Monthly Archives: March 2021

Pro bono counseling: How to make it work

By Bethany Bray March 24, 2021

The 2014 ACA Code of Ethics encourages counselors to “contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return.”

This is an important tenet of the counseling profession, and one that pulls at counselors’ empathy and call to social justice. However, counseling clients for a reduced fee or for free – pro bono – in a private practice setting comes with some caveats.

John Duggan, senior manager of continuing and professional education at the American Counseling Association, stresses that private practitioners who have any kind of third-party contract, such as agreements to accept clients from an employee assistance program, Medicaid or elsewhere, must take positive steps to avoid risk if they charge anything other than the same rate for service for 100% of their caseload. This is due to several reasons:

  • Charging different rates for services reimbursed by federally funded programs opens the practitioner to risks of fraud accusations or investigations by the U.S. Centers for Medicare & Medicaid Services (CMS). In general, Medicaid and other third-party insurance plans prohibit practitioners from waiving copays.
  • Insurance companies may be unwilling to honor a fee schedule if a practitioner charges different fees for the same contracted service to different clients.
  • Offering remuneration to clients is unethical and potentially illegal (see Standard A.10.b. of the 2014 ACA Code of Ethics). While there are exceptions, waiving copays/fees and underbilling are potential HIPAA violations.

Lastly – and perhaps most importantly – Standard C.5. of the ethics code prohibits discrimination in professional counseling. Offering different fees to different clients could potentially make a counselor’s health care business vulnerable to accusations of discrimination or lawsuits, Duggan says.

The only private practice scenario that would be exempt from the above points is if a counselor does not have any existing third-party contracts and treats 100% self-pay clients, without insurance, he notes.

“It is ethically essential to prioritize our work that’s pro bono,” says Duggan, a licensed professional counselor and licensed clinical professional counselor. “However, the bottom line is that professional counselors who manage a health care business should also operate as ethical businesspeople. Always consider ethical, legal and compliance issues before reducing fees, copays/fees or underbilling.”

Duggan points out that there are many ways a counselor can do pro bono work that do not involve counseling clients on their practice caseload. Volunteer or reduced-fee work in the community – anything from public speaking or leading workshops to mental health response during disaster situations – can be a rewarding way for counselors to give back.

There are also organizations and agencies that facilitate the counseling of clients outside of a clinicians’ existing caseload. Duggan points to the Pro Bono Counseling Project (probonocounseling.org) as an example. The Maryland-based nonprofit pairs clients with limited incomes who are uninsured or underinsured with volunteer practitioners for free mental health care.

When it comes to navigating the nuances of pro bono work, Duggan suggests counselors refer to ACA’s numerous resources, most notably the 2014 ACA Code of Ethics (including standards C.1. and I.1.b.) and The Counselor and the Law: A Guide to Legal and Ethical Practice by Anne Marie “Nancy” Wheeler and Burt Bertram, particularly Chapter 3 (available at counseling.org/store). Practitioners may also want to consult an attorney for guidance.

****

2014 ACA Code of Ethics, Standard C.6.e.

“Counselors make a reasonable effort to provide services to the public for which there is little or no financial return (e.g., speaking to groups, sharing professional information, offering reduced fees).”

  • See the full ACA Code of Ethics at counseling.org/ethics
  • ACA members who have further questions can schedule a practice or ethics consultation with ACA’s counseling specialists by emailing ethics@counseling.org. 

****

Pro bono: Opportunities

  • Remain cognizant of the potential for exploitation of clients, attend to their vulnerabilities, and consider their best interests in all professional decisions.
  • Look for opportunities to serve your local community by providing some pro bono services that capitalize on your unique interests and skills (e.g., speaking, teaching, mentoring, leading support groups, volunteering at a local nonprofit clinic).
  • Remember: Pro bono services are subject to the same rigorous ethical standards as all other counseling services. Practitioners offering clinical mental health services must also remain compliant with state and federal laws.

Source: John Duggan, senior manager of continuing and professional education at the American Counseling Association

  

****

Read more

Counselors who enter private practice often find themselves confronting the push and pull between their desire to provide empathic, client-focused care and the need to turn a profit. Counseling Today will take an in-depth look at this topic in the magazine’s April cover article, “Finding balance in counseling private practice.”

 

****

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

Counseling Connoisseur: Navigating the losses of COVID-19

By Cheryl Fisher March 22, 2021

[NOTE: This is this second piece in a COVID-19 recovery series. See the first installment here.]

Elsa, my 2-year-old poodle, and I enjoy our routine walks in the neighborhood. It has become more frequent since the onset of COVID-19, and we both look forward to the fresh air, change of scenery, and connecting with the neighbors as we pass by (socially distanced, of course). On this day, we approached the home of my new neighbors. They are a young couple, and during our last encounter, they indicated they were pregnant and expecting their first child. They had just pulled up in their driveway and were disembarking the vehicle as we walked toward them. “I’ll get him,” the husband called to his wife as he exited the car. “Oh, they had a boy,” I thought. “How wonderful.” I slowed my pace to see if I could get a peek from across the street where Elsa and I dawdled. He opened the back door to his vehicle and proceeded to unbuckle his son. Imagine my surprise when a toddler jumped out of the car! When did that happen?!

****

I have heard it said that 2020 is the year that wasn’t. As we all stayed safe in our homes, socially distanced from friends and family, an entire year went by — without us. Oh, things happened, but many of us were not able to participate in the regular encounters that add richness to our lives. Weddings, births, celebrations, graduations and even funerals took place in non-traditional and much more private ways. Gatherings consisted of virtual or outdoor activities. Basic shopping was outsourced to delivery services, and additional errands occurred with faces shielded and six feet apart.

To make matters worse, the arrival of 2021 did not magically remove the pandemic or correct the social injustices and political tensions experienced. The losses have been and continue to be great. At the time of this column’s publication, the World Health Organization reports over 116 million confirmed global cases of COVID-19, and over 2.5 million people have died.

Navigating death during a pandemic is beyond challenging, as I experienced when my father-in-law died recently. He had contracted COVID-19, along with other residents in his assisted living community. He had recovered, but never completely. On Friday, Jan. 30, we received a call that his health was failing. My husband and I rushed to the facility where he resided. After testing negative to a rapid COVID test, we donned mask, shield and bodysuit to enter into my father-in-law’s room. Other than visits where we spoke through his window while we stood outdoors, it was the first time we had seen him in several months. He was unresponsive but resting peacefully. My husband asked me to set Pandora to Glen Miller (one of his father’s favorite musicians) and proceeded to tell his father about all that we had experienced since we last saw him. We rambled about the holidays (that we were unable to experience together), the home renovations we were starting and our hope to have family gathered as soon as safely possible.

Because only two people could visit at a time, we had to wrap up our visit when my brother-in-law and his wife arrived. My husband and I stood on either side of my father-in-law, rubbing his arm and holding his hand, and told him we would see him soon. We left knowing it would be our last time with him. He died early the following morning.

The grief associated with this loss is profound. As I discussed in an earlier article, “Counseling Connoisseur: Death and bereavement during COVID-19,” the traditional rituals that help in grief recovery are often altered or absent due to pandemic safety protocols.

In addition to the loved ones we have lost, there have been a plethora of other losses, actual and symbolic. Symbolic loss is often intangible. Sometimes it accompanies death but is not acknowledged as a loss. For example, my father-in-law’s memorial service is delayed until it is safe to gather, thereby preventing the emotional closure that funerals and memorials provide in the grief recovery process.

Other tangible losses include the millions of lost jobs due to the economic impact of the pandemic. The loss of community and social support during isolation and quarantine may be unquantifiable and thus “intangible,” but its effects are significant. Additionally, life happened — without us gathering to record or mark it. The loss caused by our inability to gather for significant events will become more and more evident as we begin (in time) to reconnect with friends and family.

For example, after becoming fully inoculated with the Pfizer vaccine and continuing to follow the Centers for Disease Control safety protocol, I returned to a couple of my favorite group fitness classes (now small, ventilated, physically distanced, and masked). It felt like a homecoming after a yearlong hiatus. The four or five of us in attendance spent the first few minutes of class just catching up. “So, what did you do this past year?” It was uncanny how life had continued for each of us apart. There had been cancer remissions, divorces and retirements, along with weddings and babies born. Except for what I like to term the “COVID cushion” of a few pounds of weight gain for some of us, everyone looked the same. They looked great. I had not realized how much I had missed this community of women I have sweated with side by side for over twenty years!

There have been so many losses this year, and the eager anticipation of a return to some semblance of normalcy is palpable. However, things have changed, and it is important to prepare our clients and ourselves with tools to navigate the losses resulting from the pandemic.

Navigating loss

Prepare for change: Life has continued, and things have changed. An entire year has passed in the lives of our family and friends. While you may have remained in contact, it will be different when it is safe to resume getting together this year. People may have died or moved. New members may have joined the family or friend group. Expect change.

Acknowledge loss: Recognize the changes. Honor the losses. Gatherings may be bittersweet. So much time has passed. So much has been missed. So much economic hardship for so many individuals. Talk about it. Journal. Seek therapeutic support.

You can’t go back, but you can move forward: The truth is that even when it is safe to resume previous activities, it will never be the same. It can’t be. Too much has happened. While we may mourn the past, maybe that is not a bad thing. Perhaps, we can use our experiences and create a better future with what we know now. As C.S Lewis suggested, “You can’t go back and change the beginning, but you can start where you are and change the ending.”

 

The pandemic has brought a lot of loss. While we are more cognizant of the actual losses of death, we must also be aware of the symbolic losses we have experienced. We can acknowledge the sadness of missing out on life experiences, the inability to give comfort in person when family and friends struggle with health or economic distress, or the loss of group celebrations. We can recognize the cumulative grief and fear caused by the pandemic and political injustices. We can prepare ourselves for the shock and mourning that may accompany our re-entry into our post-lockdown lives over the next year, brace for the changes that occurred while we remained sheltered in place, and ready ourselves for life to continue.

 

****

Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online MA in Clinical Counseling.  Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy; and geek therapy. She may be contacted at cyfisherphd@gmail.com.

 

 

****

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

Loving what may sting: In literature and in therapy

By Johanna Bond March 15, 2021

A good book has been a steadfast companion for me throughout my life. At times, literature has provided me with a reason to step back from a busy life and retreat into much-needed introvert space. Other times, it has given me a safe haven, the company of imperfect yet lovable characters, a deep emotional awakening of empathy or a connection to a part of myself that I hadn’t previously recognized.

When clients step foot in my office (or these days, click onto our telehealth sessions), I’m hoping to provide many of the same things that a good book has provided for me. I’m hoping they will feel heard and emotionally connected — to themselves as well as to me, their counselor. As counselors, I think it is important that we consider the parallels between the offerings of strong literature and the interpersonal healing connection of therapy. I say this because literature can be a solid complement to therapy, a tool for self-exploration, and also because of what literature can offer to us as imperfect humans ourselves. As a writer and editor in addition to being a counselor, I hold the connections between therapy and the written word close.

In the 2002 novel The Secret Life of Bees (my favorite novel), Sue Monk Kidd welcomes readers to accept things that could sting through writing that is full of gentle metaphor. She uses elements of the writer’s craft to highlight an “invisible claim” — the statement at the heart of the writing and the takeaway the writer hopes to share with the reader.

The invisible claim in Kidd’s novel echoes the work of therapy in many ways, and especially of Internal Family Systems (IFS) therapy. To further explore the parallels between therapeutic self-exploration and writing, I’ll focus on IFS.

As Richard Schwartz and Martha Sweezy write in their 2020 second edition of Internal Family Systems Therapy, this approach to therapy includes the concepts that everyone has internal parts, that all parts are valuable (although they can become constrained or burdened), and that everyone has at the core a Self with the ability to lead. Acceptance and curiosity are at the heart of IFS as a therapeutic approach. Those same things are at the heart of The Secret Life of Bees. Just as we may use various techniques in therapy to reach curiosity and acceptance, Kidd uses elements of writing to demonstrate loving the things that could sting us.

Diving into the beehive

In Chapter 5, white protagonist Lily and her Black companion Rosaleen find refuge with Black beekeeper August Boatwright and her sisters after running away from a racist-fueled incident and a harsh home. As 14-year-old Lily begins to come to terms with the accident that killed her mother years before and the complicated emotions she feels toward her family and herself, Kidd brings to light (or, perhaps, to dark) the depth of the characters, their interpersonal relationships and the impact of racism. Using the metaphor of beekeeping, Kidd introduces the reader to the invisible claim of loving the things that could sting us. Through this metaphor, in conjunction with Kidd’s use of darkness and place, readers are able to wade into the parallels between the elements of writing and the internal growth of the story’s characters.

In this chapter, Kidd begins to clarify the role of the bees who feature so prominently as a metaphor in the book. At the opening of the novel, and prior to arrival at the beekeeper’s house, Lily experiences bees buzzing in her bedroom. Each chapter opens with a different fact about beehives to set up the events to come. August, the primary beekeeper, shares with Lily the “bee yard etiquette”:

  • She should not be afraid, but “Still, don’t be an idiot; wear long sleeves and long pants.”
  • She should not swat.
  • She should whistle if feeling angry.
  • Above all, “send the bees love. Every little thing wants be loved.”

This is truly the heart of the novel, although readers might not know it yet because they have not fully encountered all the things that can sting. However, by discussing “bee yard etiquette,” August provides the framework to understand Kidd’s invisible claim that is interwoven through the novel: that we can (and should) love the things that may sting us; that even those dangerous things — outside of us, like the bees, or inside of us, like our emotions or our history — deserve love.

Into the darkness

The bees aren’t the only potential danger Kidd encourages readers to love; the dark, too, features prominently. The chapter opens with a statement of fact that if we were able to follow a bee into its hive, the first thing to which we would have to adjust is the darkness. After establishing that bees do their work in the dark, Kidd facilitates important moments for her characters in the dark too. As is clear when she writes of August letting “out a sigh that floated into the darkness,” and later when August and Lily walk back to the house when “darkness had settled in and fireflies sparked around our shoulders,” darkness provides a scaffold for letting go and experiencing gentleness after work time. In the dark, the characters are able to give freedom to their emotions and acknowledge their secrets.

At the end of the chapter, Lily walks by starlight to the wailing wall where she can acknowledge her feelings toward her mother and hopes to let them go. She says, “I … studied the darkness, trying to see through it to some sliver of light.” Although it’s not yet clear to Lily, Kidd is making it clear to readers that real sight will occur in the dark, not in searching for the light. In creating this awareness and sharing the character’s secrets, Kidd allows readers to feel that they are themselves akin to the darkness. Similarly, in therapy, we sit in our clients’ darkness with them and create the emotional space for them to develop insight.

Along with the literal darkness of night, Kidd uses the darkness of racism as an element of the story and an element of personal growth for Lily. It is noteworthy that Kidd addresses racism directly in the story while simultaneously writing about darkness (as mentioned above) in a way that does not vilify it. So much literature equates darkness with malevolence, grouping in gradients of skin color in the process. Kidd defies this norm by wading into the darkness of night openly and also through the growth of the protagonist’s racial awareness.

In this chapter, Lily overhears August discussing with her sister June the lack of acceptance others might have for Lily and Rosaleen, pointing out, “Who’s gonna take them in if we don’t — a white girl and a Negro woman? Nobody around here.”

Each character, including Lily, is aware of the impact of race. She becomes even more aware of it as she is surrounded by Black women and men in her new surroundings. She becomes aware of the racism around them, between them and within them.

Lily overhears June naming Lily’s whiteness to August and states to the reader, “This was a great revelation — not that I was white but that it seemed like June might not want me here because of my skin color.”

She later states, “Mostly I felt resentment at June’s attitude. … There was no difference between my piss and June’s,” and later still comes to share that “I felt white and self-conscious sitting there, especially with June in the room. Self-conscious and ashamed.”

Lily is aware of the human similarities between herself and June, as well as the differences and her own privilege as a white person. By exploring racism — with all its metaphorical stingers — Lily is able to better understand herself and fully engage in relationship with those around her, including June. In the course of a few pages, Kidd unpacks immense growth and personal exploration of Lily’s understanding of race, leading readers to understand racism as another aspect of the invisible claim.

In the midst of unpacking racism, Kidd uses interpersonal (and intrapersonal) relationships to deepen the invisible claim of loving what might sting. The Boatwright sisters demonstrate their love for one another even if they don’t always like one another, and August shows unwavering love through her welcome of Lily. In return, Lily acknowledges that “I wanted to make her love me so she would keep me forever.”

Initially, Lily does not accept herself in an attempt to be loved by August; however, she later uses August’s acceptance as a model to accept herself. This is first shown through Lily’s acknowledgement of her anger and grief toward her mother at the end of the chapter, when Lily visits May’s wailing wall. She states, “Placing my hands on the stones, all I wanted was not to ache so much.” But instead of pushing off her feelings, she places a paper with her mother’s name into a cranny in the wall. Lily is beginning to accept the difficult emotions and the pain that goes with them, just as August and the other sisters work to accept and love one another despite the potential for pain.

Similarly, in IFS therapy, clients get to know their internal parts, including the parts that have the potential to sting. As counselors, we are able to model acceptance and curiosity, two things that clients may begin to develop themselves toward their internal parts. And as healers, we are constantly doing our own work to accept our internal parts and emotions.

Each detail of Kidd’s writing reflects the invisible claim, including the places featured within the chapter. Two of the main locations of the chapter represent acceptance for an emotion or activity. First, the reader learns of May’s wailing wall, where May (and later Lily) write out their troubles on pieces of paper and tuck them into crevices between the rocks. The wall is created for May to have an outlet for grief and becomes a symbol for grief and sadness; the characters are able to accept these difficult emotions by connecting with the wailing wall. The second place is at the beehives, where Lily and August face the danger of bee stings and the anger that can cause them.

Each of these places has a difficult emotion or activity associated with it, but each also holds the potential for growth by engaging with the place. The wailing wall allows for an acceptance and letting go of grief, whereas the beehives allow for tolerance of anger and room for love at the same time.

Kidd engages with the typically danger-ridden metaphors of bees and darkness (literal darkness, as well as the darkness of racism and internal difficult emotions) and invites readers to explore them in the same gentle manner that August welcomes Lily and Rosaleen to her home. In bringing to life place and metaphor, Kidd clearly states the invisible claim that the difficult things around us and within us — the things that we think may sting or harm us — are actually worthy of love and can facilitate growth. Kidd weaves the invisible claim in seamlessly with the narrative, leading readers through a metaphorical parallel to the action and character growth taking place in the chapter.

These elements of writing — the use of metaphor, darkness, relationships between characters, and place — each enhance the emotional souvenir of the book of loving the things that could sting us. In therapy, we are working to achieve the same outcome with our clients, although in therapy, the things that may sting are often internal parts of one’s self.

What’s on your bookshelf?

Diving into these details of the text further enhanced my own understanding of why I connect to the book’s characters and to the enticing darkness of which Kidd writes. I’ve shared The Secret Life of Bees with clients as an adjunct to the work we are doing, in order to process what they might connect with in the text.

I encourage other therapists to look at their bookshelves and consider which works of fiction (or poetry or any other genre) have had an impact on them as a person. What about those books resonated with you? Considering this can be useful for your own self-exploration and may also provide insight for your work with clients.

My love of reading augments my work as a counselor. Not all literature requires an in-depth explication to understand its impact on the reader. And not all literature coincides as neatly with therapy as The Secret Life of Bees. That being said, I highlight these details of Kidd’s writing to show how we can use the elements of literature to better understand the work we do and the depth of our own humanity.

 

****

Johanna Bond is a licensed mental health counselor at Perspectives Mental Health Counseling PLLC (perspectivesroc.com) in Rochester, New York. She also works as a freelance editor at Perspectives’ Pen, offering editing services for creative, academic and therapy-focused writing. Her writing has been featured on The New York Times Well blog and HuffPost, and she currently blogs for Psychology Today. Follow for more updates at johannabond.com or on Twitter: @johannambond.

****

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.

Enhancing the genogram to incorporate a narrative perspective

By Les Gura March 11, 2021

The first time I watched my internship supervisor use a genogram, I became enamored. Here was a tool that instantly created dialogue between counselor and client as they reviewed family history, dynamics, health, socioeconomic data and more.

But a funny thing happened when I began incorporating the genogram into my own work as an intern. Although the genogram helped promote conversation, I found I couldn’t always use the information gathered to help connect the issues presented by clients.

So, as I’ve often done since beginning my second career as a clinical mental health counselor after 35-plus years as a journalist, writer and editor, I put on my critical thinking cap. Might there be a way to do more with a genogram — a way to put my narrative experience into it?

I began to think about how writers create a cohesive narrative in fiction or nonfiction.

In America’s Best Newspaper Writing, Christopher Scanlan and Roy Peter Clark of the Poynter Institute note that when writers write in chronological order, they invite readers to enter a story and stick with it.

Phoebe Zerwick, director of journalism at Wake Forest University and a columnist I worked with when I was metro editor for the Winston-Salem Journal, refers to chronologies not just as a way to organize stories, but as a way to understand stories. “Once you have the events laid out on a timeline, you can pinpoint the most meaningful ones for the purpose of telling a story,” Zerwick told me in an email conversation. “That story is a series of ‘scenes.’ The timeline helps identify the scenes to draw out. Other events might be summarized or ignored. But without an understanding of the underlying chronology, the meaning of the story falls apart.”

So, why wouldn’t helping clients develop chronologies — along with a genogram — create a more cohesive story for my clients? To be sure, chronologies are not something new to practitioners and social service agencies as a means of tracking incidents relevant to a presenting client. In genogram work, chronologies have typically been used as a side tool to flush out connection between family occurrences and a specific presenting problem.

When I started working full time in September 2019 for CareNet Counseling as a licensed clinical mental health counseling associate, I decided it was time to merge chronology and genogram. My goal was not just to seek connection with specific family relationships or occurrences, but to allow clients to themselves identify and discuss the reasons behind key moments in their life — the “dominant narrative” that brought them to counseling — that may or may not be connected to their family history.

Thus was born the “geno-chronology.”

How a geno-chronology works

One of the principal jobs of a therapist is to help create moments of insight for clients. Toward that end, when I work from a narrative perspective, one of the first things I do is encourage clients to identify a “three-word dominant narrative” that brought them to counseling (see my previous article “Counseling from an editor’s perspective”).

I typically ask clients to do this as a homework assignment at the end of an initial assessment session. At our next meeting, we discuss the client’s identified three-word narrative to learn more details about current feelings and how things got to this point. When clients recognize and understand their dominant narrative, they often send signals — by their excitement or impatience — that help me decide to begin the geno-chronology.

As with the three-word dominant narrative, building the geno-chronology usually starts with a homework assignment. The purpose is to continue to engage the client in the process of therapy between sessions. Already in my career, I’ve observed that clients typically are more eager to get into work if they’ve done a homework assignment.

The assignment for the geno-chronology asks clients to identify “key moments” in their life — as few as two or three, or as many as 20 or more. What qualifies as a key moment? I typically use my own life as an example: I tell clients about the devastation I felt when my father died unexpectedly when I was 22, the joy of being the person to deliver my daughter (also unexpected) 10 years later, and the transformation I began after being fired at age 51 and recognizing that my life’s work as a journalist was over. In other words, key moments can represent triumph, failure, fear or any other emotion. If the moment is something that lingers in a client’s mind, it’s probably for a reason that’s worth discussing in therapy, regardless of whether it becomes part of the chronology.

Sometimes, based on the sessions that take place before the geno-chronology work begins, I might ask clients to pay particular attention to moments related to a specific issue — depression in their life or times when they felt overwhelmed, or devastating or traumatic incidents, for instance. For most clients, however, it’s a broader canvas from which they choose.

A fictional case study

Let’s use a fictional case study to illustrate how a geno-chronology provides therapeutic value.

Rob is a single white man, 34 years old, who initiated counseling when he was experiencing depression. Rob is a marketing manager, which is his first leadership role since graduating from a state university. Despite what appears to be a burgeoning career, Rob says he has been sleeping late and even called in sick to work twice in the past three weeks. He says he is not drinking any more than usual, he is not suicidal and he continues to maintain good physical health, although he has been eating out more frequently; he says he has been too lazy to cook.

From our earlier work, Rob’s three-word narrative was “life bores me.” I also know the basics of Rob’s upbringing: He is the middle child of three, with a high-achieving older sister who is a corporate attorney and mother of two, and a fun-loving younger sister who is a freelance writer and the darling of the family. Rob’s parents divorced when he was 16; his father is recovering from alcoholism. Both of his parents continue to work, and neither has a current romantic relationship.

I’m going to use a large artist’s pad for the geno-chronology, just like we would use for a traditional genogram. I usually turn the pad horizontally and draw a line across the bottom with an arrow pointing forward. I have only one instruction for Rob when I ask him to share his key moments: “Don’t necessarily go chronologically, even if that’s how you thought of them. Just begin with the moment that most stands out in your mind, and we’ll go from there.”

The late journalist Don Murray wrote about this idea for chronologies in his book The Essential Don Murray. “Do not start at the beginning, but at a moment of intensity,” he advised. Murray noted that readers understand the demands of chronology and know that when the timeline ends, they will have reached a heightened level of understanding. Similarly, counselors can make more sense by ascertaining the level of urgency when a story begins at a moment the client chooses rather than simply starting at the beginning.

Rob indicates that he’d like to begin with the first depressive moment he recalls — being a college sophomore, when he would lie around in his dorm room and miss class. He says he was bored and wound up spending hours playing video games and noshing on junk food, ignoring invites from his roommates and fraternity brothers to go out. Rob stops at that point, and I recognize the story needs to be fleshed out.

Scanlan and Clark note in their book that good editors help reporters unfreeze time in a story, often turning flat explanation into action. Questions for reporters include: When did that happen? Tell me the story of how that came to be. Do you know the history of this problem? As a counselor, I’m going to take that same approach, gently coaxing more detail from Rob by using the common narrative therapeutic practice of questioning.

I ask Rob if anything happened in his family at that point. “No,” he responds. “In fact, despite the divorce, things were getting a little better at that time because Dad finally sobered up, and when I saw him, he was great.”

Yet Rob’s grades were plummeting. “So, how did you get out of this funk?” I ask him.

His eyes light up. “Well, a professor in my major pulled me aside, basically, and told me he knew I was better than this and that if I accomplished even half of what he believed I could, I’d have a great career ahead of me.”

Rob says he went back to his room, tossed out some unopened bags of chips and hit the books for that day. He also began accepting invites to parties. It was the end of his depressive period, which had lasted a month. “To tell the truth, I’d almost forgotten about that period until you gave me this assignment,” he says. “But it was the first time I can remember being in that kind of funk.”

That is a lot of information to process, and I file it away knowing there is more to Rob’s story. But first, there are other key moments to consider.

Rob goes on to report two other “funks” between that incident and what he’s experiencing now. One of those depressive periods lasted six weeks. It began when his older sister got married; he couldn’t get a date, and that made him look at his life, where he had few friends and wasn’t socializing. The second depressive period lasted about three months and had occurred only a year and a half ago. That incident centered on breaking up with a girlfriend of four months after another wedding; she told him the event made her realize she had no interest in a long-term relationship with him.

I go back to the beginning, a question I often use at the start of my initial counseling assessment: “Why are you sitting in that chair, right here, right now?”

“Well,” Rob says, “I suppose this latest episode began when I saw my baby sister had an article published on HuffPost. I felt really proud of her. And yet that night, I got hammered.”

Once again, I know there is more to investigate. So, in the sessions that follow, Rob and I build a traditional genogram above the chronology. I begin to see a pattern, although I keep it to myself. It feels to me that Rob’s key moments of depression are closely tied to a perception of inadequacy, especially fed by the achievements of his siblings and a lack of connection with his parents, or both.

I ask him whether, as a middle child, he’s ever felt lost. He acknowledges he has, saying his mother bonded closely with his sisters, but he felt he hadn’t been able to have that type of close relationship with his father because of the alcoholism. In fact, Rob admits he resents that his dad got sober only after Rob was in college and his parents’ marriage had collapsed.

The conversation has Rob intrigued. He can look at the geno-chronology and see his key moments, which include both the “what” of the incident in question and the “significance” of it as he described it to me and I jotted notes next to the entry. Rob eventually brings up his resentment of his sisters and what he believes is his own lack of achievement in his personal and professional life. He thinks about his father, who bounced from job to job during his drinking years, always earning but never establishing a career of which to be proud. Rob feels that his marketing career is like that — enough to pay the bills but nothing that cultivates a sense of pride. And he doesn’t even have a family of his own.

The key moments of Rob’s chronology in this case have direct ties to his genogram. Rob is ready to talk in more detail about his lack of self-esteem, which, it turns out, was his true dominant narrative all along, hiding behind what was, in effect, the bravado of “life bores me.” Rob considers this and eventually recasts his three-word dominant narrative to “Failure overwhelms me.”

The addition of the chronology to the traditional genogram provides a visual cue for Rob to see the connection of the identified key moments in his life to the family system in which he was raised. Although it takes some time, the process prepares Rob, with a more accurate, self-identified dominant narrative, to begin the work of moving away from that dominant narrative and toward a preferred alternative narrative that he will identify in sessions to come.

Chronology and connection

Each incident that a client considers a key moment should be given weight during therapy. I’ve had entire sessions built around one key moment, as clients delve into a trauma they suffered in childhood, the story of the death of one of their children or how they made a life-changing decision. When clients are prompted by proper questions, these moments become a way to help them bring context to the stories of their lives, both in the period in which the moments occurred and in the present day.

In her book The Genogram Journey, Monica McGoldrick notes that “even the worst and most painful family experiences — alcoholism, sexual abuse, suicide — are part of our accumulated identity.” She goes on to write that “only by understanding what led to those behaviors can we begin to understand the dark side of ourselves and learn to relate more fully to others.”

The strength of the geno-chronology is that in today’s more fragmented immediate families, “the dark side of ourselves” often presents when clients have long separated — physically, emotionally or both — from their nuclear family. Adding good and bad life incidents to a genogram forms a more complete picture for clients and thus creates more opportunities for insight.

My ultimate goal in using narrative interventions is to help my clients identify a “preferred narrative” that will replace their dominant narrative. We use the same three-word approach. Clients have latched on to the concept by this point in therapy because during the building of the geno-chronology, I have asked them to develop three-word narratives for different points in their life. Looking back at past narratives identifies character traits that have developed through their families and relationships and have come into play during their key moments — all of which are conveniently on display in the geno-chronology. In the fictional case study I have presented, Rob might eventually settle on a preferred narrative of “Rob craves more.”

When clients identify a preferred narrative, we have a rich foundation from which to understand how character traits become magnified, lost or strengthened. We can have conversations about the process of gaining better awareness and control of character traits, enabling clients to move away from the dominant narrative and toward the preferred narrative. Rob might learn to recognize that despite his perception of self-failure, he can identify successes in his life, such as his ascension at work to a managerial role. We can discuss the traits that helped him achieve that, and he can learn to use those traits in other areas of his life.

Ultimately, the geno-chronology is a story-building tool that adds a narrative element to the classic genogram.

One of the things I have enjoyed most about becoming a counselor after a lifetime of writing and editing is letting go of my own concept of story. As a writer, my job was not just listening, but also absorbing the information from interviews and research and then determining the story to be told. As a counselor, I have the privilege of listening, absorbing and then allowing the chips to fall, with minimal guidance from me. I have ideas, and I can share those ideas, but the client is the protagonist of their own story.

****

Les Gura is a licensed clinical mental health counselor associate and national certified counselor based in Winston-Salem, North Carolina. He works for CareNet Counseling, where he is part of a two-year residency program and also serves as director of communications. Contact him at lgura@wakehealth.edu.

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

****

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.

Five regrets of the counselor

By Whitney Norris March 8, 2021

When I am supervising rookie counselors, one of my favorite discussions that often arises naturally concerns how unique the work of a therapist is. Yes, it is often incredibly tough work, but at the same time, we get an intimate, front-row seat to the experience of hope, pain, change and healing. (Along these lines, if you haven’t read Irvin Yalom’s The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients, I highly recommend it.) If we can truly be witnesses to this on the deepest level, there are so many incredible lessons that we are privileged to receive.

I recently came across an article about the book The Top Five Regrets of the Dying: A Life Transformed by the Dearly Departing, written by Bronnie Ware. After years of transformative work in palliative care, Ware summarized much of what she had learned from her work, first in a blog post and later in a 200-plus-page book. As I read, I found myself taking each of Ware’s lessons and adapting them to the unique work we do as counselors. I think that many counselors will be able to relate to these regrets and lessons.

1) “I wish I’d had the courage to live a life true to myself, not the life others expected of me.”

The work of Virginia Satir immediately came to mind when I read this one. It seems to me that perhaps a few too many of the pioneers and educators in our field want to, essentially, clinically clone themselves. Often, models come with a complete list of do’s and don’ts. I was even given an acronym in graduate school that taught me the exact way to sit during a counseling session. What I’ve always appreciated about Satir’s work is that she encouraged clinicians to be their own unique version of a great therapist.

When we’re new to the field, especially as interns, most of us do, in a sense, “try on” the techniques and styles of those we’re learning from. This, I think, is totally appropriate. Problems can arise, however, if we never grow out of that.

I’ll never forget the first time I was undoubtedly confronted by this “clinical differentiation” process. There was one specific professor in my graduate program whose therapeutic way of being I nearly idolized. I learned so much from him, and it so happened that much of our unique styles naturally overlapped. Then, one day, I was challenged to see some distinct ways in which they didn’t.

I had had a tough, conflict-ridden family session a few days previously, and we were watching the tape together in supervision. After talking through an overview, my supervisor told me he thought I should call and apologize to one of the family members for drawing the hard boundary that I had. After what felt like the longest eight seconds of my life, I swallowed hard and said, “But I’m not sorry.” I still felt I had done the right thing and could easily articulate why.

My supervisor paused thoughtfully and said, “Then you shouldn’t apologize.” And that was it.

He taught me an incredible lesson that day. We all need to be open and receptive to the information we can glean from what mentors, supervisors and others expect of us as counselors. And we need to be intentional about how and why we do what we do, whether that involves the companies we choose to work for, the clientele we choose to see, or the model and theories we posit. But we were never meant to do someone else’s therapy. We are meant to do only our own. To live the “therapy life,” we are meant to live uniquely.

2) “I wish I hadn’t worked so hard.”

The standpoint from which we view quotas and session numbers is greatly influenced by our training, workplace, financial situation, capacity, etc. With this lesson presented by Ware, I find myself wondering whether, at the end of my career or end of my life, I will be wishing I had worked more to see more clients or given more individual attention to each of the clients with whom I worked.

To put it more bluntly, if I have regrets here, will I regret quantity or quality? Will I wish I had worked with a smaller caseload in order to pursue more specialized training or to take more time to read books and research about the specific needs and patterns of the clients with whom I worked? Or will I look back and wonder why I didn’t work to see more clients in order to help more people? Will I wonder why I didn’t find a way to branch out on my own so that I could have more choices in how much I worked? Will I end up regretting that I didn’t follow what my mind and body were telling me about my capacity?

I don’t believe there are many rights or wrongs here. I believe our best bet is simply to make this choice more consciously. When I think ahead, I imagine myself wishing only that I had made my choices with more intention — made them on purpose instead of letting other factors, in a sense, choose a path for me.

3) “I wish I’d had the courage to express my feelings.”

I sat with some of these lessons longer than others in applying them to our work as counselors. After I read this one though, the application came to mind immediately.

While writing this article, I’ve also been reading through Louis Cozolino’s The Making of a Therapist: A Practical Guide for the Inner Journey. There have been many aspects of his candidness in writing to counselors-in-training that I have appreciated. This has stuck out the most to me in his many pleas to approach the work with humility — to admit when we’re in over our heads or when we need help. What I most appreciate is how Cozolino points out, much like Jeffrey Kottler does in his writings about counselor development (especially in On Being a Therapist), that this never ends. We never hit a stride where we no longer have questions, insecurities and specific struggles with clients.

Beyond that, most excellent therapists I know have at some point even questioned whether they should or want to be doing this work. Those of us who work through that well don’t keep it to ourselves. Doubts aren’t built for that kind of response. The path of least resistance is to talk through them with courage or, as Brené Brown would say (in Rising Strong), “rumble” with all that being a therapist does and will continue to bring up in us. I think the bravest among us have come to realize that there’s no shame in that.

As I said earlier, this work is tough — beautiful and tough. To not expect it to be accompanied by a somewhat constant dose of vulnerability can set us up for burnout and, eventually, at the end of the road, perhaps regret.

4) “I wish I had stayed in touch with my friends.”

In my mind, this one piggybacks off of No. 3. I have little doubt that when I look back at the end of my career, I will perhaps be even more grateful than I am now for the colleagues who made themselves available to process through these courageous conversations about the difficult and emotional work that crossed our paths.

One of the dangers of the field shifting more toward private practice than larger agency work is how easily this can lead to a sense of isolation before we see it coming. Even when we work with people we enjoy in these settings, we’re often just “ships passing in the night” during the last five minutes of the hour. Experts in interpersonal neurobiology are speaking more to the importance of the co-regulatory processes in therapy (see The Heart of Trauma: Healing the Embodied Brain in the Context of Relationships by Bonnie Badenoch). We will be best served to keep this in mind beyond just our one-on-one work with clients. I believe that getting support from colleagues is not just important, but actually essential, to doing good work.

In The Making of a Therapist, Cozolino spoke to some of his pushback on this need and his own reconciliation of it over time: “Put a group of us together in a facility designed to help clients and you find that at least half of our time and attention is dedicated to taking care of each other. For years, I found this confusing and demoralizing, and I wondered why we couldn’t put our own problems aside and just do our jobs? After much reflection, I realized that this attitude doesn’t work. Everyone in mental health, clients and caretakers alike, needs help, support and healing. Trying to help clients without helping the helpers ultimately fails.”

5) “I wish that I had let myself be happier.”

Lately, I’ve been finding myself wanting to abandon the term “self-care” because it’s so overused and, I think for the most part, misunderstood. The last point I want to make here really goes beyond the term anyway.

There’s no way around the frequent intensity of our work and the unique stressors found in such close and intentional proximity to pain and suffering. Sure, there are tangible things we can do about that, as I’ve mentioned earlier (and as Emily Nagoski and Amelia Nagoski expertly highlight in their book Burnout: The Secret to Unlocking the Stress Cycle). But we also can’t escape the reality that, as counselors, we don’t have the luxury of not taking care of ourselves. We can’t do the work we do, at least not for very long, unless we tend to ourselves.

I tell students in my practicum classes that if you’re not willing to make attending to your own physical and mental well-being a distinct aspect of your job day to day, then you need to find another career. We have to take care of ourselves like it’s our job. Because it is. That’s how we let ourselves be happier, among other things. Suffering as a badge of honor and martyrdom has no place in this profession. It certainly doesn’t make us more effective as counselors, and it definitely doesn’t make us healthier, more loving people outside of the office.

The following quote from Brianna Wiest, from a blog post she wrote for Thought Catalog, comes to mind so often for me that I think people are tired of hearing me say it: “Self-care is often a very unbeautiful thing. … True self-care is not salt baths and chocolate cake, it is making the choice to build a life you don’t need to regularly escape from.”

Thinking about the end of life while still somewhere in the middle of it can bring incredibly valuable insight — into our priorities, how we spend our time, our expectations, our habits and even our worldview. I think it is really important to ask ourselves whether our perspectives and patterns are forging paths of regret or paths of health and healing. Then, with appreciation for whatever arrives with this exploration, we have the opportunity to cultivate a courageous, balanced, emotionally honest, collaborative and happier work life that we can look back on with pride and immense gratitude.

 

****

Whitney Norris is a licensed professional counselor and supervisor who co-founded and works as a trauma specialist at Little Rock Counseling & Wellness in Little Rock, Arkansas. She is currently pursuing her doctorate in clinical and translational sciences, with plans to study childhood adversity and prevention through the lens of public health and policy. Contact
her via whitneynorris.com.

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

****

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.