missing from typical systematic reviews is an objective measure that uniformly assesses the results from the different studies. 

Meta-analyses

Meta-analyses are often referenced as a type of systematic review meriting the gold standard of clinical knowledge. Meta-analyses, like all systematic reviews, evaluate similar studies along factors or themes that are selected a priori. However, these forms of evidence utilize a statistical procedure — effect size — to reduce sources of bias in the conclusions. This is the objective uniform measure that is lacking in systematic reviews.

Basically, effect sizes report the magnitude of progress from a treatment. It has often been stated that effect size actually indicates the importance of the results rather than the likelihood that the results are not due to chance, as is the case with statistical significance.

Increasing the rigor from our previous example of a systematic review to that of a meta-analysis would therefore involve utilizing effect sizes. Rather than building upon the a priori themes for comparison, this meta-analysis would compute the effect sizes from measures reported in each study. Then, from the selected studies, average effect sizes would be computed for each treatment protocol so that meaningful comparisons could be made and so that each protocol could be graded on its efficacy.

Beyond the evidence

While the concept of EBP originally relied on the practitioner to consider only data-based research rather than the opinions of authorities to guide clinical practice, the field of medicine built upon this to include other parameters. Specifically, this newer definition defines EBP as the integration of the best research evidence with clinical expertise and patient values. The expansion of this definition clearly illuminates the additional paradigm shifts that account for cultural sensitivity and patient involvement for treatment decisions, while acknowledging that there are advantages and disadvantages.

Advantages

EBP has advantages and disadvantages. The 2005 American Psychological Association Presidential Task Force on Evidenced Based Practice described EBP as the integration of science and practice. It acknowledged that much research is needed to determine that a treatment is effective. However, the research demonstrating a treatment protocol effective then needs to become a practice offered by clinicians who are treating patients in the field. So, one must consider both the efficacy and the clinical utility of the treatment.

The APA task force defined efficacy as the way in which we evaluate the protocol and examine how strong the evidence is within that evaluation. The clinical utility of the protocol must then explore if the treatment is generalizable and feasible and the cost benefit of the treatment. The marriage of research and practice leads to better clinical outcomes for clients.

EBPs offer clinicians and their clients information on the efficacy of a treatment. This research can inform the expected time frame and outcomes of a given treatment. It clearly demonstrates what the EBP will treat and the age groups for which evidence is provided. It is then up to the counselor to determine if the EBP is a good fit for the child and family. After all, most children do not present with the exact parameters as the control group in a research study. Nor does the current COVID-19 pandemic offer counselors traditional clinical sittings or historic data mirroring the current situation. 

Disadvantages

Not all individual differences can be accounted for in each EBP. For example, one should consider how development, gender, gender identity, culture, ethnicity, race, age, family context, religious beliefs and sexual orientation play a role in treatment. Clients should also have input into their treatment protocol and be afforded informed consent. This may lead to their desire or preference for one type of treatment over another.

As counselors, it is our duty to inform clients of the costs and benefits of treatment approaches but, ultimately, clients determine whether they will proceed with the EBP. During our current times, clients may agree with a treatment approach but have difficulty with technology or face other barriers that decrease their comfort with telemental health.

One example of considering fit for EBP is with cognitive behavior therapy (CBT). Pamela Hayes discussed the specific challenges between CBT and multicultural therapy. She acknowledged that CBT is evidence based for many disorders and populations, but it may have limitations when applied to some cultures.

Specifically, she named three major limitations:

1) CBT has strong assertiveness themes, overlooking cultures that favor subtle communication.

2) CBT has present focus, neglecting the past.

3) CBT cognitions are focused on individualism, with less regard for environmental interventions.

The last limitation may be especially problematic for individuals with physical disabilities, for whom the disregard of environmental barriers may be great. In response, Hayes recommended culturally responsive CBT modifications.

However, not all EBPs have recommendations on how to modify them to fit certain clients or populations with which the counselor may be working. Therefore, while a treatment may be proved effective for a particular age or disorder, it may be in contradiction to the client’s values. In addition, there may be other barriers to consider, such as technology, privacy or logistics, as is the case currently for many practitioners.

COVID-19 forced many counselors to examine their “practice as usual.” Many sought to gain certification in telemental health so that they could continue offering services to existing clients. This in many ways followed best practices and guidance from the 2014 ACA Code of Ethics, which prohibits abandonment of clients.

At the same time, this also forced clinicians to consider whether their treatment of choice was still possible via telemental health or whether another practice/protocol made more sense. For example, in the field of child and adolescent counseling, many play therapists examined the feasibility of child-centered play therapy (CCPT), which is an EBP, via telemental health. Dee Ray expressed the opinion that CCPT might not be the best treatment for telemental health but acknowledged that a similar theoretically oriented treatment involving the parents — filial therapy — could be amenable to telemental health.

Case study

Jane is a 7-year-old girl who experienced anxiety, reportedly resulting in behavioral outbursts and refusals to comply. Jane was seen by her counselor for approximately six sessions prior to the clinic’s closure due to COVID-19 and a statewide stay-at-home order. Jane’s counselor met state board requirements to provide telemental health services, but she could not conceptualize how to work with Jane using CCPT as she had prior to the stay-at-home order.

Jane’s counselor researched the EBP literature and identified other options for the treatment of childhood anxiety. However, the counselor found herself limited in her training, which restricted her ability to provide EBP services outside of her current scope of practice.

Jane’s counselor discussed the options, including a referral, with Jane’s parents in a scheduled telemental health parent consult. In the consult, the counselor discussed the benefits of filial therapy and the typical populations with which the modality is used in therapy. The counselor also explained that the parents would be more involved in session because filial therapy utilizes parents as change agents.

Jane’s counselor stated that this type of therapy would translate to telemental health in ways that CCPT would not. For example, CCPT relies on the therapist-child relationship to facilitate change. This may be difficult to achieve via telehealth because the therapist is not in the room. Filial therapy, on the other hand, relies more on the parents as change agents and may work well via telemental health because the parents are in the room with the child. In addition, they meet with the therapist via telemental health to learn the techniques to use with their child. Through the weekly telemental health sessions, parents are able to discuss challenges while receiving guidance and supervision, making this method more amenable to telehealth.

EBP databases and clearinghouses

Mental health practitioners can access several EBP databases and clearinghouses online, allowing them to consider different approaches to meet the individual needs of clients and cases. A wide range of techniques and programs is available, and through these clearinghouses, practitioners can make comparisons and learn about the reliability and evidence for the techniques and programs. We will highlight a few examples of databases and clearinghouses that we use within our practice when working with children and adolescents.

The seventh edition of the Collection of Evidence-Based Practices for Children and Adolescents With Mental Health Treatment Needs is an educational tool that specifically highlights available mental health treatments for nonclinicians. The guide breaks down treatments into what works, what seems to work, what does not work, and what has not been adequately tested. It highlights disorders such as adjustment disorder, autism, anxiety, depression and many more.

The Results First Clearinghouse Database is powerful because it combines available EBPs from nine national clearinghouses encompassing the categories of crime and delinquency, child and family well-being, education, employment and job training, mental health, public health, sexual behavior and teen pregnancy, and substance use. The programs can be broken down by category, setting, clearinghouse or rating. The rating scale breaks down programs based on highest rated, second-highest rated, mixed effects, no effects, negative effects and insufficient evidence. The following clearinghouses highlighted in this article are included in the Results First Clearinghouse.

Blueprints provides information on programs to promote healthy youth development and to decrease antisocial behaviors in children and adolescents. The database is geared toward youth, families and their communities, from prevention to intervention programs. The database breaks programs into three categories of research: model plus, model and promising.

The California Evidence-Based Clearinghouse for Child Welfare provides information and resources used by any professional who may work with children and families in the welfare system. The database breaks down treatments based on a scientific rating scale that includes well supported by research evidence, supported by research evidence, promising research evidence, evidence fails to demonstrate effect, concerning practice, and not able to be rated.

Social Programs That Work provides information on social policy programs. The goal is to enable policy officials and other readers to readily distinguish these programs from other available programs that do not have supportive evidence. The guide breaks down programs into top tier, near top tier and suggestive tier. Of particular interest to practitioners, it highlights some early childhood, parenting, substance abuse and suicide prevention programs.

The National Institute of Justice’s CrimeSolutions provides information on criminal justice, juvenile justice, and crime victim services outcomes to inform practitioners and policymakers about what works and what does not. The database breaks down programs and practice outcomes into effective, promising and no effects.

The Substance Abuse and Mental Health Services Administration Evidence-Based Practices Resource Center provides clinicians, community members and policymakers with resources and information on a variety of topics, including mental health services.

The U.S. Department of Health and Human Services Teen Pregnancy Prevention Evidence Review identifies programs with evidence of effectiveness in reducing teen pregnancy, sexually transmitted infections and associated sexual risk behaviors. The database breaks down studies based on a quality rating of high, moderate, low or not applicable.

 

Additional resources

  • For practitioners hoping to learn more about the EBP process, Evidence-Based Behavioral Practice is a useful online training resource.
  • “Evidence-based practice in social work: A contemporary perspective” by James W. Drisko and Melissa D. Grady, Journal of Clinical Social Work
  • “Evidence-based practice in psychology” by the American Psychological Association Presidential Task Force on Evidence-Based Practice, American Psychologist
  • “Clinical expertise in the era of evidence-based medicine and patient choice” by R. Brian Haynes, P.J. Devereaux and Gordon H. Guyatt, BMJ Evidence-Based Medicine
  • Evidence-based practice for the National Association of Social Workers
  • “Evidence-based practice: A common definition matters” by Danielle E. Parrish, Journal of Social Work Education.

 

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Krystal Vaughn is a licensed professional counselor supervisor specializing in children ages 2-12. As an associate professor at Louisiana State University Health Sciences Center-New Orleans, she enjoys both teaching and providing clinical services. Her research interests include autism, supervision, play therapy and parent consultation. Contact her at kvaugh@lsuhsc.edu.

Kellie Giorgio Camelford is a licensed professional counselor supervisor specializing in parenting, women’s issues, children and adolescents. She has received specialized training in the fields of play therapy, school counseling, parenting and perinatal mood disorders. As an assistant professor at Louisiana State University Health Sciences Center-New Orleans, she enjoys teaching and supervising students, as well as providing clinical and community services. Her research interests include ethical issues in counseling and supervision. Prior to teaching, she was a professional school counselor at a local parochial high school in New Orleans, and a private practitioner.

George W. Hebert is a faculty member in both the Department of Clinical Rehabilitation and Counseling and in the Master of Physician Assistant Studies Program at the Louisiana State University Health Sciences Center-New Orleans. He is a licensed psychologist and holds certificates as a school psychologist and supervisor of school psychological services. He specializes in the assessment and treatment of learning and behavior problems for school-age children and their families, and supervises interns and practicum students in the university-based Child and Family Counseling Clinic.

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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.

Primum cura te ipsum: First, heal thyself

By Samuel Kohlenberg August 17, 2020

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During this bizarre and painful epoch beset by pandemic, racial trauma and social injustice, there is a growing emphasis on clinician well-being and self-care, and rightfully so.

Countless articles and blogs have been written about self-care for counselor clinicians, and here is one more. Why write another one? Because as a counselor educator and supervisor, I want to sell you on a goal other than being OK enough to work. Because avoiding burnout is not enough. We need to set the bar higher to competently render care. Make no mistake, this is an ethical issue.

Like many, perhaps, I have always found Latin venerating in a way that underscores the importance of a phrase or idea. Whether carved into cornerstones or encircling university seals, the tradition has gravitas. One idea I find worthy of such reverence, as it pertains to psychotherapy and behavioral health, is that clinicians need to “do their own work.” Therapists need to heal.

Whether it is through traditional talk therapy or other means, therapists need to attend to their own trauma, developmental journeys and growth. While the oft-cited phrase attributed to Hippocrates, “primum non nocere” (first, do no harm), is a vitally important doctrine in mental health, I am suggesting that there is an overlooked and more sequentially vital step in terms of primacy required to avoid doing harm: that therapists confront and deal with their own issues.

Although therapists are often told that they need to take care of themselves and “do their own work,” I do not believe there is enough understanding regarding why this is so crucially important. Yes, it benefits the therapists, it may mitigate burnout, and it may increase professionals’ longevity in the field. But from my perspective, not enough emphasis has been placed on the idea that people who are not OK do not make competent therapists.

This is not to say that people who have endured trauma or have previously met criteria for a behavioral health diagnosis should not pursue jobs as therapists. Far from it. Many of the best therapists I know are as good as they are in large part because of the difficult roads they have had to walk.

There are many ways to describe how therapists doing their own work might affect them professionally, but I am going to focus on three ideas:

1) Your nervous system is an instrument for attachment work and relationship, and it is shaped by how much work you have done.

2) Doing your work helps you project less and become more aware of your projections.

3) Having done the work means being able to genuinely relate to what your patients are going through instead of just understanding. (Note: Although I say “patient,” please feel free to substitute “client.” The reason I prefer patient is that I feel it better emphasizes the connection between the physical and psychological realms, and given the field’s current understanding of the interconnection between the two, I intentionally use language that fits in both lexicons.)

The nervous system

In a typical stress response, a perceived threat can activate the amygdala, leading to the release of epinephrine and coordinating a sympathetic response to the stressor. Typically, this sort of sympathetic activation means that you are no longer using the circuits associated with optimal social engagement (consider, is it harder to tell how other people feel when you are angry?).

The social engagement system is characterized by the feeling of social connection, the ability to read social cues, eye contact, voice modulation and comfort. All of these things shut down when we go into sympathetic activation as part of a stress response.

Imagine a therapist who has yet to “do their own work” sitting in their office listening to their patient describe a traumatic event. Even if an activated therapist gives no obvious facial expression or gesture, how do you think the person sitting across from them will be affected by the therapist’s nervous system switching gears from social engagement to fight-or-flight?

Imagine for a moment a scared child running to a parent or caregiver and being met with warm eyes, a soft smile and a soothing voice. Now imagine the same child being met with scared eyes, decreased facial muscle tone and a flat voice. In which situation is the child going to be more OK?

Similar dynamics play out in therapy. This means that therapists’ ability to stay in their social engagement system affects patients’ likelihood of being OK while doing things such as trauma work. Part of a therapist’s work is using their nervous system to help resource a patient’s nervous system. For some, it will take significant and ongoing work to be able to do this well. 

Awareness

Awareness and projection share a simple relationship: The more aware you are of your projections, the less likely you are to inadvertently allow those projections to affect your relationships with others.

Regardless of theoretical underpinning, modality or clinical philosophy, virtually all types of psychotherapeutic work regard the relationship between therapist and patient as instrumental. Thus, if the therapeutic relationship itself is one of the primary means by which therapists ply their trade, and a lack of awareness can lead to one’s projections interfering with relationships with others, there is an argument to be made that therapists are on ethically dubious ground if they practice without having cultivated enough awareness and done enough work to overcome this potential pitfall.

You are missing your patient if all you can see is your projection. You are not going to realize that it is a projection if you have yet to cultivate enough awareness. 

Relating

There is a difference between understanding what someone is going through and being able to truly relate to it. While psychotherapists are undoubtedly an empathetic bunch, helping someone engage in the process of developmental therapeutic growth beyond where you yourself have grown is no easy task.

Imagine for a moment a 40-year-old in the midst of an existential crisis. Now imagine an empathetic and well-meaning 14-year-old attempting to help that 40-year-old. Unfortunately, a developmental stage is not always as clear as chronological age, and this can lead to blind spots for clinicians that may negatively affect quality of care. Being able to genuinely relate to what your patients are going through is important, and the 14-year-old is going to have a heck of a time helping the 40-year-old.

Keep doing your work

The thing that all of the above ideas boil down to is relationship. It is your job to ensure a helpful clinical relationship, and the relationship itself is the greatest clinical tool that you have. Ensuring that this primary tool is going to be functional, let alone optimal, can require time, effort and a willingness to endure the discomfort necessary for growth.

Of course, more basic day-to-day self-care is still important for fighting burnout and for resourcing one’s self, especially when you are tasked with taking care of others and especially during times in which nobody seems to be OK. The invitation, the challenge, the mandate, is to not stop at “resourced.”

Aim higher. Embrace catalysts for growth and development. Get comfortable with discomfort when it means a potential breakthrough. Do it for you. Do it for them. Do it like it’s your job.

 

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Samuel Kohlenberg is a clinical psychophysiologist, licensed professional counselor and behavioral health educator specializing in the treatment of stress. He is a master of education in the health professions fellow at Johns Hopkins University and a postdoctoral fellow at Saybrook University and works in private practice in Denver. Contact him through his Facebook page or through his website at denverstressclinic.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.