Monthly Archives: June 2021

Therapy services: Money talk

By Stephanie Cox June 22, 2021

Here’s a topic that professional counselors love to talk about and don’t feel awkward at all bringing up: Money!

Let’s get it out there and acknowledge that in the counseling profession, money isn’t fun to talk about. That’s because the nature of our business is a sensitive one. We’re not selling the public “goods,” we’re providing a service. And this service isn’t a run-of-the mill one like doing your taxes or grooming your dog. We’re working with you to heal some of the most painful parts of your life. We’re helping you cope with tragedies. In some cases, we’re trying to keep you alive. It’s because of the sensitivity of the work we do as professionals that we can often feel “bad” for charging you money for this service.

Among my therapist friends, we frequently talk about our fees and all that comes with it. We go into this profession to help people. Still, reality comes in and we have to balance our hearts with our checkbooks. We have to reconcile that in order to use our skills, we have to pay our bills.

Speaking of bills, as therapists, we sure do have a lot of them. Some standard ones: student loans from undergrad, grad school or both, the costly liability insurance required to operate, the licensing fees, the required continuing education courses, our HIPAA (Health Insurance Portability and Accountability Act) secure phone lines, email and practice management software, marketing and advertisement costs, office space rent, material for clients — things add up. This doesn’t begin to touch the normal living costs we all have to consider such as other bills, mortgage payments, health insurance and food.

Kaspars Grinvalds/

As counselors, we know that we need to make money to live, but that guilt when we have to raise our fees or charge a client after a particularly emotional session is real. Something I try to remind my therapist friends (and myself) of is that at the end of the day, we are a business. It feels gross to say that because what we do feels like more than that.

However, when I think of all the people who are doing such hard work and seeing such positive change in their lives, it helps to reassure me. To stay in this business and stay available to use my skills to help people who are changing their lives for the better, I have to keep my lights on and pay my bills. I love what I do and am glad that I can keep doing it. I worked hard for these skills so that you can work hard to get better.

Even so, this question can be and needs to be explored in deeper context: Why isn’t mental health therapy more affordable?

Why isn’t mental health therapy more affordable?

This is an important and complicated subject. To start, as stated above, therapy is a service just like any other. Therapists are doing a job, and to do that job, they need to be paid a fee. But why can that fee seem so high?

If you think about the structure of therapy and compare it with similar industry services — such as CPAs, attorneys and other professionals whom you pay for providing a service rather than a product — it begins to make sense. Instead of selling a product, we’re selling time and expertise.

We don’t question why attorneys charge so much for their time. We understand that they had to go to school to become the best at their craft. In turn, we pay for access to that knowledge. The same holds true for professional counselors and other therapists. We had to go through extensive training and schooling (and accumulate substantial debt) to master the skills to serve you in the office.

Even so, this argument can feel shaky when we apply it to therapy because there is an assumption that therapists should be more compassionate to the needs of the population. Good mental health should be a human right, so why not cut people a break and provide these services at discounted rates so that more people can benefit for longer? After all, this is mental health — shouldn’t everyone be given the tools for better living?

Without a doubt, mental health services should be accessible to everyone and finances being a barrier is a societal ill. What isn’t always understood is that therapists also fall victim to this conundrum. We do not benefit from society not valuing mental health services.

Believe me when I say we wish we could provide all of our clients with a reduced fee. What makes this impossible is that most therapists whose fees are the highest are in private practice. There is no product to sell to make their profit, so it is their time and service that become their only source of income. Without a salary and a steady paycheck from a corporation, they rely on their fees alone to cover the costs of running their business, as well as the leftover income to pay their bills and support their families. This puts them in a bind.

What can be done?

This bind is one that could be remedied if mental wellness and mental health were prioritized by our society. For example, if the government had programs that supported mental health professionals and supplemented our incomes, we could reduce our fees and more people could be seen without us requiring assistance to live. If programs were created to provide mental health allowances to individuals so that services didn’t have to be paid for out of pocket, that would be another great way to allow therapy for all. If insurance companies raised their rates and paid a livable reimbursement rate for therapists (more on that later), more of us would accept insurance and our clients could pay less.

I hate the way that mental health is devalued in our country. Those of us who are therapists got into this field because we want to help people, and we’re aware there are whole swaths that we can’t reach. If we did, we couldn’t be in business for long, and then no one would benefit. I am hopeful though that change is coming. The more vocal people become about wanting mental health rights, the more likely we are to see them given.

If you’re looking for a professional counselor or other therapist and finding that the finances are not working out, I encourage you to ask if the therapist is able to offer a sliding scale or reduced fee. Until then, I know it’s a bummer seeing that price tag. We don’t like it either.

Why many therapists don’t take insurance

It’s true that you can find therapists in private practice who take insurance, but it won’t always be the case. Previously, I touched on some of the reasons behind the fees that therapists charge. Now, I’m going to explain why we don’t always accept insurance as a way to cover those costs.

If a therapist wants to accept insurance, there is considerable time and cost associated with this form of payment. To begin with, therapists have to apply to insurance companies in order to take their insurance. This process is complicated and lengthy. It can take anywhere from four months to a year to get approved. An insurance group will approve a therapist only if it recognizes a need in that area for the therapist’s services that isn’t already filled by another provider. It is common to be denied because there are already enough providers in the therapist’s area.

If you are among the chosen, the process gets more complicated from there. You must sign a contract with the insurance group and agree to a fee schedule. While I can’t share the specific fees that insurance companies pay to therapists, it is almost always less than what a therapy session costs. In fact, it can be anywhere from one-third to one-half of what a therapist normally charges for their services.

Additionally, therapists are not actually paid when they render the service to the client. After having the session, therapists must complete a time-consuming process of medical billing to submit a claim to the insurance company requesting pay for the service provided. Depending on a number of factors, the insurance company can deny the claim. In that case, the therapist has then worked for free. If an insurance company does approve the claim, they pay the therapist weeks later.

Mental health therapy agencies and group practices that have specific medical billing and coding teams have the time to dedicate to this complicated process. Providers who work with these agencies are also usually paid a steady salary so that the delays in insurance payments are not felt as acutely. That’s why you are more likely to find providers that take insurance in these settings.

In contrast, private practice therapists usually forgo these challenges because the cost in time and money does not make for the most efficient business practice. Self-pay among private practice therapists is simply a lot easier. In addition, insurance companies require therapists to diagnose clients in the first session and submit that to the insurance company or else services will not be covered. Not all therapists (or clients) agree with this practice of requiring a diagnosis, so this is another barrier to accepting insurance.

No surprise, this is a broken system. There should be alternative affordable systems in place to make therapy accessible to all people who want it and feasible for all therapists to provide it. Some therapists try to lower the barrier of finances by doing pro bono work or offering reduced-fee sessions.

Reduced fees and pro bono work

Therapists are encouraged by their codes of ethics to provide a portion of their sessions at a lower cost or, if possible, to offer some services pro bono (free).

Because we have limits to how many services we can provide at a reduced fee or for free, there is usually a cap on the number of clients who can receive this benefit at a given time. This depends on the individual therapist’s finances and choices, but most therapists will have a line on their business page stating whether they are open to “sliding scale” fees. This means that therapists will work with clients to determine what they can afford.

Sometimes this sliding scale comes with stipulations such as a set number of sessions or a set frequency, but talk with your therapist about what they can do for you.

Pro bono services work in a similar fashion. Therapists can provide some services for free, either directly or in a more generalized setting such as providing services for a charity, school or church.

If a therapist does not currently have any open slots for reduced-fee work, don’t lose hope. Whenever those clients graduate or phase out, those spots may become available again, so be sure to keep asking your therapist to be put on a waitlist for such services.

If you are a therapist and don’t currently provide these services, I highly encourage you to reconsider. I offer several reduced-fee spots on my caseload and am glad that I do because, as stated previously, therapy should be accessible to everyone.

Money talk as therapists is not fun, but it is necessary. If finances are a barrier for you to receive services, I encourage you to be honest about that with a potential therapist. We truly do want to help, and most therapists will work with you to get you the help you need. Now that you’ve been given some insight into the financial workings of this field, I hope you will have the confidence to seek help if you’re a potential client and to provide help if you’re a practitioner.



Related reading, for counselors:



Stephanie Cox is a licensed mental health counselor in Florida specializing in therapy with children, families and adults with mild to severe mental health and relational issues. She holds a degree in psychology from the University of North Florida and a Master of Science degree in counseling psychology from Grand Canyon University. Contact her via:


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.

Team from Montclair State University wins ACA’s 2021 Doctoral level ethics competition

June 21, 2021

This award recognizes exceptional, demonstrable understanding of the ACA Code of Ethics, the foundation of ethical professional counseling practice. Each year, ACA honors top-ranking teams in both Masters and Doctoral level graduate degree programs.



Culturally Responsive Ethical Decision-Making During COVID-19

By Rebecca Randall, Sunanda Sharma and Matthew Tirrell

Department of Counseling, Montclair State University

ACA Graduate Student Ethics Competition – Doctoral Category

Faculty Advisor: Dr. Dana Heller Levitt



The COVID-19 pandemic imposes novel conditions on counseling supervisors and extends the boundaries of ethical considerations. Remote supervision of counselors-in-training, as described in the current case, poses unique challenges to the supervisory triad. To evaluate the proposed scenario for potential ethical dilemmas, the authors consulted and applied the Transcultural Integrative Model (TIM) for ethical decision-making (Garcia et al., 2003). The authors identified several concerns that involve the stakeholders in the case, including: client welfare, counselor impairment, the supervisory relationship, the praxis of virtual supervision during COVID-19, and professional gatekeeping. The case content was examined from a multicultural lens and assessed for congruence with the foundational principles and standards of the counseling profession. Proposed courses of action include remediation for the counselor-in training, support for the supervisor-in-training, and collaborative, culturally responsive communication among the stakeholders.


Culturally Responsive Ethical Decision-Making During COVID-19

COVID-19 prompted professional counselors to adapt to rapidly changing circumstances with no advanced preparation. Despite this, the counseling profession responded by shifting: how counseling services are delivered, how counselor educators and supervisors are preparing counselors-in-training, and how counselors-in-training are working with clients under these challenging circumstances (Bray, 2020). In this context, Caila, a doctoral level supervisor and student, encounters a number of ethical concerns which impact several stakeholders. We will assess the case and offer recommendations for the most appropriate course of action through use of the Transcultural Integrative Model (TIM) for ethical decision-making (Garcia et al., 2003).

Transcultural Integrative Model of Ethical Decision-Making

The TIM is an ethical decision-making model that accounts for personal, professional, and collaborative perspectives on ethical dilemmas (Garcia et al., 2003). The TIM is the most conducive model to explore the various dimensions of this case, due to its focus on cultural context and its utilization of social constructivist strategies to collaboratively formulate an ethical response. Caila’s intersecting identities (e.g., race, gender, ability status) and the issues of power and privilege between all the stakeholders inform a number of concerns within this case. We will use the Multicultural and Social Justice Counseling Competencies (MSJCC) to examine each stakeholder’s positionality with respect to their marginalized and privileged identities (Ratts et al., 2016). We will analyze this case through a multicultural lens, informed by the MSJCC, which will permeate our use of the TIM: interpreting the situation, formulating an ethical decision, weighing competing nonmoral values, and planning and executing the selected course of action (Garcia et al., 2003; Ratts et al., 2016).

Interpreting the Situation Through Sensitivity, Awareness, and Fact-Finding

The first step in the TIM (Garcia et al., 2003) is to seek a deep understanding of the potential ethical dilemmas posed in the case. Identification begins with a close examination, informed by the cultural perspectives of each stakeholder, attention to the foundational ethical principles of the profession, and commitment to accurate interpretation (Garcia et al., 2003). There are several ethical considerations in this case: client welfare, counselor impairment, the supervisory relationship, virtual supervision during COVID-19, and professional gatekeeping. The stakeholders in this case are Kyle, Caila, Dr. Smith, Kyle’s clients, and the site supervisor.

Client Welfare

Kyle reported to Caila that his site is not following recommended COVID-19 safety guidelines, which puts his clients at risk. Although Caila attempted to contact the site, her inability to conduct a live site visit precludes her from effectively evaluating client well-being. Caila did not inform Dr. Smith of Kyle’s safety concerns, which exacerbates the clients’ vulnerability. Dr. Smith’s lack of awareness exposes problematic relational patterns in the supervisory triad that may further threaten client well-being.

Counselor Self-Awareness and Self-Advocacy

Counselors are called to grow in self-awareness and to self-monitor for potential impairment (ACA, 2014). Caila has not been fully transparent in her supervisory relationships about her compromised self-efficacy amid the stress of quarantine. Similarly, as counselors and supervisors are charged with advocating for client welfare, they are also called to self-advocate for their wellness. Caila’s difficulty with self-monitoring and self-advocacy is a significant concern with implications for her supervisory relationships and client welfare.

Supervisory Relationships

Transparency and cultural awareness in the supervisory relationship, which appear to be challenges for these stakeholders, are essential to competent supervision and counseling (ACES, 2011). Kyle and Dr. Smith met for supervision without informing Caila, and Caila withheld critical information from Dr. Smith regarding her tenuous mental and physical states. Additionally, ​Kyle draws on commonly used microaggressions against Black women (Moody & Lewis, 2019), which warrants an exploration of his intent and meaning.​ ​Culturally-informed ethical concerns extend to Caila and Dr. Smith’s relationship as well, given its cross-cultural and hierarchical nature. Attention to sociocultural positionality and power differentials appears to be of concern in the supervisory relationship dynamics.

Informed Consent in Virtual Supervision

Supervisors must provide comprehensive informed consent to supervisees prior to engaging in virtual supervision. It is unknown to what extent Caila has met this responsibility. It is unclear if Caila communicated her decision to conduct virtual supervision exclusively in her professional disclosure statement, as suggested by Kyle’s reported dissatisfaction with the absence of in-person supervision.


Caila and Dr. Smith are responsible for monitoring Kyle’s patterns of behavior to ensure adherence to professional and ethical counseling standards (ACA, 2014). Dr. Smith is also obligated to continually assess Caila’s competence as a supervisor. Caila’s and Dr. Smith’s struggle to communicate transparently about their respective responses to Kyle’s resistance (e.g., his hesitance to address safety concerns at his site and his response to Caila’s feedback) raises concerns about their efficacy as gatekeepers. Ultimately, Dr. Smith is responsible for ensuring both Caila and Kyle act in ways that safeguard their clients’ well-being.

Formulating an Ethical Decision

Once counselors have fully engaged in a thorough process of exploration, reflection, and fact-finding, they review the ethical dilemma, guided by the ACA ​Code of Ethics​ (2014) and other pertinent guidelines, and seek collegial consultation (Garcia et al., 2003). A review of all of these resources inform possible courses of action.

Relevant Ethical Standards

A.1.a. Primary Responsibility.​ ​Congruent with the fundamental principles of beneficence and nonmaleficence, the primary responsibility of counselors is to “respect the dignity and promote the welfare of clients” (ACA, 2014). Perhaps the most significant concern in this case is client welfare at Kyle’s site. All of the stakeholders in this case have a responsibility to act in the best interest of their clients and ensure their safety.

A.7.a. Advocacy.​ ​Counselors and supervisors are responsible to act as advocates when they identify barriers to clients’ and supervisees’ well-being. Kyle identifies safety concerns at his site and is called to advocate on his clients’ behalf, yet he is hesitant to do so. Likewise, Dr. Smith is responsible for inquiring into the well-being of and advocating for his students and supervisees.

F.5.b. Impairment. Supervisors hold the dual responsibility of ensuring client welfare and fostering supervisee growth. Caila must engage in ongoing self-reflection and self-monitoring to recognize how COVID-related challenges have compromised her ability to carry out her supervisory responsibilities.

F.2.b. Multicultural Issues/Diversity in Supervision.​ ​Supervisors are responsible for broaching issues related to multiculturalism and diversity in their work with supervisees. Given the differences in their racial identities, as well as the hierarchical nature of the supervisory relationship, Caila must broach cultural differences with Kyle, as well as issues pertaining to power and privilege, in order to model effective broaching in the counseling relationship.

F.4.a. Informed Consent for Supervision.​ ​In their use of virtual platforms, counselors and supervisors maintain the responsibility to adhere to established standards of care. As Caila decided to utilize online supervision, it is imperative that she discuss this choice, as well as its implications, in the ongoing process of informed consent with Kyle.

F.6.a. Evaluation and F.6.b. Gatekeeping and Remediation.​ ​As a supervisor-in-training, Caila has the responsibility to give Kyle concrete feedback about his performance and to keep her faculty supervisor apprised of challenges she experiences. As a counselor educator and faculty supervisor, Dr. Smith is responsible for supporting and empowering Caila in her work with supervisees. He will further attend to his supervisees’ developmental needs and tailor his interventions accordingly.

Possible Courses of Action

Once counselors have identified and explored the implications of professional standards, they generate potential courses of action, attending to the positive and negative consequences of each, and engage in consultation (Garcia et al., 2003). Caila is the catalyst for an ethical course of action because, as the case stands, Dr. Smith and Kyle have decided to work together without consulting her. Possible courses of action either include Caila not taking action or addressing Kyle or Dr. Smith separately. ​Caila’s inaction maintains the status quo, leaves Kyle’s clients at risk, and misses an important opportunity for her and Kyle to grow as culturally responsive advocates and counselors.​ Another consequence of Caila’s inaction might be that Kyle would not receive remediation necessary for his development, and he will be at risk of “gateslipping”, a phenomenon in which counseling students who require additional support and education continue through their program without remediation (Gaubatz & Vera, 2006). If Caila chooses to address Dr. Smith or Kyle individually, there would be limited accountability for ethical action and remediation. It is possible Caila will encounter resistance by enacting an ethical course of action; however, there is overwhelming positive value if she chooses to address the identified concerns.

Planning and Executing the Selected Course of Action

Caila, Dr. Smith, Kyle, and Kyle’s site supervisor have contributed to the issues in this case in different ways, and each party will have varied ethical responsibilities. There are common factors to each party’s action: transparent communication, consultation, critical reflection, broaching race and culture, safeguarding client welfare, and documentation. The concrete actions outlined for each stakeholder are based on considerations from the TIM (Garcia et al., 2003).


COVID-19 pandemic conditions necessitate that counselors “practice what they preach” by engaging in self-care and protecting their health, just as they would recommend to their clients (Bray, 2020, p. 21). As an individual at higher risk, Caila is conducting her work remotely in order to remain safe; however, she is not impervious to the psychological toll of the pandemic. It is imperative for Caila to reflect upon how her marginalized intersecting identities as a Black woman with compromised health inform her worldview, value system, and actions (Chan et al., 2018; Fickling et al., 2018) through the pandemic. ​The contrast between Caila’s sociocultural status and her positional authority in her evaluative role as a supervisor-in-training (Rapp et al., 2018) may have led to a tentative approach to her gatekeeping responsibilities.​ C​ aila must reflect upon why she is reticent to disclose her emotional struggles and recognize that her silence jeopardizes her standing in her doctoral program, her supervisory relationships, and the welfare of her supervisees’ clients.

Caila will benefit from consultation with a departmental advisor or mentor to receive support as she navigates this process and so she may receive guidance about how to engage Dr. Smith and Kyle in a productive dialogue. Caila should schedule a virtual meeting with Dr. Smith to disclose how COVID-related challenges have impacted her supervisory practice. Caila must also address Dr. Smith’s decision to supervise Kyle without consulting her, suggest a meeting between the three of them to address concerns in their supervisory relationship, and work collaboratively with the field placement coordinator to investigate COVID-related concerns at Kyle’s site.

Dr. Smith and the remediation committee at the university will determine specific interventions for Caila; however, crucial components to be infused throughout are: increasing her personal awareness (Roach & Young, 2007), implementing strategies to aid in her development as a supervisor and gatekeeper, (Henderson & Dufrene, 2017; Rapp et al., 2018), and learning how to broach race and culture (Day-Vines & Holcomb-McCoy, 2013). In order to become a culturally responsive counselor educator and supervisor, Caila must acknowledge that effective counseling begins with her self-awareness (Day-Vines & Holcomb-McCoy, 2013). She must recognize how cultural context impacts clients’ concerns and how important it is to model broaching race and culture with her supervisees (Day-Vines & Holcomb-McCoy, 2013). Through her critical reflection and professional development process, Caila will take steps to protect client welfare at Kyle’s site, strengthen her self-monitoring skills, and further develop her identity as a supervisor (Fickling et al., 2018).

Dr. Smith

Dr. Smith can engage in critical reflection using the MSJCC (Ratts et al., 2016) to increase his self-awareness about his power and privilege in his roles as a male counselor educator, supervisor, gatekeeper, and faculty member (Chan et al., 2018). It is crucial for him to respond to his diverse students’ needs and leverage his privilege to support the stakeholders in this case (Chan et al., 2018; Fickling, et al., 2019). Dr. Smith must also reflect on what contributed to his decision to circumvent Caila by offering Kyle supervision, rather than empowering them to address their working alliance directly (Rapp et al., 2018). After this reflection process, Dr. Smith must meet with Caila to follow-up about her experience in quarantine, how she is balancing her responsibilities, and how he can support her. Dr. Smith and Caila should also schedule a meeting with Kyle to: address the challenges in Kyle and Caila’s working alliance, collaboratively create an action plan with the field placement coordinator to address the challenges at Kyle’s site, and integrate the MSJCC into the counseling and supervisory relationships (Fickling et al, 2018).

Dr. Smith should inform Caila and Kyle that he will approach the remediation committee to create plans that are grounded in guidelines such as the ACA​ Code of Ethics​ (2014), the CACREP (2016) standards, and the university’s gatekeeping policies in the student handbook (Shuermann et al., 2018). Dr. Smith must ensure that the plans address Caila’s and Kyle’s specific needs in a way that fosters their professional development (Henderson & Dufrene, 2017). Finally, as a counselor educator and faculty member, Dr. Smith has an ethical duty to advocate for his diverse students. As he engages in critical reflection, recommends remediation, and documents this process from his perspective, it is incumbent upon Dr. Smith to share his experience with his colleagues, department chair, and university officials to implement more inclusive policies that support Black and minoritized counselor education doctoral students like Caila (Henfield et al., 2013).


Kyle’s contribution to his personal and professional growth will depend on his personal “reflective stance,” defined as the counselor’s willingness to seek self-reflection opportunities and openness to change (Pompeo & Levitt, 2014, p.85). Accordingly, Kyle will agree to meet with Caila and Dr. Smith to discuss their concerns. Through a balance of challenge and support, Caila and Dr. Smith will guide Kyle’s process of critical reflection to promote his self-awareness. Kyle must reflect on his reluctance to advocate for his clients. Caila and Dr. Smith can validate his fear of negative evaluation but firmly remind him of his primary ethical responsibility and commitment to the foundational principles of the profession.

Cultural responsiveness is an ethical mandate for counselors, and therefore Kyle must reflect more on his cultural identities and how his assumptions, values, and biases inform his decision-making as a counselor and supervisee. For example, Dr. Smith and Caila can challenge Kyle to reflect more on his resistance to Caila’s feedback, as well as his inappropriate response to it (e.g., enlisting Dr. Smith for supervision without Caila’s knowledge). Some resistance to supervisors’ critical feedback is normative (Bernard & Goodyear, 2019), but it is curious that Kyle initially was unable to provide concrete examples of what he reports as “aggressive and too critical.” Such terms are examples of gendered racial microaggressions often applied to Black women in work and school settings (Moody & Lewis, 2019), and Kyle must reflect upon his statements to determine if they accurately represent his work with Caila. The depth of Kyle’s critical reflection, as well as his responsiveness to the specific actions recommended by the remediation committee, will encourage his ethical development.

Site Supervisor

Finally, the proposed action plan must include consideration of Kyle’s internship site. Dr. Smith, Caila, and the department’s field placement coordinator should collaborate on the creation of a plan for addressing the COVID-related safety concerns at Kyle’s site. At minimum, this plan should designate a field coordinator or faculty supervisor who can conduct an in-person investigation. Based on these findings, additional measures can be discerned. Dr. Smith or Caila will further communicate to the site supervisor the importance of open and timely communication. Optimally, faculty, students, and site supervisors will commit to “collaborative gatekeeping” (Dean et al., 2019), which helps to prevent “gateslipping” (Gaubatz & Vera, 2006), in addition to meeting counselors’ fundamental responsibility: to respect client dignity and promote client welfare.


Caila, Dr. Smith, and Kyle are involved in a case with myriad issues, and there are serious ramifications if proper ethical action is not taken. Although COVID-19 has posed several challenges, counselors, supervisors, and counselor educators must still promote ethical practice through transparent communication and collaborative supervision in service of client welfare. We have identified the ethical concerns and the relevant standards from the ACA ​Code of Ethics (2014), and we have proposed an ethical course of action using the TIM (Garcia et al., 2003). The course of action was rooted in foundational counseling principles, racial and cultural awareness, and the counseling literature. Caila, Dr. Smith, and Kyle may all learn from this situation and grow in their professional development which will serve them and their future students, clients, and supervisees well.



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.

Counselors and the urgent care clinic: A new accessible delivery option

By James Todd McGahey and Melanie Drake Wallace June 18, 2021

Few would argue that 2020 was a watershed year in many respects. The COVID-19 pandemic, social and economic inequities, a racial reckoning, and environmental disasters collided and coalesced into a reality marked by tremendous challenges, the likes of which could hardly have been predicted. This confluence of factors has created an increasing need for counseling and mental health care.

The dramatic increase of individuals reporting mental distress has garnered national attention and sharpened societal recognition of the relationship between mental and physical health. Consequently, mental health and well-being, or a lack thereof, have taken on new urgency and can no longer be ignored.

Our recent work, respectively, as a mental health counselor in an urgent care setting and a professional counselor supervisor and educator has given us a unique, firsthand perspective on this valuable opportunity. We believe that the immediate/urgent care facility offers a promising new setting for the provision of mental health care. A number of urgent care facilities have already incorporated mental health services into their practice with positive results. Mental health providers have become vital components of integrated and interdisciplinary teams. Therefore, the primary objective of this article is to promote and highlight the integration of collaborative mental health resources into these care clinics.

Mental health care and urgent care

A drive down most urban thoroughfares, suburban boulevards or even rural town roads often leads to a sighting of an urgent/immediate care facility or at least an advertisement for one. The proliferation of these clinics over the past few decades has resulted in their ubiquitous presence on the community landscape and the health care scene.

The dramatic increase in mental health issues across the population, exacerbated by the COVID-19 pandemic, demands a mitigation strategy. An effective intervention that has also seen a rapid increase recently is the incorporation of mental health care within the urgent/immediate clinic setting. There have been positives and negatives regarding both results and outcomes, inspiring us to examine the advantages and disadvantages of this burgeoning concept.


The urgent care concept of providing accessible health care emerged in the 1970s. Initially, these clinics were staffed by physicians who provided basic care for minor issues such as colds and sore throats and minor accidents requiring first aid. Over the years, the number of immediate/urgent care facilities increased and the range of treatments expanded.

Increased treatment options, expanded availability, timely care and affordability are among the reasons that an estimated 3 million patients visit urgent care centers weekly. Their convenience, accessibility and omnibus approach of addressing various medical issues, including the acquisition of a primary care doctor, make them an attractive alternative to the bureaucratic and often alienating nature of the traditional health care industry. The COVID-19 pandemic also exposed various weaknesses and inequities within our traditional health care system, positioning the urgent/immediate care industry as a vital component of a comprehensive plan to prevent and mitigate such crises.

Mental health issues

Urgent care, COVID-19 and lingering effects

The vital role of the urgent/immediate care facility has been confirmed throughout the pandemic. These facilities have functioned effectively as testing centers, providing rapid testing and results to the public. They provided access to health care providers as the pandemic burdened and overwhelmed traditional health care access.

With the growing relationship between mental health care and urgent care, providing mental health services for the increasing prevalence of mental health symptoms seems an essential and effective strategy. The COVID-19 pandemic is leaving a trail of lingering implications, including economic and psychological effects, that are not yet fully known.

Whereas physical risks and symptoms of the pandemic will improve with vaccines and increased knowledge of the virus, mental health issues may endure as people struggle from serious issues that may become chronic or episodic. As reactions to the pandemic and the accompanying stressful environment increase negative symptomology, an overall benefit may be the increased exposure of mental health issues.

 Growth of delivery systems

Other trends, primarily driven by the pandemic, include an exponential increase in the use of telemental health options. These include various mental health providers opting to use these delivery platforms with their clients and clients seeking mental health services from online counseling companies.

Online counseling service companies usually provide subscription plans and packages and match clients with a qualified provider. These companies have experienced strong growth recently, with the appeal being that all aspects of the care can be provided through an online platform. These aspects may include insurance utilization, intake interviews, therapy sessions and the ability to schedule appointments.

Traditionalists and critics argue that a vital element of the counseling relationship and process are forfeited in the telemental health format. In addition, most insurance companies have not embraced or reimbursed these efforts. Some disadvantages of online counseling include the loss of intimacy in the in-person counseling relationship, the lack of coverage by insurance, unreliable technology, the difficulty of treating serious mental health disorders, and the general absence of nonverbal communication. 


Omnibus service and accessibility: Urgent/immediate care facilities currently have a large capacity and continue to expand in all areas of the country. The addition of providing mental health services in these existing and future facilities would expand exposure and treatment (proactive, reactive and crisis) to reduce the prevalence of mental health disorders — disorders that cost billions financially through expenditures and loss of work.

This omnibus approach is conducive to “one-stop shopping.” Many mental disorders present initially as physical symptoms. Thus, these can be treated by the health care provider, who can then refer the patient/client in house for mental health evaluation. This would prevent long delays in accessing services rather than patients being referred to outside mental health professionals who may have long waiting lists or may not be accepting new patients. The amalgamation of mental and physical health services in one facility would create a comprehensive continuity of care.

COVID-19 implications: The pandemic has increased the prevalence of mental health needs across all populations. Like the distribution challenges of the COVID-19 vaccine, distribution of mental health services is also a challenge. Using the existing delivery system and structure of the urgent/immediate care industry could provide a substantial increase and reinforcement to the existing mental health services that can be offered or provided to individuals in need.

Professional practitioners: Access to professional mental health providers, especially psychiatrists, has reached a crisis stage. The number of new physicians choosing psychiatry has been declining over the decades, whereas the number of retiring psychiatrists is increasing. Rural access to mental health care is extremely limited or unavailable, and urban access is limited by long wait times and “no new patient” policies. These factors are not conducive to successful treatment of mental health conditions.

Medical professionals available at immediate/urgent care facilities can collaborate with experienced licensed professional counselors/therapists who are educated and skilled in the treatment of mental health to successfully assess, diagnose and treat through medication, psychotherapy or a combination of the two.

Loneliness: AARP has warned that the coronavirus pandemic is also causing a loneliness epidemic, which with the aging population, accounts for almost $7 billion a year to the cost of Medicare. Loneliness is also a contributing factor in other conditions, making people more vulnerable to Alzheimer’s disease, high blood pressure, suicide and even the common cold. Some researchers propose that loneliness is more dangerous to people than obesity and smoking. Like mental health, loneliness carries a stigma that hampers assistance efforts.

The simple presence of another human with whom to converse, witness or socialize leads to more positive outcomes. One of the most effective methods of improving loneliness is cognitive behavior therapy (CBT), which helps individuals examine their thoughts, perceptions and assumptions and how they affect behaviors — including behaviors that may be leading to loneliness. Increased access to mental health providers in affordable, accessible and convenient urgent/immediate care facilities can help stem the negative effects of loneliness and other social isolation ailments that are growing as a result of the pandemic environment.

NYC Russ/


The parity of behavioral/mental and physical health services has long been an issue. The Affordable Care Act addressed many of these issues by enacting legislation that required equal coverage of mental and physical health, but there is room for improvement.

The National Center for Health Statistics reported in 2018 that suicide ranked as the 10th-leading cause of death across all ages in the United States. In 2016, suicide became the second-leading cause of death for ages 10-34 and the fourth-leading cause for ages 35-54. Having immediate access to mental health care is critical to reducing this rate and many more mental health diagnoses.

The immediate/urgent care system, in concert with the mental health community and their professional providers, can be a strong partner in addressing these societal concerns. Counselors should take leadership roles in advocating for change, especially in these delivery systems. Appeals to local governments, insurance companies and counselor training programs may result in easier accessibility for all populations. Mental health professionals can advocate for urgent care clinics to create mental health positions in their groups, as many clinics have more than one location.

It is important that we highlight the potential of a seamless, omnibus approach of a single comprehensive visit or location for addressing all health needs or issues. Ultimately, with a marriage between urgent/immediate care clinics and mental health counselors, accessibility and quality of care can be increased and challenges and obstacles reduced.



James “Todd” McGahey is a licensed professional counselor, a national certified counselor and an associate professor of counselor education at Jacksonville State University. He also serves as a consultant and mental health provider at Beach Family Urgent Care in South Carolina. Contact him at

Melanie Drake Wallace, a licensed professional counselor supervisor and national certified counselor, is a professor and department head of counseling and instructional support at Jacksonville State University. She also serves on the Governing Council of the American Counseling Association. Contact her at


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.

What discomfort can teach you

By Shari Gootter and Tejpal June 16, 2021

Comfort is something we all seek. The notion of “being comfortable” is highly prized (and promoted) in our society. It is considered a major selling point if you are in the market to buy a bed, clothes, a car, a pair of shoes — almost anything. But the overvaluing of comfort in our lives can come at great cost.


Our relationship with comfort and discomfort is influenced by our culture, our personal history and our personality. If we are born in a tradition in which failure is not an option and social success is the norm, we may challenge ourselves with long hours of work or study to avoid the discomfort of failure. If we are born into a family where depression or anger was part of the daily landscape, we may want to avoid these emotions at any price and dissociate when these feelings arise. Taking a deeper look at our relationship with comfort and discomfort provides us insight on our path toward acceptance and happiness.

Discomfort exists at many levels:

  • At the physical level, it may manifest as a headache, a digestive issue or a skin irritation.
  • At the emotional level, it may manifest as anxiety, worry or depression.
  • At the mental level, it may manifest as constant agitation, an inability to focus or ambivalence in decision-making.
  • At the heart level, it may manifest while experiencing loss, change or separation.
  • At the spiritual level, it may manifest as existential angst, lack of purpose or a feeling of disconnection.

Certain life events can be challenging and unfamiliar. If we are clinging to any form of comfort, we will limit our ability to adapt and grow. Through the years, the overpromotion of comfort, happiness and pleasure has created tremendous distortions. There is no tolerance for any amount of discomfort and tremendous impatience for any kind of pain. When comfort is the only choice, resilience and the ability to overcome adversity are lost.

Running from discomfort

If you want to stay centered and at peace, you need to stop running away from discomfort (or always running toward pleasure). Running from discomfort prevents us from being able to see and feel what is present. It holds us in a false state of reality and never allows us to know our true selves. On the other hand, being uncomfortable teaches us to transcend pain and pleasure, thus allowing us to be true to ourselves. It also allows us to see clearly when challenges occur.

The constant promotion of pleasure and comfort has contributed to the emergence of addictive behaviors. For example, many individuals use food, medication or gaming as a way to soothe their pain or “escape” their stress. This starts with a tremendous obsession of the mind that makes us believe there is only one way. When our mind gets frantic about one thing, there is no room for anything else and our behavior becomes extremely reactive. As soon as we grasp for more comfort, we become intoxicated. Intoxication does not necessarily have to involve a substance such as alcohol. We can be intoxicated with power or greed. As soon as we are intoxicated, we lose our intelligence and our ability to be present.

When you experience discomfort, we suggest that you stay away from labeling it, contracting and wondering when the pain will go away. None of us came to Earth to suffer, but none of us came to earth to run away from suffering either. Every time that you hit your limitations, you have the opportunity to unfold and open.

Mara, one of our clients, was struggling with tremendous discomfort. She was never satisfied with herself and experienced ongoing anxiety about her future. She dealt with her pain by consuming alcohol. After several years of doing this, Mara was no longer able to follow through with much of anything, and she ended up getting fired from her job. This was a much-needed wake-up call for Mara to realize that she needed help. When she first came to see us, she had a strong motivation to rid herself of her discomfort. But as she learned to develop a sense of compassion for herself, she grew more able to embrace her discomfort. Mara came to understand that when she was trying to cover up her discomfort, she was actually opening the door to self-destruction.

Accepting discomfort

Accepting our discomfort is led not only by bravery but by our heart center. At that moment, we choose to accept who we are. Our will does not help to heal our pain; our heart does. For Mara, getting fired was the saving grace. Others may go deeper into negative coping mechanisms that further enhance patterns of self-sabotage before determining to change their relationship with discomfort.

Often, when we experience discomfort, we perceive it as a threat. We want to separate from our discomfort to protect ourselves. When we do this, we create the opposite of what we are looking for. The more we separate from our discomfort, the more we separate from ourselves, and the more pain we experience as a result.

Underneath any discomfort, there is a fear. For some it could be the fear of missing out. For others it may be the fear of not being in control, or the fear of being overwhelmed and losing sense of self.

The longer we numb our discomfort, the more stuck we may feel. The longer we reject our discomfort, the louder our ego becomes. The practice of allowing discomfort is the practice of integration. Integration occurs when we allow our behavioral patterns, traits, emotional states and experiences to come together in a more unified and organized state. Without integration there is separation, and with separation there is distortion.

The purpose of pain is to awaken the heart, not trigger the mind. It is not about overcoming pain; it is about recognizing and being willing to learn from it.

Some spiritual traditions will bring discomfort to the core of their practice. The intent is to teach the practitioner to stay whole while in pain and to prevent the mind, led by the ego, from directing the experience. The focus is not on overcoming pain but rather on surrendering and allowing the experience of pain to expand where it wants to be. It teaches the mind not to separate but to allow. It teaches the mind to go beyond subject-object relationship. At that moment, there is an alchemy happening in the body, and one may shift from pain to bliss because the mind is not locked into form.

The practice of being uncomfortable

Regardless of your spiritual tradition and belief system, meditation is a great way to learn to be still with discomfort. Many people express difficulties when trying to learn to meditate and often give up, believing they are not good at it. The purpose of meditation is not to add pleasure or pain but rather to develop a neutral mind that allows whatever arises. Consistency in a meditation practice paves the way for acceptance and humility, which are two beautiful qualities of the heart.

If you are able to stay still during pain, without hoping for pleasure to come, you are free. If instead of fighting against the pain, you welcome it fully, you will shift and heal. When this happens, you will realize that pain and pleasure are not opposites, but simply sensations; you are now living beyond polarities.

Being uncomfortable does not always relate to pain or pleasure; our own fears and limitations can create great discomfort. To avoid discomfort, we may prevent ourselves from taking risks and put our self-development on hold. Some may feel stuck and have pushed the pause button, whereas others might operate on autopilot by staying with their to-do list. For example, some people may stay in a relationship or job even though they know it is no longer serving them. Both are forms of avoidance.

As we learn to allow pain to be part of our experience, we need to notice other possible scenarios that prevent us from learning about our discomfort. The first scenario is to be attached to our pain, allowing it to become our identity. At that moment, our life revolves around our pain, and this limits our ability to heal and make positive changes. The second scenario is to be uncomfortable with others’ discomfort. This steers us toward being “people pleasers,” constantly focusing on others’ well-being and avoiding being in touch with ourselves. Related to this second scenario, it can also be challenging to be around someone we deeply care for who is experiencing a great deal of discomfort. We may want to “fix it” or change it as a sign of love.

The practice of being uncomfortable teaches us to stay connected with ourselves, to be curious and open. It teaches us to be relaxed and surrender into the discomfort. The more we want to control our discomfort, the more stuck we become.

Allow discomfort to be part of your experience. Welcome it fully from the heart center. At the core of your pain or fear, you will grow and you will learn.


To become comfortable with the uncomfortable, we invite you to try the following practices. As with every practice, consistency and repetition are key to gaining insights and creating change.

Practicing in itself can create discomfort. It is when you are the least inclined to practice that it may be the most beneficial. Practice teaches you to go beyond your emotional reactivity. As you keep showing up for yourself, it will get easier.

Meditation Tonglen

Tonglen is a meditation practice found in Tibetan Buddhism and used to awaken compassion. Through acknowledging our own and others’ suffering, we open our hearts.

  • Sit in a comfortable position. Lengthen your spine and draw your shoulders down your back. Soften your face and jaw. Close your eyes.
  • Connect to one part of you that is in pain at a physical, emotional, mental, heart or spiritual level.
  • Notice the quality of your pain.
  • Imagine all of the people with a similar experience and inhale their pain. Do not be afraid to “inhale” others’ pain. You will not get more pain. In fact, you may feel some relief.
  • Exhale; send relief.
  • Repeat the process for at least three minutes.


Some of you may be really reluctant to start this practice and others may simply love it. The benefits of journaling are priceless. It helps you process emotions or situations with more awareness and clarity. It is a safe container to express your voice. Research on journal writing therapy indicates positive outcomes related to identifying emotions and feelings and reducing stress. It can be a catalyst for change and healing.

  • Think of something that makes you uncomfortable. Is this new or old? What are the main emotions you are experiencing? What behaviors or strategies have you implemented? What did you learn about yourself?

Take action

Taking action is where the true learning takes place. You get an opportunity to truly assess your relationship with discomfort and stretch yourself.

  • Do something outside of your comfort zone.




This article is based on a chapter from our book WAY TO BE – 40 Insights and Transformative Practices in The Heart of Being. For more information, go to



Shari Gootter is a licensed professional counselor and certified rehabilitation counselor with decades of experience in designing and leading workshops for diverse populations. Her focus has been on helping people shift while going through losses or adjustments. She has also created programs for counselors that assist them in developing a framework that supports lasting transformation. Shari is a therapist in private practice and has taught yoga for decades. Contact her at

Tejpal has over 30 years of experience supporting individuals on their journey toward healing, life purpose and real joy. Tejpal blends her intuition, energy healing, creative processes, life coaching and yoga into her work. Tejpal was born in France and moved to the U.S. 25 years ago. She has worked with people from many cultures and traditions.


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.

Team from New Jersey City University wins ACA’s 2021 Masters level ethics competition

June 15, 2021

This award recognizes exceptional, demonstrable understanding of the ACA Code of Ethics, the foundation of ethical professional counseling practice. Each year, ACA honors top-ranking teams in both Masters and Doctoral level graduate degree programs.



ACA Graduate Student Ethics Award for Master’s Degree Students

By Mercedez Ruiz, Felipe Alexandre, Jay Sontag and Carl Bain of New Jersey City University


Madigan, Racine, Cooke, and Korczak (2020) stated that COVID-19 required an urgent change to the implementation of mental healthcare. With stay-at-home mandates and business lockdowns occurring in the interest of public safety, clinicians needed to adapt in order to provide much-needed services to their clientele while ensuring medical safety for all parties. Telemental health services allowed for a continuation of care while adhering to the safety protocols put in place. Benefits to telemental health include a reduction in certain barriers to treatment (transportation, access in rural & urban settings, reduced cost; Madigan, Racine, Cooke, & Korcak, 2020). However, there are also significant limitations to telemental health such as magnifying social inequalities (lack of adequate or no internet connection, lack of devices that can connect to the internet, lack of internet literacy; Madigan, Racine, Cooke, & Korcak, 2020). There is also the question of a clinician’s comfort and competence level to provide telemental health services. All of these benefits and limitations combined create a very unique situation that many clinicians and students may be facing when navigating telemental health services. This brings us to Shannon’s dilemma as a practicum student whose clinical field experience changed drastically due to the pandemic.


Decision Making Model: Identification of Problem, Application of Code of Ethics, and Nature of Dilemma

Shannon’s site has allowed for distance counseling but has not ensured that supervisees are able to offer knowledgeable or competent client care. In addition to lacking telehealth training, Shannon does not possess the right technological resources and cannot offer an appropriate setting to deliver confidential, ethical, or effective counseling remotely. Because supervision is overseen virtually, Shannon is finding it difficult to maintain a healthy working relationship with her supervisor (B.3.c. Confidential Settings; American Counseling Association, 2014). Shannon’s lack of training and resources, and the current management style of her supervisor, may be contributing to her feelings of discomfort towards distance counseling. Shannon is certainly faced with unique challenges caused by a global pandemic but attempting to overcome these issues would be consistent with the foundations that the counseling profession is built on.

While their recent attempts to meet have been unsuccessful, Shannon must work quickly to improve the relationship with her supervisor and address her personal concerns (F.8.d. Addressing Personal Concerns; American Counseling Association, 2014). By working closely with her supervisor, Shannon will have the best chance of achieving her main objectives — delivering confidential, knowledgeable and competent client care during practicum.

Shannon must ensure that she is skilled enough to provide distance counseling, so she must ask her supervisor to direct her towards the best telehealth training module. When discussing options, Shannon should be ready to suggest some of the online courses that she has found, especially if her supervisor is unfamiliar with telehealth training. By working with her supervisor to identify optimal telehealth training resources, Shannon may be able to obtain the right levels of knowledge and competency (H.1.a. Knowledge and Competency; American Counseling Association, 2014).

Next, Shannon must identify the best way of delivering private and confidential care to clients. Because she lives with two roommates, it may be unrealistic for Shannon to expect privacy for herself or her clients. Furthermore, internet providers in her area do not offer reliable service, which will likely lead to continued frustration for Shannon and her clients. While Shannon can inform clients of the benefits and limitations of digital counseling, the level of care that she can offer under current conditions could potentially do more client harm than good.

Shannon’s community mental health agency is limiting in-person activities; however, mental health providers do qualify as essential under current guidelines. Once she is knowledgeable in digital counseling, it may be prudent of Shannon to explore the possibility of offering distance counseling to clients from the mental health agency rather than her apartment. The agency site will presumably have the technological resources that Shannon needs for distance counseling. It is also very likely that the site can offer a private setting for Shannon to conduct digital counseling alone and undisturbed. Shannon is uncomfortable offering counseling under her current circumstances; however, it is possible that her feelings may change once she is able to offer counseling under better conditions.

Despite the global pandemic, in-person mental health services are still the only way that some individuals can obtain treatment. Fortunately, the Community Mental Health Centers Act of 1963 mandates that these community centers provide a wide range of federally and state- funded outpatient services to the underprivileged and low-income community (National Council for Behavioral Health, 2021). As such, it is possible that Shannon’s site will continue offering in- person counseling to some capacity. During conversations with her supervisor, Shannon should also explore the possibility of offering in-person counseling services at the agency. By doing so, she may be able to serve the disadvantaged members of her community, while at the same time, provide therapy in a way that is more consistent with her previous training. While providing in- person therapy may be a good option, Shannon must carefully discuss the various safeguards and protocols that are in place at the agency in order to make the best decision for herself and her clients.

Potential Course of Action

We have determined the following as possible courses of action for Shannon to take. We concede that each option has some undesirable consequences and/or risks associated with them. They are: A) to continue working from home by problem-solving individual issues; B) to explore the option of returning to the site or her university; or C) to discontinue practicum. Problem-solve current work-from-home situation (Option A)

Step 1. Consider getting supplemental training in telemental health. Telehealth training courses can be found online and are usually completed in under eleven hours (Center for Credentialing & Education, 2021). Shannon should seek out other professional development resources such as the ACA to receive additional training (there are digital resources available on the website).

Step 2. Documenting site supervisor. We are not of the opinion that this supervisor needs to be reported, given the current unusual circumstances regarding COVID-19. We do, however, believe that Shannon’s supervisor may be behaving unethically and in a way that is unjust both to Shannon and, more importantly, to the clients she is serving. Shannon should keep a regular and accurate record of the number of meetings missed by the supervisor as well as detailed notes regarding anything that has led her to believe that the supervisor is “distant.” This way Shannon has a log of the things that have been done outside of her control that may be affecting her current growth and practice as a counselor, as well as her mental health as a pupil.

Step 3. Work out a strict schedule with roommates. The efficacy of this plan is seriously limited by what kind of space Shannon has, but the reality is that she cannot continue to work in her current environment if there is any risk to the clients’ privacy.

Step 4. Work closely with her graduate program supervisor. One step which needs to be taken before any other action or plan is put in place is that she must get in contact with a program supervisor regarding the difficulties experienced with the site supervisor. While her weekly group meeting might not be the optimal time for her to voice her concerns, she still must make the time and space to reach out if she is to proceed ethically.

Desirable Outcomes

Shannon will be able to continue practicum. Naturally, Shannon is eager to complete her hours and graduate in a timely manner. Trying her best to adapt to and persevere in the current global situation would be important for Shannon’s livelihood and may even be necessary depending on her current economic standing. Additionally, clients will be able to continue service with the same counselor they are used to and with whom they have formed a rapport. It is important to remember that especially during times of national and worldwide crisis, clients who have underlying emotional challenges are made more susceptible to negative thoughts and feelings. Shannon should try very hard to continue seeing her usual clients, but only if she can provide care competently and with integrity.

Undesirable Outcomes

Shannon still has difficulty with her internet. Since this is a problem with her region as a whole, this is not a resolvable issue, and Shannon would have to continue seeing clients with the understanding that calls or sessions may be dropped. A significant risk of this ethically is that if Shannon is seeing a client who is contemplating hurting himself or others, she is at even more of a disadvantage than the normal (suboptimal) remote session would allow, since she may not be able to get back into contact with the client. Likewise, a client may forget her circumstances and misinterpret a dropped call, triggering feelings of rejection or abandonment.

Even with a schedule resolved and use of headphones, it may be unavoidable that the roommate could overhear information regarding a client. For the roommates to even know the name of Shannon’s clients is a breach of the clients’ privacy, and so the specifics and nuances of the living situation really could provide an insurmountable block for Shannon’s practice. In addition, during quarantine the roommates may not have another location to go and may be uncomfortable with leaving home or even susceptible to the COVID-19 virus. Given these circumstances, it would be important for Shannon to consider how much space she and her roommates have and if there is a way to ensure maximum possible privacy.

Return-To-Site or Find Secure Alternative Location (Option B)

Step 1. Consider getting supplemental training in telemental health.

Step 2. Seek more and better support from the site supervisor. This may require Shannon to go to her program’s faculty with her documentation or she could simply go to the supervisor and be direct about her discomfort. We would advocate the latter as a show of professionalism and respect, but if Shannon is struggling emotionally and mentally then having additional support may be necessary.

Step 3. Inquire about the potential for Shannon to be counseling clients remotely, from the site. This option has the highest potential for positive outcomes out of our three solutions.

Desirable Outcomes

As stated above, we believe that the clients should whenever possible have continuous service from the same individual to whom they have grown accustomed. Rather than seeing clients face-to-face, the risks of catching or transmitting COVID-19 are made lower by continuing to have remote therapy. Shannon’s internet service will be better at the site than in her home. Client privacy is guaranteed if Shannon is able to practice in a space similar to her previous onsite area of practice. The security and integrity of Shannon’s practice will be improved significantly if she is able to be onsite and interact with her direct site supervisor or other mental health practitioners at the community health center. Shannon can still attempt to gain feedback and consult with other professionals, rather than being isolated in her home during her practicum. Finally, Shannon can still gain her hours and experience, graduating from her program on time.

Undesirable Outcomes

It is still possible that the site may not allow for Shannon to return by herself or may not view her services as “essential.” Shannon may still have unresolved issues with telemental health even if she receives supplemental training and has a more efficient environment. Shannon may also be uncomfortable with elements related to COVID-19, particularly if she relies on public transportation for her commute or if she is in an especially vulnerable group for contraction of the virus. If Shannon is able to drive directly or walk to her site, and if the center is open and has regular sanitation maintenance, then her risk is reasonably low.

Discontinue Practicum (Option C)

Step 1. Admit Incompetency. If Shannon cannot remedy her current situation greatly using options A or B, then it is not ethical for her to continue practicing and seeing clients in this way. If she is not able to guarantee safety, privacy, and quality care to her clients, then unfortunately Shannon should show respect to the profession and her clients by stepping down temporarily and resuming her program when circumstances are better for her.

Desirable Outcomes

While we sympathize with Shannon and think that this option is to be pursued only if no other alternatives remain, it is the better option ethically. In her current state, Shannon is doing a great deal of unintentional harm. She is damaging her clients, and herself, emotionally. Shannon is not comfortable with her current level of care, which indicates that she is not in the correct place emotionally or mentally to be taking on the difficulties of others. During an unprecedented time when many people are undergoing loss, trauma, financial difficulty and instability on such a wide scale, mental health practitioners are needed and needed at their best. She is also violating her clients’ right to privacy. Shannon cannot currently guarantee their privacy by continuing to practice in an open space where her roommates may hear information or recognize faces. Currently, Shannon is also not receiving sufficient supervision to learn from or grow from her experience, meaning that even if she completes the hours necessary that does not mean her education will have been of sufficient quality to begin practicing or obtain a license.

Undesirable Outcomes

Shannon’s clients will face the difficulty of transferring counselors, and given the pandemic, it is possible that there is a shortage of working mental health practitioners to fill her spot. As stated above, we are of the opinion that it is very undesirable for clients to be taken from the counselors they have relationships with, especially during this time of general upheaval and instability. This will also have unfortunate consequences for Shannon. She may have to put her career on pause, may face financial instability, and may even experience a worsening of her currently suboptimal mental state. Our advice to Shannon if she absolutely had to follow this option would be to prioritize her own mental health and try to decompress from the stressful situation and painful decision.

Review of Options and Conclusion of Best Course

Our conclusion on reviewing these options and the positive and negative consequences of each, is that Shannon should first attempt to implement option B. If she is able to go to the site with her laptop and mask and can deliver care safely (and perhaps even receive improved site supervision and further training in telemental health) then we believe this imposes the fewest ethical violations and risks. If this option is made impossible by the site or another factor relating to Shannon’s health and comfort, we would urge her to follow the steps outlined in option A and to seek guidance on how to proceed ethically from her program’s faculty. We are unanimous that Shannon should not pursue option C unless absolutely all other factors are unimprovable. Just as a counselor would encourage their clients not to give up and to problem-solve their issues, we would hope Shannon does not cave under pressure but rather gathers herself and tries again.

Evaluation of Selected Course of Action

After reaching a conclusion regarding the best choice of action, we administered three self-tests to evaluate our choice. The first was the test of justice, asking ourselves if we would treat others in a similar situation the same (Remley & Herlihy, 2016). The second test was the test of universality, asking ourselves if we would recommend our course of action to others in a similar situation (Remley & Herlihy, 2016). If other counseling students or clinicians found themselves in a similar situation, we felt confident and comfortable that we would provide them with similar recommendations. Offering a menu of options such as receiving additional training, problem-solving privacy/internet issues at home, and seeking support from supervisors/colleagues provide the individual with an array of options that are culturally sensitive. In regard to Shannon’s situation, and those who are in similar situations, it is difficult to provide a one-size-fits-all solution to this. While for some working out a schedule with a roommate is an easy fix, others may find this very difficult. Keeping in mind that every counseling student does not have identical home environments, access to high-speed internet, and access to private office space, we feel that the course of action listed in option B is culturally considerate and promotes justice and universality. The final test was the test of publicity, asking ourselves if we were willing to have our actions be known to others (Remley & Herlihy, 2016). We felt willing to have our course of action be known and felt hopeful that having others know of our actions could provide guidance to those in similar situations.



In summary, we understand that as a graduate student and aspiring mental health counselor maintaining the competence of a consummate professional is not just an ideal but is paramount and attainable. We believe in order for Shannon to proceed ethically and with the most professional standard of care, these are the optimal options to ensure that both the clients receive adequate counseling and Shannon eschews continuing to do her clients a disservice, which could lead to irreparable harm. We also believe that these are the requisite steps to ensure her clients receive counseling that is conducive to a healthy and appropriate environment while also giving Shannon the space where she feels comfortable, competent, and supported by a present and active supervisor.



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.