Monthly Archives: January 2022

Making every moment of clinical supervision count

By Tiffany Warner January 18, 2022

When I started providing clinical supervision nine years ago, the standard at my clinic was to use the entire session to discuss cases. Case review is foundational to the supervision process, but later in my career, I learned of alternative methods of supervision. Even when I used different methods, however, there were still too many topics to cover during the one hour of supervision per week. 

Whether one looks at the 2016 Council for Accreditation of Counseling and Related Educational Programs (CACREP) Standards or the 2014 ACA Code of Ethics, it is clear that supervisors are responsible for addressing a multitude of areas with supervisees. Unfortunately, figuring out how to cover every topic seems daunting at best and impossible at worst for many supervisors, especially when coupled with their gatekeeping responsibilities. In reality, there are too many core domains in counseling to cover in every supervision session, and this must be balanced with ensuring that supervisees discuss cases for client welfare. In addition, supervisees are often unsure what to bring up in supervision; without structure, they have difficulty identifying the most salient cases or topics. 

I know from my early experiences that this was a significant challenge. I was often trying to figure out what needed to be addressed first in supervision. I recall one example when I was working with a supervisee on the topic of self-care, but as the supervisee described their self-care practices, I could hear themes related to professional development, lack of confidence, ethical considerations and diversity factors. This moment raised many questions for me: What area do I address? Is it realistic to address them all? Do we have time to do that and discuss the supervisee’s clients to ensure quality of services? 

At this point, most supervisors, myself included, would focus on any high-risk needs, but the options are not always between low-risk and high-risk situations. Consequently, in my early career, I chose to address the areas in which I was most confident or that most interested me. This response is consistent with many of the supervisors I meet as well. 

To confront this challenge and to change my pattern of addressing limited topics, I developed a three-step method to help myself cover more topics with supervisees in the same amount of supervision time. I have found this three-step method has not only helped address a wider range of areas in supervision but also modeled for supervisees what types of issues to introduce. The development of this three-step method started when I was running internship groups in a master’s counseling program. I found it very challenging to cover all the core areas that students were trying to learn while also helping the students make the leap from book knowledge to application. However, I did not want to create so much structure that students no longer had the opportunity to discuss urgent or complex cases. Therefore, the three-step method that I started using includes: 

  1. Identifying a topic list
  2. Collaborating with supervisees on the schedule 
  3. Developing processes to incorporate topics naturally
    into supervision

This three-step method can be incorporated into individual or group supervision formats. At its core, the method is designed to help supervisees deeply apply the knowledge gained during their education. 

Step 1: Identify a topic list

Whether you are someone who loves order (like me) or prefers a more organic flow, identifying a topic list can be useful to help keep pace as a supervisor. It enables you to ensure core areas are addressed and provides an opportunity to assess the supervisee in different competencies. In a sense, this creates personal accountability by developing core areas that need to be addressed and devising a method to track them.   

The topic list I have most often used is a case conceptualization. This assists supervisees with identifying important parts of a case conceptualization, learning ways to articulate the case and working toward a cohesive understanding of the case. Several options are available for outlining a case conceptualization (see also “Case conceptualization: Key to highly effective counseling” by Jon Sperry and Len Sperry in the December 2020 issue of Counseling Today). You can use the case conceptualization format that is most familiar. However, I prefer using the following outline because the order helps students build a deeper understanding of their cases. 

  1. Background and historical information: Salient details such as family structure, relationships, historical trauma, history of mental health or addiction issues, mental health treatment and medical history.
  2. Presenting problem or concern: Client’s description of their problem, what they hope to achieve, risk factors and substance use.
  3. Testing and assessment measures: Identification of any test or assessment measures that are useful for the client, their problem or treatment.
  4. Diagnosis: Past and current diagnosis, differential diagnosis process.
  5. Multicultural considerations: Demographic information, diversity or cultural considerations for the case, important cultural components that impact treatment or mental health.
  6. Systems or developmental theory considerations: Identification of any systems or developmental models or theories that are important for this case.
  7. Counseling theory: The theories or modalities that are being used, research support for the counseling theory.
  8. Treatment plan: Description of the goals, objectives and interventions for the case.
  9. Ethical considerations: Current or potential ethical issues that apply to this case. 

Another option for the topic list is to use the 2016 CACREP Standards, specifically the eight core counseling domains found under Section 2.F.: 1) professional orientation and ethical practice, 2) social and cultural diversity, 3) human growth and development, 4) career development, 5) counseling and helping relationships, 6) group counseling and group work, 7) assessment and testing and 8) research and program evaluation. Although this topic list does not provide the ordered structure of a case conceptualization, it does cover the core areas that developing counselors need to understand and apply to clinical cases. 

One final option would be to use the various competency standards for professional counselors such as the Competencies for Addressing Spiritual and Religious Values in Counseling developed by the Association for Spiritual, Ethical and Religious Values in Counseling or the Minimum Competencies for Multicultural Career Counseling and Development created by the National Career Development Association. Using competency statements can be particularly beneficial if you are supervising within certain settings such as a religious institution or career center. Depending on organization of the competency standards, you would use each standard to help build competencies over the course of supervision. Because most competency standards include a focus in areas of knowledge, awareness, skills and ethics, you can still cover most of the areas outlined in the case conceptualization but with a focus on a particular genre or population. 

My three-step method provides flexibility for you to create a topic list that fits the supervisee, setting and population. I believe the case conceptualization is a better option given its practicality to the counselor’s everyday work. In addition, it provides language and an understanding of the case that is easier to translate into documentation, billing and other business aspects of a counselor’s work. No matter what topics are used, what is important is identifying a list that fits well within your supervision model and setting.

Step 2: Collaborate in setting the schedule

The onus is on the supervisor to ensure that the supervisee is building competency, which might lead to the supervisor determining the schedule of topics. However, there is value in involving the supervisee in this process. In this second step, the supervisor brings the suggested topic list to the supervisee to establish the schedule of topics. This has several purposes. 

First, it provides opportunity to assess the supervisee and their developmental level. You can use formal or informal processes at this step. The goal is to ascertain what the supervisee understands and their current skill level. In this way, you can tailor the list to the need of your supervisee.

Second, this step helps the supervisee take ownership of their development by identifying their own strengths and growth areas, which can assist you in targeting how to incorporate each topic (see step 3 below). For example, a supervisee might show solid understanding of counseling theory but need more assistance with knowing when to use what theory. Another supervisee might demonstrate strong skills with understanding a case but struggle to create a cohesive case conceptualization. At this step, supervisees are also able to identify areas of interest that might be included in the schedule of topics. 

Finally, this step can model the process of collaborating with a client to develop goals. This creates a great parallel process in which the supervisee learns how to work together to create the goals for supervision, which translates well to the counseling room.

After collaboration, the schedule is set up to address one topic per supervision session within a specific time frame, such as over a three-, four- or six-month period. At the end of this time frame, the schedule could be repeated or a new schedule created. 

At the conclusion of this step, you’ll have a set schedule of topics that incorporates the topic list from step 1 along with the supervisee’s feedback. So, you could end up with a four-month rotation of topics in which weeks one through nine focus on going through the case conceptualization and weeks 10 through 16 focus on reviewing the supervisee’s areas of interest. Another option might be a schedule in which each CACREP standard is reviewed in weeks one through eight and then weeks nine through 16 are spent taking each standard deeper to strengthen the supervisee’s development. In this way, the creation of the schedule becomes part of the supervision process. 

Step 3: Incorporating topics into supervision

While the schedule of topics is very structured, the final step offers more flexibility. I prefer to weave the topic into the cases or questions that are already discussed in supervision. In this way, the schedule of topics can be inserted into supervision organically. It uses time more efficiently by capitalizing on what is already brought into supervision. It also enhances a supervisee’s understanding of how these topics directly relate to their current clients. For example, if the topic is “diversity considerations,” you might pose questions during the case discussion or use an existing case to explore the topic deeper. Because this process is more organic, it requires that you quickly formulate the best plan to incorporate the topic. 

To help explain this process better, I’ll offer a case vignette of a supervision meeting. In this example, the topic of the week is the “presenting problem or concern.” The supervisee has brought up a particular case that has been difficult for her because she does not think progress is being made in treatment. The supervisee has been discussing a client who has sought treatment for depression but reports continued depressed mood and lack of motivation. In addition, the client reports a history of addiction but has been clean for six months. The supervisee and client have been seeing each other for five sessions. 

This supervisee has struggled in the past with clients who lack motivation. So, prior to this portion of the supervision session, the supervisor and supervisee focused on the countertransference that the supervisee experiences with clients with low motivation. At this point, the supervisee has had the opportunity to work through the reason for bringing up the case, and the supervisor sees an opportunity to bring in the scheduled topic. 

Supervisor: As I mentioned earlier today, this week’s topic is the presenting concern, and it seems like this client might be a good fit for the topic. As you have mentioned, the client seems to lack motivation. Tell me about what the client’s presenting concern is or how the client would describe their problem.

Supervisee: Well, when we first started, he said he wanted to be less depressed, but we have not really worked on that much. He doesn’t seem to want to talk about anything when he comes in.

Supervisor: So, he identified reduced depression when he started. What other things did he mention?

Supervisee: I can’t think of anything. 

Supervisor: Let’s see if we can’t expand on that a bit. It is common for clients to not have a clear description of what they want when they first start. Based upon your meetings with the client, what do you think the presenting problem or concern is?

Supervisee: I guess that is part of the challenge when I meet with him. I am still not sure. I guess he wants to reduce the depression, but it has been so hard to discuss this with him.

Supervisor: So, we have already established that he lacks motivation, which is common with people who are depressed. I wonder if we can be more specific and think about how you might describe the problem from either a behavioral, cognitive, affective or interpersonal lens? 

Supervisee: Well, he has mentioned several times wanting to see his children again. He stopped seeing them after his last relapse. This might be a behavioral problem that he doesn’t see his children. 

Supervisor: Great. How have you explored this area with him so far?

Supervisee: We haven’t done much. When he brings it up, I ask about what he can do to make that happen, and he just becomes upset. 

Supervisor: Well, it sounds like there might be some deeper challenges there, but let’s finish up with the presenting problem. You have at least one possible goal for the client. I wonder if there are others.

Supervisee: When he talks about wanting to see his children, he has mentioned several times about how he is a failure because of his past substance use. So, I guess there could be something there regarding a cognitive-based problem. 

Supervisor: So, it seems like there are maybe more specific concerns that you could bring into session.

As this vignette makes evident, the supervisor addresses the main concern brought to supervision and uses the same client to also address the day’s topic. This leads to an even richer conversation with the supervisee around some barriers to treatment, such as unclear goals. By using the existing client to discuss the topic, the supervisor is also able to skip repeating the case information, which utilizes supervision time more efficiently, and connect the topic to the clinical issues that the supervisee is wanting to address.

I prefer a more organic incorporation of the topics, but for some supervisors with less experience, this may be too challenging at first. Another option is to have set time during supervision to cover the topics. This could include doing activities such as role-plays, reviewing the major content in the topic area, selecting a client who fits well with that topic or using vignettes to discuss a topic. For example, if that week’s topic is “background and historical information,” the supervisor might role-play how to conduct an intake interview. If the week’s topic is “diagnosis,” the supervisor could include a vignette to help the supervisee work through differential diagnosis. This process can be useful when working with supervisees who are early in their development as counselors. However, it can also seem forced or too basic for more advanced supervisees or require setting aside time that might already be limited. 

Another aspect to consider when choosing the process for incorporating the schedule of topics is the background knowledge that the supervisee possesses. Some supervisees come to supervision with a strong understanding of the different topics, whereas others are early in their development or didn’t receive much prior training on the topic. In these instances, taking time to provide a short training or refresher may be useful. For example, if the topic is “test and appraisals,” you might consider reviewing validity, reliability and the process for determining an appropriate test. 

Finally, you have the option to use some or all of the processes identified here. You could consider providing a short training on the topic, identifying key questions and bringing those questions into the cases discussed during supervision. Ultimately, as a supervisor, you will determine which process fits best with your development as a supervisor, your supervisee and your setting. 

Benefits and problem-solving

An additional benefit of this three-step method is that it assists you in knowing what core areas have been addressed throughout supervision. It is easy to be unaware of the developmental areas that are missed with supervisees, and structuring supervision in this fashion can help mitigate this potential issue.

fizkes/Shutterstock.com

This can then translate well during evaluation times to allow for a more robust formative evaluation process. For example, some evaluations used in state licensure require that a supervisor specifically address the counselor’s diagnostic competency. The supervisor who uses this three-step method can be confident of their assessment of a supervisee’s diagnostic skills. 

The biggest challenge to using the three-step method can be the appearance of rigidity. As any supervisor knows, there are times when high-risk or urgent clinical needs take precedent over any other topic in supervision. Using a topic list does not preclude you from addressing urgent needs; there is space to change course in supervision and not address the topic. 

In fact, the topic list can produce the identification of urgent needs more regularly by training the supervisee on the different areas that should be addressed in supervision. For example, regularly bringing in ethical considerations can move the supervisee from seeing the ethical standards as rules and toward realizing how ethics standards apply to specific cases. This in turn can help supervisees move beyond just addressing confidentiality and abuse reporting to also recognizing potential boundary issues and scope of practice questions. 

The three-step method and group supervision

We have focused mostly on the use of this three-step method in individual supervision. However, there is value to using it in group supervision as well. 

In group supervision, managing time is even more challenging because multiple supervisees are vying for space to address clinical issues. Often, the goal with group supervision is that supervisees will learn as much from each other as from discussing their own caseloads. By establishing a topic list and schedule, you can be sure that more topics are covered for the benefit of multiple supervisees. 

Regarding the earlier vignette, if this conversation took place in a group setting, the other members would have the opportunity to listen and offer feedback on how to address countertransference and the role the presenting problem can play in treatment, even without bringing up their own cases. This could result in these supervisees being more likely to incorporate the presenting problem in other cases. 

Using the three-step method as a supervisee

The role of the supervisor is to teach, model and assist the supervisee in development as a counselor. But even if you are not providing direct supervision — if you are receiving supervision instead — you can still use this three-step method in your own development. 

This could include developing your own schedule based on the case conceptualization provided to you in your training or the competencies that you want to improve. After creating the schedule, you can use that to determine different topics that you want to address in supervision while prioritizing the high-risk issues and supervisor instruction. In this way, you can receive the benefit even if your supervisor uses other models of supervision. 

Supervision is a beautiful process of becoming a seasoned counselor, and as a supervisor, I have had the honor of walking with many supervisees through this process. I take this charge very seriously, which is why I emphasize providing a well-rounded supervision experience. Using this three-step method, I have found success with engaging supervisees on many fronts more efficiently while providing practical application of a counselor’s core functions.

 

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Tiffany Warner is a licensed professional counselor and board-approved supervisor who specializes in working with severe and persistent mental illness. She is currently working as adjunct faculty at Multnomah University and is pursuing her doctorate in counselor education and supervision through the University of the Cumberlands. Contact her at twarner@multnomah.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.

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

Overcoming counselors’ hesitancy to engage with autism

By Jennifer Jenkins January 17, 2022

According to estimates from the Centers for Disease Control and Prevention’s Autism and Developmental Disabilities Monitoring Network, approximately 1 in every 54 children are identified with autism spectrum disorder (ASD). As the number of diagnoses continues to increase, there will in turn be an increased need for services, including mental health services.

As a licensed associate professional counselor, AutPlay therapist and registered play therapist-in-training, I am familiar with the mental health needs presented in those with ASD. As a mother of two children with ASD, I also have a personal perspective that gives me an empathetic understanding of the autism world and the families of individuals with autism. 

There is a famous saying in the autism community credited to professor and researcher Stephen Shore: “If you’ve met one person with autism, you’ve met one person with autism.”
But what does that mean, and how does it relate to the world of counseling?

ASD

ASD is a neurodevelopmental condition characterized by severe and pervasive impairments in communication and social interactions and repetitive and stereotyped patterns of behaviors. ASD is a spectrum disorder or heterogeneous and not linear, meaning that individuals are autistic in different ways. In other words, ASD symptoms fall on a continuum and present in various combinations, with some individuals showing mild symptoms in an area and others showing more severe symptoms. This is important for counselors to consider because every single person with ASD can present with their own complex and unique symptomatology. It is also meaningful to note that ASD is a lifelong diagnosis and affects the entire family. 

In plain language, individuals with ASD can be described as literal, direct, honest, persistent and loyal. Additional reported characteristics include the individual being uncomfortable with direct eye contact and preferring specific textures of food and clothing. Typical behaviors include stimming, which can consist of rocking, flapping of the hands, pacing or verbal repetition. Unexpected events or changes in routine can cause distress in individuals with ASD, and their social/emotional skills are behind, exaggerated or even nonexistent. That being said, it is important to remember the heterogeneous nature of ASD; not all of the characteristics will be present in every individual with ASD. 

The autism community

Interestingly, a substantial amount of dissension exists in the autism community as a whole. As the mother of two children with ASD who are very different yet similar, I have many parental opinions. My children, who are actually autistic, have their own views on autism. Furthermore, the medical community has opinions on autism, and then those individuals who are autistic have their opinions. So, who is right? How do we tell the difference, and what is our role as counselors? 

It is critical to consider all evidence-based research practices and the opinions of stakeholders (i.e., medical professionals, parents, and individuals with ASD). However, it is important to know how we, as counselors specifically, can help and what role we can play to assist the ASD population. 

Within the autism community, there are individuals with ASD who dislike applied behavior analysis (ABA) therapy; they want the word disorder to be changed and have very insightful opinions. In addition, there must be a standard in identifying autism in the medical community. Some commonality through the newest definition in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders is the best attempt to have a standard definition for ASD for all stakeholders. Finally, parents of children with ASD, like myself, have a variety of opinions. As a parent, I want to hear the voices of those who are actually autistic, but I also know that certain therapies did work and helped my children achieve as much as they have so far in life. 

As counselors, it is essential to think of our helping role and how we might have a positive impact on the mental health of individuals with ASD. 

ASD and mental health

So, what mental health needs do individuals with ASD really have, and are those not just symptoms of the ASD diagnosis? Although that is an intriguing suggestion, it is just that — a suggestion. The research on ASD and mental health reveals that psychiatric comorbidity for children with ASD is as high as 70%-75%. The most common areas of comorbidity are anxiety disorders, attention-deficit/hyperactivity disorder, obsessive-compulsive disorder (OCD), depression and eating disorders. Overall emotional regulation can be internalized (anxiety, depression or OCD) or externalized (tantrums, crying and acting out). 

Anxiety and depression in ASD are common, and clinical studies have found that clinically significant anxiety symptoms are associated with increased irritability, sleep disturbance, disruptive behaviors, inattentiveness and health problems. Anxiety in ASD can exacerbate typical ASD symptoms such as social impairment, negatively affect daily living skills and adversely influence relationships with teachers, peers and family. Failure to recognize or treat anxiety associated with ASD leads to unhelpful management of symptoms, whereas treatment can improve independent function. 

Depression is four times more likely to occur in individuals with ASD than in their neurotypical peers. Typically, depression occurs more in the teen or adolescent years and carries into adulthood. Studies on depression and ASD have found that depression increases with age due to social and communication deficits combined with perseverative behaviors. 

Emotional regulation is another core area of concern. Emotional regulation is the concept of controlling the intensity of one’s emotions, at either a conscious or unconscious level, before or after a triggering event. In describing emotional regulation as it applies to ASD, Rebecca Shaffer and colleagues, writing in the Journal of Autism and Developmental Disorders (2019), concluded that emotional regulation can be adaptive or maladaptive. Adaptive regulation implements effective coping strategies, whereas maladaptive regulation is associated with behavioral challenges. Overall, children and adolescents with ASD struggle with emotional regulation, thus reducing their ability to cope with current and future stressors. 

Individuals with ASD have difficulty with social and emotional understanding related to adopting the perspective of others or perspective-taking. Some research on individuals with ASD who have demonstrated higher levels of adaptive emotional regulation has also shown greater prosocial behaviors and increased social development. 

Evidence-based practices

ABA is considered the “gold standard” in the treatment of children with ASD. ABA is an empirically evaluated treatment that effectively reduces inappropriate behaviors and increases learning, communication and appropriate behaviors. The professionals who have the education and training to utilize ABA in practice are called board certified behavior analysts (BCBAs) and registered behavior therapists (RBTs). These professionals are trained in how and when to use specific approaches, with the BCBA establishing the plan and the RBT executing the plan. If the behaviors of an individual are deemed maladaptive or socially unacceptable, they can be altered or changed by applying ABA principles. 

Although ABA is considered the gold standard, there are some limitations to ABA, such as defining socially acceptable behavior, which depends on the culture. Additional limitations can include waitlists to access ABA services, the time commitment for services (many BCBAs will recommend a minimum of 10-20 hours of ABA per week for individuals), and financial considerations, because these services are not consistently covered by all insurance plans. Within the field of ABA, researchers such as Justin B. Leaf and colleagues, writing in Behavior Analysis in Practice in 2017, have expressed concern that the training and assessment content is not extensive enough or consistent with current research for appropriate training in the overall implementation of behavior therapy. 

Finally, it should be noted that ABA is a behavioral approach and does not address the mental health needs of children or adolescents with ASD.

What about CBT?

If I received a nickel for every time that cognitive behavior therapy (CBT) was suggested for my children with ASD, I would be a very, very rich mom. As a counselor, I understand the robust research basis of CBT, and I even use it in practice. So, why would I have any thoughts other than, “Yes, use CBT”? 

In the world of ASD, children who understand their diagnosis even a tiny bit are told that they think differently, that their brain works differently. With CBT, we would suddenly be telling them that their thoughts are irrational. The mom in me is like, “Great, my children are going to need therapy on top of their therapy.” 

In my practice, I have heard from many other ASD families and caregivers who have also been told to try CBT. They question whether their child possesses the mental understanding to comprehend CBT techniques. CBT is talk therapy. In addition, there is the question of whether CBT is developmentally appropriate. CBT requires more complex, symbolic, abstract, metacognitive, consequential and hypothetical thinking, consistent with the greater cognitive sophistication of adults, not that of children or adolescents with ASD.

Counselors’ hesitations

There is limited research on counselors working with the ASD population and, again, ABA is typically the first treatment modality suggested. However, ABA is a behavioral treatment and not appropriate for social-emotional and overall mental health needs. 

So, why are counselors hesitant? One of the first concerns is that individuals with ASD do not respond the same way to treatment interventions as neurotypical children do. That means that services are unprepared to adapt, support and treat this population. Some counselors mention a lack of training. Most counselors feel comfortable treating anxiety and depression, but the lack of training and understanding of individuals with ASD prevents some counselors from engaging in therapy with this population. Another concern counselors may have about working with the ASD population is that the therapy process can be challenging due to a lack of clear treatment goals, complex presentation, considerable time spent on care coordination and a slow rate of progress. 

The good news? Despite these challenges, many counselors have reported a willingness to serve the ASD population, especially when provided with better training and interventions. 

Therapeutic alliance and ASD

The counselor’s magic wand! The therapeutic alliance is a known contributor to treatment outcomes in counseling. The therapeutic relationship between child and counselor strongly influences the productiveness and progression in the child’s journey to personal growth and self-healing. 

For children with ASD, the therapeutic alliance is thought to account for a significant portion of therapeutic outcomes. Overall, the therapeutic alliance encourages clients’ compliance with treatment and motivates them to engage in optimal emotional processing. Finally, the therapeutic alliance is essential with children with ASD because it:

  • Serves as a model for relationships with others
  • Provides them an environment in which to learn and practice social skills and receive feedback
  • Helps them improve their overall functioning by providing them with a better understanding of themselves and others 

A therapeutic working relationship is best established with a child through play, and building this relationship is an essential element of any therapeutic process. 

Play therapy

Play is an instinctive way of expression and exploration for children. Play acts as a medium of expressing a child’s inner world and needs and allows the child to alter reality and make it more manageable. Play is critical because it provides a platform for the child to express symbolically what they are unable to put into words. 

As defined by the Association for Play Therapy, play therapy is the “systematic use of a theoretical model to establish an interpersonal process wherein trained play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development.” 

Play therapy has been shown to be effective in addressing a wide range of children’s presenting problems, including emotional and behavioral issues. In play therapy, children use toys, art supplies and sensory media (e.g., clay, play dough, sand) to communicate through action rather than through words, thoughts, feelings and experiences. Play therapy can be directive (structured/focused) or nondirective (humanistic) in nature. 

Play therapy has been established as a developmentally appropriate intervention for children and adolescents, in contrast to the traditional counseling approach of talk therapy. Play therapy is appropriate for children because of their limited ability to think abstractly. Play is considered the natural form of expression for children, allowing them to work through issues that are appropriate to their developmental level. Play is naturally reinforcing, making it an easy way to engage children in working on their difficulties. 

Counselors use skills in play therapy such as tracking to follow along with play and stating aloud what the child is doing in order to show attending. Play therapists restate things said in play, help summarize and organize what is happening in the play and reflect back feelings when expressed by the child. 

Play therapy and ASD

Given the heterogeneous nature of an ASD diagnosis, a diverse intervention may be the best option to treat the variabilities. With a child with ASD, there is a need for therapeutic flexibility, which calls for a therapist possibly changing their style of work, expanding their theoretical orientation and actively seeking approaches that can best address a particular child’s needs and concerns. Play therapy is appropriate for children with ASD because it provides opportunities to engage in play activities, improving empathy through the development of social, language and cognitive skills and overall relationships. 

Another challenge with children with ASD is communication. Through play therapy, toys become the child’s primary means of expression, giving them the ability to project their feelings on ambiguous stimuli. When play occurs in a safe, caring and culturally sensitive environment, children can freely express themselves. This expression allows them to work on self-esteem and social anxieties without fear of breaking the rules. With play as a therapeutic technique, children have the opportunity to learn about their world through inquiry and exploration. 

There are various theoretical underpinnings for play therapy, including psychoanalytic and Jungian play therapy, child-centered play therapy, cognitive-behavioral play therapy, filial play therapy, Theraplay and AutPlay therapy. This is not a comprehensive list of all the play therapy modalities. Counselors can easily find a natural theoretical connection with play therapy. 

Play therapy certification is a post-licensure credential and includes the following credentials: registered play therapist, registered play therapist supervisor and school-based registered play therapist. Play therapists undergo extensive training, supervision and education in play therapy to earn these credentials. The Association for Play Therapy (a4pt.org) is the national professional society that governs the play therapy credentials. It also provides many resources for professionals, including extensive research, training and education.

myboys.me/Shutterstock.com

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Jennifer Jenkins is a doctoral candidate in the counselor education and supervision program at Capella University. She is a licensed associate professional counselor and former school counselor. She works in a private practice in Warner Robins, Georgia, where she specializes in helping clients and families with developmental disabilities. Contact her at jjenkins72@capellauniversity.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.

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

Reintegrating into a changed world amid an ongoing pandemic

By Katie Bascuas January 12, 2022

Samuel Bearer, a licensed professional counselor in St. Louis, remembers hearing a podcast interview back in fall 2020 with sociologist and author Brené Brown in which she described how the initial shock of the COVID-19 pandemic and its effects on people’s day-to-day lives had helped many individuals push through the early stages of the crisis, but after several months of pandemic living, people were starting to wear down. 

“When there’s a sense of ‘I’ve been dealing with the unknowns for so long,’ there’s more and more energy it takes to maintain that level of hypervigilance,” Bearer says. “That comes at a high cost.” 

At that point in the pandemic, many counselors began witnessing an increase in anxiety and depression among their clients. Some providers shifted their practice from one that had focused on supporting clients with self-actualization to one that supported clients with learning survival skills. 

“You can’t self-actualize if you don’t have your basic needs met,” says Ashleigh Jackson, a licensed mental health counselor in Melbourne, Florida. “So, if there was a job loss or a partner’s job loss, money and paying bills became the priority.”

Fast-forward 12 months, and the levels of exhaustion and stress felt by many were even higher. The need for further decision-making and risk assessment turned a new corner as people started returning to work and school amid a surge in COVID-19 cases resulting from the delta variant.

As breakthrough cases mounted, dampening some of the initial excitement about the vaccine’s promise to significantly slow the virus’ spread, many people were left to wonder when or if the pandemic would end. Add to that the heated political debates around mask wearing and vaccine mandates, as well as a deluge of negative media coverage, and you get a recipe for increased levels of anxiety, depression and fatigue. 

Counselors were faced with supporting clients as they navigated even more change, with added layers of uncertainty, during this reentry phase. Despite the challenges and the continued strain on many individuals — including counselors themselves — some providers began to identify opportunities for growth, both for clients and the profession.  

Reassessing values around work and home

For some people, the initial reentry phase was an exciting time — a chance to return to old activities and familiar ways of life. But for others, it presented added stress for any number of reasons, including individual health concerns, the complexity of navigating a “new normal” and, for some, the realization that they were now very different from the person they had been 18 months earlier when the pandemic began.

To help clients manage some of the uncertainty around the reentry phase, Bearer says he tried to help clients see the opportunities in the transition. “The reentering is also about ‘Do I want to go back to doing what I was doing, or do I want to make a switch?’” Bearer says. “Anytime we face a crisis like that or we lose a piece of our identity, which might have been part of the work that we did — and all of that might have gone up in the air — there’s a sense of ‘Has this fundamentally changed me or not?’”

Some of those changes might include minor adjustments, such as changes in appearance or office attire. “I’ve seen several clients transition back to work and wonder, ‘Do I have to do my hair again?’” Jackson says. “But you don’t have to do these things. Those were all things that we thought that we had to do, and now we learned that we don’t.”

Some shifts that people were experiencing were more significant, however, such as deciding whether they wanted to return to working in an office setting or whether they even wanted to keep their jobs. Both Jackson and Bearer say that being a sounding board for clients to explore alternative work or employment scenarios became an important part of their work. Bearer also used the opportunity to help clients assess their values around work. 

For example, Bearer found that for various clients, 18 months of teleworking had different effects on their work-life balance. Whereas some found the extra time valuable to devote to personal or family needs, others struggled with delineating their work and home lives and subsequently felt overwhelmed. 

“To whatever degree that we have been affected by the pandemic, there may be moments that we come to where we can clarify for ourselves, to say, ‘Hey, if I’m feeling the tension between the value of work and the value of home, how do I clarify that for myself?’” Bearer says. “It’s normal that we fluctuate through life, but now we are learning more how to recognize which stage we’re in and what we need to prioritize.” 

Bearer hopes that as more people reenter the workplace or return to pre-pandemic commitments, they get the opportunity to identify a new balance among all of their responsibilities, whether that’s at work, school, home or with family. He encourages people, where possible, to recognize this as an opportunity not to default to the broader culture, but rather to make individual choices that better resonate with their unique goals and lifestyles.

Halfpoint/Shutterstock.com

More people taking risks

In addition to decisions around work and how to return to an office or workplace, Jackson says she has noticed more clients taking large leaps of faith and making significant life changes as things began to open up more. “People are learning that life is short and everything can be gone in a moment,” she says, “so some are taking drastic risks, moving across the country, ending relationships, ending careers.”

The combination of those life changes with the physical reentry process can be a lot to manage at one time, adds Jackson, who compared the reentry phase during COVID-19 to reentering the world post-divorce or after the loss of a loved one. “We’re not the same,” she says. “But we have to figure out ‘Who am I now?’ integrating everything that’s happened, and then determine ‘How do I show up?’” 

Jackson says that encouraging clients to reintegrate slowly and giving clients “permission” to not be awesome at reintegrating right away was helpful in her work with individuals feeling tension around the reentry process. She also helped to normalize clients’ fears and concerns, taught grounding and mindfulness strategies, and recommended that clients take advantage of collective resources, such as meditation and breathing apps. 

Managing added stimuli

Those techniques are also helpful when dealing with the overstimulation that can come with reentry, says Emily McNeil, an LPC who owns the Mariposa Center for Infant, Child and Family Enrichment in Denver.

“Meeting all the demands of work and family and extracurriculars … it’s a trigger for a lot of depression and anxiety because people went from very low stimulation, in a lot of ways, to incredible stress and more demands, on top of the fact that we’re not out of the pandemic,” McNeil says. She incorporated a healthy dose of mindfulness, breathing and somatic techniques to help clients focus on the present moment and encourage them to take one day at a time. 

McNeil and other clinicians in her practice also began referring clients to other providers, including acupuncturists, psychiatrists, massage therapists and craniosacral therapists. Given that she primarily works with children, McNeil and her colleagues also found themselves reaching out to schools more frequently. “We’ve been creating community with schools to make sure that the schools and the family and the community-based providers are all on the same page with how to support children who might be struggling,” she says. “So, our amount of case management at this time is really high.”

Not only are people being barraged with added stimuli from the physical reentry process, but many are also feeling overwhelmed with the noise coming from the media.

“It seems like we’re constantly being bombarded with breaking news and information and opinions right and left, and this can often take us out of the present space and into a pseudo reality,” says Kristin Prichard, an LPC in Houston. “Then you compound that with a novel worldwide pandemic and the restrictions and lockdowns, and it can cause our brains to go into survival mode and trigger a recurrent fight-or-flight response.”

Prichard also noticed that some clients began to create rigid opinions or reactions to try and compensate for and feel safer amid the influx of information and differing opinions. “They want to go to an extreme and say, ‘I’ve weighed it, this is my decision, and I’m not going to waiver from it,’” Prichard observes. “It’s like a protection mechanism.” 

To help clients manage this type of fixed thinking, Prichard says she tries to meet clients where they are and model flexibility. “Something that I’ve tried to help individuals navigate in therapy is being more open-minded and taking in that information, but finding a way to process it before just automatically going to an answer,” she says. “[It’s about] exploring options.” 

Encouraging flexibility was helpful when supporting clients as they navigated interpersonal relationships at a time when more people were gathering but not everyone was on the same page about risk and safety precautions. Prichard urged clients to have an open dialogue, as much as possible, with those they were involved with. “The best thing to move forward is to recognize that nothing is set in stone, and you really need to have open communication with others and have patience and a general level of respect,” she says.

Recognizing resilience

Despite the increase in mental health disorders and the challenges centered on navigating a new normal, another theme that many counselors noticed as the pandemic wore on was a rise in demand for therapy services. This can be interpreted as a sign of resilience, according to some providers.

“While at times it is difficult to navigate, and there are lots of challenges and setbacks as we progress and then take a step back and then progress forward, overall I’ve recognized that more people are reaching out for help,” Prichard says. “You’re seeing the resiliency of individuals and people wanting to reach out for support.”

The reentry phase provided yet another pivot point — or opportunity, depending on how you look at it — to help reframe people’s mindsets from one of discouragement and frustration to one of strength and adaptability.

“There are so many times when I’ve felt, and when I’ve heard from colleagues, clients and supervisees, that I can’t take one more thing, and then there is [one more thing], and people keep going,” McNeil says. “They figure it out.” 

McNeil began using examples of people’s resilience to help validate their strengths. “A lot of people who are coming to counseling say things like ‘I’m broken,’ and I never agree with that, but this has been an opportunity for people to look within themselves and see all the things that they continued to do over the last year and a half and hold the mirror up and say, ‘Actually, you’re not broken. Look at how resilient you are even as hard as this has been. You’ve gotten through it, or at least to this point.’”

While counselors were helping clients recognize their personal resilience in the face of one more hurdle, many professionals were also recognizing their own limits and fatigue. Thus, a potential side effect, or benefit, of the pandemic’s longevity was the realization among some counselors of the need for greater personal and professional well-being to ensure effective and sustained practice.

“I’m a huge proponent and advocate for therapists having their own therapy,” says Jackson, who realized a greater need to engage in personal therapy during the pandemic. “Everyone was in crisis, as opposed to a few [clients] every week, so I had to enlist my own support to process how this was all affecting me.”

In addition to therapy, some counselors found themselves reaching out more to colleagues and others in the field who were facing similar experiences. 

“I think it is really helpful to build a community of support,” McNeil says. “So, having colleagues who have your back, whether you work with them or whether they’re peers who you get coffee with or connect over Zoom with. [Having] other people who really get what you do and can share notes with you about what it’s like to work in a virtual world when we’re a relational profession.”

A new balance?

The reentry phase also presented an opportunity to assess the value of teletherapy, which became a necessity in the early stages of the pandemic but less imperative once the vaccine became widely available.

“At first I, as well as some of my colleagues, were leery of telehealth,” Prichard says. She explains that the fear of losing a sense of physical presence and connection with her clients, as well as the potential difficulty of picking up on clients’ nonverbal cues, initially made her question the effectiveness of teletherapy. However, after several months of providing virtual services to clients, Prichard says she came to respect the benefits that telehealth provides. 

“What it does offer is a sense of calmness or peace for the client to know that at any time, they can check in for a therapy session from wherever they are, and they can do it in their own space, feeling comfortable, and they don’t have to deal with all the stressors and ins and outs of going into a session like traffic and parking,” Prichard says. “From that standpoint, I think it’s been a unique but rewarding thing to realize that we can provide good service care in different forms than we first recognized.”

While there are very real benefits to teletherapy, in-person therapy continues to have its benefits as well. So, what will the future delivery model for professional counselors look like? Maybe a mix of both. 

“You can move forward with the new technology and a new way of doing things while still respecting other ways that you’ve done things before and finding a balance between the two,” Prichard says. 

This balanced approach may also present the opportunity to serve more clients, especially if licensure portability can keep track with the technology, Jackson adds. (To learn more about the Counseling Compact effort that the American Counseling Association is supporting, visit counselingcompact.org.)

“I am encouraged that the pandemic has brought a lot of counselors to virtual,” Jackson says. “It has increased accessibility for so many people who otherwise would not get therapy, and I’m really hopeful that this will carry over into more portability for us so that we can see people in different places. We will be dealing with the effects of this for a really long time, so we need to be able to help as many people as we can in the ways that are ethical.”

 

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Katie Bascuas is a licensed graduate professional counselor and a writer in Washington, D.C. She has written for news outlets, universities and associations.

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

Behind the book: Distance Counseling and Supervision: A Guide for Mental Health Clinicians

Compiled by Bethany Bray January 11, 2022

The COVID-19 pandemic exponentially increased counselors’ use of distance counseling and moved telebehavioral health from a lesser-used, avant-garde approach to a mainstream practice within the counseling profession, say Daniel G. Williamson and Jennifer Nivin Williamson, co-editors of the ACA-published book Distance Counseling and Supervision: A Guide for Mental Health Clinicians. There are both pros and cons that come with this development, but, most of all it affords an opportunity to refine and implement best practices for distance counseling.

“The COVID-19 pandemic quarantine will serve as a watershed event that ushered in the use of telehealth … It is remarkable how our profession rose to the occasion during this crisis,” say the Williamsons, who are both core faculty with Capella University and co-founders of PAX Consulting and Counseling in Texas. “It is an exciting new frontier for the field. The challenge in the ethical and legal aspect is that the technology and oversight are a moving target, and it is challenging for counselors to keep pace with the changing rules and regulations.”

 

Q+A: Distance Counseling and Supervision: A Guide for Mental Health Clinicians

Responses co-written by book co-authors Daniel G. Williamson, Jennifer Nivin Williamson, Marty Jencius, Susan Belangee, Stephanie Marder, Jeff Parsons, Angela McDonald, Jason Martin and Mykia Griffith.

 

From your perspective, what are some “pros” and “cons” that have come from counselor’s increased use of telebehavioral health?

Jason Martin: The clearest and greatest “pro” is definitely the increased availability of counseling that telebehavioral health brings. If someone has access to the internet, they can now access counseling services. People who live in more remote areas, have transportation issues, or health issues can now access counseling. Because of the hesitance some clients have about seeing a counselor within the community where they live and work, they now may access counseling services in other communities, thereby providing an additional layer of privacy within their home community. Above all else, these “pros” provide unprecedented access to care, and that impact cannot be overstated.

The “cons” are a bit more complicated. First, while the technology used for telebehavioral health continues to become more user-friendly, there are still many people who may struggle with the technology necessary to make it work. Some may not even have the devices needed to access telebehavioral health. Second, it also may bring insecurity to the counseling environment. No longer may the counselor be able to restrict who may enter the therapeutic setting because the client’s environment may not be secure or even private. Third, some clients and counselors may experience interacting through a computer screen to be less intimate and personal than meeting face-to-face, thereby affecting therapeutic rapport, and increasing possible distractions.

 

The circumstances of the COVID-19 pandemic have led to some clients never meeting their counselor in person. What are the nuances that counselors should be aware of and mindful of when treating a client 100% virtually?

Marty Jencius and Stephanie Marder: Counselors should be aware that a virtual presence is possible even when meeting with clients using telebehavioral health. Like many tools available for use by counselors, how a client’s outcome is impacted depends on how the counselor wields the tool. Clients can form a solid therapeutic relationship with a counselor online or over the phone. It may not be a counselor’s preferred way of working, but in response to the pandemic, counselors have had to embrace a change leading to a new way to provide client service.

Some insights gained from practicing online throughout the pandemic:

  • Invest in a good microphone and earbuds so your client can hear you clearly and you can hear your client without distraction from outside noise.
  • Consider your space and have good lighting when conducting video sessions. It is just as vital for the client to see you as for you to see the client.
  • Have a plan for when technology is not operating properly.
  • Pay attention to observable cues the client could potentially misinterpret or misread when meeting virtually (e.g., thinking the counselor is tearing up when they are scratching their eye).
  • Create specific guidelines to prevent clients from being distracted or multitasking during appointments (running errands, driving, etc.)
  • Try to wait an additional one or two seconds after you think a client has stopped speaking to avoid talking over one another due to lag.
  • Working with younger children can still be a challenge; however, adolescents can often adapt to telehealth quickly.
  • Do not automatically think older clients would be averse to using technology for distance counseling. Like many of us, they have developed a new comfort with video chat.

We encourage practicing counselors to seek continuing education opportunities as telebehavioral health counseling evolves.

 

What would you want counselors to know about navigating virtual sessions with a client who is not alone or in a private area (i.e. children are in the background, a spouse or parent is in the next room, or a client is at their workplace on lunch break, etc.)?

Daniel and Jennifer Williamson: Confidentiality is an ongoing concern in any counseling relationship, and one of the largest changes in the shift to telehealth is that the counselor has lost the ability to control many aspects of the clinical space. Educating clients about what constitutes an appropriate clinical space and how to be creative in finding appropriate meeting places is an important and ongoing conversation. We define being in a clinical space as being alone in a room with a door, the door is closed, and a “sound machine” is on. Clients can be creative in finding ways to create their own “clinical spaces.” Many have met in walk-in closets, parked cars, offices, bathrooms, and garages.

It is helpful when counselors remain aware of nonverbal shifts in attentions that indicate someone has entered the clinical space. It is important for the counselor to continue to explore informed consent surrounding the importance of clients protecting their own privacy. The ability to create a clinical space should be considered during the initial evaluation to identify if the client is suitable for this modality.

It might be prudent to establish a “signal” between client and counselor in the case that someone enters the client’s clinical space. A client might touch their nose or ear to indicate that someone has entered the private space and it is no longer safe to talk. Virtual services that constantly monitor for voice commands such as Siri, Alexa, Google, bluetooth connected devices, or gaming programs including Discord should also be considered, and clients should be informed about these potential breaches.

 

In the book, you mention that distance counseling will not be a best fit for some clients and that counselors must assess clients to determine whether it’s an appropriate medium. What are some “red flags” counselors should listen for that might indicate telebehavioral health is not a good fit for a client?

Daniel and Jennifer Williamson: While each client should be assessed individually, several considerations seem to signal “red flags” for the use of telehealth. Safety is a number one priority, and counselors must assess if the client is connecting from a place that is physically and emotionally safe. Clients in domestic violence situations or who are a harm to self or others might not be a good fit for the telehealth option. Emotional stability, trauma history, impulsivity, level of care, and ability to self-regulate are also considerations when evaluating clients for suitability.

It is equally important to explore the client’s comfort and skill using this type of technology. Many clients report enjoying the convenience and access that telehealth counseling provides while others miss the in-person human contact. Some clients have reported feeling stuck once the session had ended because they can’t leave the place where they explored difficult topics.

Counselors must assess the clients’ access and ability to navigate the hardware and software involved in telebehavioral health systems. Clients may not have stable internet access or updated technology for interfacing with the telehealth platform. Amber Hord-Helme created an assessment for evaluating clients for telehealth that is included in the book.

 

With vaccines widely available in many areas, some practitioners are opting to offer both virtual and in-person counseling. What would you want practitioners to know about managing this hybrid model?

Susan Belangee and Mykia Griffith: We are both currently doing the hybrid model, returning to the office one or more days a week and working virtually from the home office during the other time. One idea to manage this is to schedule clients who want to come in person on one day and any clients who wish to do sessions virtually can schedule on a different day. This can help to foster a rhythm to work depending on the day.

Is it best to have a client stick to one or the other (virtual or in-person)?
Allowing room for change allows for flexibility as well as opportunity for growth within the therapeutic relationship/alliance. Clients report that they appreciate the flexibility even if they tend to choose one option most of the time. Knowing that they don’t have to miss a session if they are unable to come into the office as planned seems to reduce stress. Life happens for everyone, and having the ability to maintain appointments through telebehavioral health will allow for continued work and continued progress.

 

During the pandemic, state regulatory boards and insurance companies broadened their acceptance of distance counseling (and telehealth as a whole). Where do things stand now – what would you want counselors to know? And/or where should they be looking for the latest updates and changes regarding insurance coverage and regulation of telebehavioral health?

Jeff Parsons and Angela McDonald: Prior to the pandemic, many state boards and insurance companies were ambivalent towards distance counseling. While some states had clear regulations around the practice of distance counseling, others did not. The pandemic spurred change in several areas. In an immediate sense, it allowed for the provision of distance counseling in most states; including registries that allowed for services across state lines. It also loosened restrictions, allowing for the use of technologies that would not traditionally be acceptable (e.g., phone, non-HIPAA software). In many cases, it opened up billing opportunities for distance counseling in states where this may not have been an option in the past. Finally, it encouraged states to actively engage distance counseling as a legitimate delivery model for counselors.

The long-term impact of COVID-19 on distance counseling will vary by state. Some provisions, such as interstate registries and loosened restrictions around phone/non-HIPAA compliant software, will likely be retracted once the state of emergency is lifted. However, it is likely that many states will (if they haven’t already) enact regulation around the provision of distance counseling, formalizing its place in our profession.

Counselors should continue to closely monitor their state(s) regulations and board activities for updates about distance counseling and supervision. Many states issued temporary changes that impacted healthcare practice during COVID-19 state of emergency declarations. As the emergency declarations expire and are lifted, boards will need to issue updated guidance to the public so that counselors can be certain that they are acting in accordance with the regulations. In some cases, boards may issue new interpretations of regulations that protect the public and attend to the expanded capabilities of safe practice in telehealth, and, in other cases states may pass legislative changes that make more permanent changes such as adopting the interstate compact for counselors or adopting broad telehealth regulations that apply in a state to many different regulated professions, all healthcare professions, or all behavioral health professions.

 

From your perspective, where does telebehavioral health fit in the future of professional counseling?

Jeff Parsons: Distance counseling is here to stay. It opens opportunities for services to a wider range of clients, including those who may have transportation or health issues. It also holds a convenience factor that may be appealing to counselors looking for flexibility in their schedules. However, its insertion into the everyday lives of counselors and clients has limitations. Confidentiality issues and video conference burnout are common complaints from counselors who have focused their practices around distance counseling during the pandemic. Likewise, distance counseling may not be ideal for all clients.

Long-term I think we are going to see significant growth in the creation of counseling agencies that focus on distance counseling. However, for most agencies, I think it’s more likely that distance counseling will be used as a tool that adds flexibility to the provision of face-to-face services. For example, counselors might use distance counseling with clients that are on vacation or have transportation issues. However, as this future unfolds, I believe states will be in a much better position to support the provision of distance counseling, as they develop much needed regulatory processes.

Angela McDonald: I am really excited to see telebehavioral health expand access to care, support continuity of care for mobile counselors and clients, and for communication skills in the tele-space to be strongly incorporated into standards for counselor education and supervision.

Susan Belangee: I think telebehavioral health is here to stay as a valid and effective treatment delivery option. The pandemic forced the profession to utilize virtual counseling options and this likely changed professionals’ opinions about how effective they could be using this method of treatment delivery. It will necessitate the development and revision of best practice guidelines as technology continues to evolve.

Mykia Griffith: Although telebehavioral health will never be able to replace the experience that comes with in-person treatment/therapy, telebehavioral health is essential for the future of professional counseling. The virtual method was previously just an option that left room for uncertainty. At this point in time, telebehavioral health has had an incredibly quick shift into our everyday reality and may prove to be fundamental moving forward.

Marty Jencius and Stephanie Marder: Telebehavioral health fits into the future of counseling by extending a counselor’s ability to reach clients when certain barriers exist (e.g., health, distance, inclement weather, global pandemic) which may have previously prevented a client from obtaining services. COVID-19 forced the counseling profession to use telebehavioral health tools more widely than ever before.

We may not need to use telebehavioral health tools as profusely as during the pandemic. However, the benefits of these tools have been demonstrated and their usefulness to the profession has promoted a willingness among counselors to explore these tools as viable options for providing counseling services.

 

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Distance Counseling and Supervision: A Guide for Mental Health Clinicians is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/store or by calling 800-298-2276.

Watch ACA President S. Kent Butler’s conversation with Jennifer Nivin Williamson and Daniel G. Williamson in a recent episode of the “Voice of Counseling” video podcast: https://youtu.be/jtIk5jJjv-0

 

Proceeds from book sales will benefit Uganda Counseling and Support Services, a nongovernmental organization that brings counseling and mental health services, education, clean water, farming and medical services to rural Uganda. The organization was established by one of the Williamson’s former graduate students, Ronald Kaluya.

 

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

The emotional and social health needs of Gen Z

By Lindsey Phillips January 10, 2022

kitzcorner/Shutterstock.com

Members of Generation Z — typically defined as those born from the mid-1990s to the early 2010s — have little to no memory of a life without smartphones or access to the internet, which is why they are often dubbed “digital natives.” They have also grown up in a world where social media, political polarization, racial unrest, school shootings and climate change are ever-present realities. 

All of that turmoil and uncertainty is affecting their mental health, with 70% of teenagers across genders, races and socioeconomic status reporting anxiety and depression as major problems among their peers, according to the Pew Research Center. A report by the American Psychological Association found that Generation Z is 27% more likely than previous generations to report their mental health as fair or poor. On a brighter note, they are also more likely than older generations to seek mental health therapy or counseling, with 37% of Gen Zers reporting having worked with a mental health professional.  

Roshelle Johnson, a licensed professional counselor (LPC) and clinical director at Light and Power Counseling in Phoenix, works with a number of Gen Z clients who are struggling with anxiety or depression. Recently, she received three calls from parents whose children had just attempted suicide. “That spoke to me about how hopeless our young people are feeling,” she says. 

Addressing anxiety

Nichole DeMoya, a licensed mental health counselor and qualified supervisor in Florida, finds that many of her clients are in a constant state of worry. Her teenage and college-age clients commonly voice concern about future careers, school shootings, financial security, climate change and societal unrest. These clients are “very worried about the future because things are so unstable for them right now,” DeMoya says. She doesn’t dismiss their concerns; instead, she helps them learn to shift their focus to the present and on what they can control. 

DeMoya also considers the individual client’s home and school environment to see if they are adding additional layers of stress. She recalls working with a 12-year-old girl who struggled with anxiety. During one session, the client revealed she was scared that a foreign country was going to bomb her city. In learning more about the client’s home environment, DeMoya discovered that the girl’s father watched the news around the clock, and this was contributing to her anxiety. 

“She was starting her day already in that fight-or-flight [mode], already in a heightened state of anxiety,” says DeMoya, a clinical director at River’s Edge Counseling, a group private practice in Jacksonville, Florida, that specializes in treating trauma. “And then she went to school where she didn’t feel safe because school shootings are an ever-present threat.” 

DeMoya wasn’t able to help the client challenge her anxious thoughts because everything the client was being inundated with told her she should be anxious. So, DeMoya spoke to the parents and explained how the news was negatively affecting their daughter’s mental health. The father had been oblivious to this and was supportive of helping ease that stressor in his daughter’s life by no longer watching the news around her. That simple change made a big difference, helping the girl to regulate her nervous system and start her day on a positive note, DeMoya says. 

Jayna Bonfini, an LPC at Associates in Counseling & Wellness in McMurray, Pennsylvania, works with several teenage girls who experience anxiety and have histories of self-injury. By engaging in self-injury, they are taking their emotional pain and distress and turning it into a physical act, Bonfini says, so she uses dialectical behavior therapy (DBT) techniques to help them learn how to better regulate their emotional distress.

“Sometimes clients will use negative coping skills to escape painful emotions because it feels like it’s the easiest way to handle them,” Bonfini says. She instead helps clients learn healthier coping strategies with DBT skills. If a client is sad, for instance, they may isolate themselves from others. Bonfini may have the client use the DBT skill “opposite action,” which encourages them to choose the exact opposite of what their emotions tell them to do. So, instead of isolating, the client would go out and engage with others or perhaps even address the situation that is causing them distress rather than avoiding it. This approach helps clients build mastery over their emotions, she adds. 

Lauren Bellenbaum specializes in working with youth ages 10-24. She ensures that her clients leave counseling with a few practical skills they can use when they have a panic attack or feel extremely anxious (such as when they have to give a speech in class). “This generation … really want[s] skills,” she says. “Talk therapy is great, and they do need that too, but they also want to come out of sessions with some practical skills … [and] practical, straightforward advice.”

Bellenbaum, an LPC, often discusses different sensory skills that clients can use to help ground themselves when they feel anxious. For example, intense sensory experiences, such as eating sour candy, smelling essential oils, using very cold water, doing high-intensity exercise or engaging in paced breathing, can decrease anxiety, she says. She often advises clients to keep grounding objects nearby in case they find themselves feeling anxious throughout the day. Other sensory skills clients may use to help decrease anxiety or stress include having a calming Pinterest board or pictures to look at, a soothing Spotify playlist to listen to or their favorite blanket or sweater to wear. 

Improving interpersonal relationships 

Many of Bonfini’s clients seek counseling for anxiety, and social anxiety in particular. It is common for many young people to dislike phone calls, but Bonfini once worked with a client whose phone phobia was so intense that it prevented her from making necessary calls, including to the financial aid office at her college. Bonfini built an entire session around preparing the client to make this call, including practicing what the client would say and engaging in some deep breathing and interpersonal effectiveness skills with her. And then they made the call together.

“They have this impending sense of doom if somebody says, ‘We need to talk,’” notes Bonfini, an associate professor of counseling at University of the Cumberlands. “It’s this whole anticipatory anxiety that they all get, [wondering,] ‘What’s coming? What’s coming?’” 

Bonfini, who presented on supporting Gen Z’s mental, emotional and social needs at the American Counseling Association’s 2021 Virtual Conference Experience, also finds that friendships are difficult for several of her Gen Z clients. They often make casual connections with people online or at work or school, but that is different from a deep, personal form of friendship, Bonfini says, and that is where they struggle. 

Online friendships further complicate their ability to make and maintain meaningful relationships. Many of Bonfini’s clients say they mainly socialize online while they are alone in their room, which can be lonely and isolating for them, she says. Some of her clients even prefer online relationships, she adds, because when they have a problem, it’s easy to block this “friend” or create a new avatar and move on.

Bonfini, co-editor of the second edition of Casebook for DSM-5: Diagnosis and Treatment Planning, observes that Generation Z as a whole lacks many of the social skills that previous generations learned through face-to-face interactions. She finds DBT techniques helpful for teaching these (and other) clients interpersonal effectiveness, conflict resolution skills and ways to communicate their needs. 

Bellenbaum, owner of Transform Youth and Family Counseling, a group counseling practice in Grants Pass, Oregon, also finds DBT useful in helping clients learn a variety of skills, including emotion regulation, distress tolerance, mindfulness and interpersonal effectiveness. These skills are important for this generation, she says, because they often struggle with healthy communication and conflict resolution. One DBT skill she often uses to help clients communicate more effectively is DEAR MAN, an acronym that stands for the behavioral strategy of Describe, Express, Assert, Reinforce, be Mindful, Appear confident and Negotiate. This strategy supports clients in expressing and getting their needs met and in telling others “no” in a respectful way, thereby increasing the likelihood of a positive outcome. 

Bellenbaum also makes use of role-plays in session to help with interpersonal issues. A client may be having conflict with a friend, for instance, and isn’t sure how to address or handle this difficult situation. So, Bellenbaum has them act it out in session. She would play the role of the friend and have the client practice using their skills to approach the friend and have a conversation about their conflict. This makes it easier for the client to have the actual conversation later in person.

Johnson, a licensed independent substance abuse counselor, and Amber Samson, a licensed clinical professional counselor in Maryland, have both found that members of Generation Z sometimes have trouble differentiating between friends and acquaintances (terms that are often conflated because of social media) or recognizing healthy versus unhealthy relationships. There can be an expectation for this population to be “friends” with everyone they talk to online or in person, notes Johnson, who runs an anxiety management group for teens. They have followers on Instagram and friends on Facebook, she says, and this can lead to them being hurt when some of these acquaintances fail to meet their expectations or aren’t there for them. 

When a client refers to someone as a “friend,” Johnson asks the client to tell her more about the relationship. If, for instance, she learns that this friend is someone the client met online and plays video games with, she explores with the client what friendship means and how not every acquaintance is a friend. 

Johnson explains the concept of friendship using a dartboard illustration, with the inner target in the shape of a heart. She points out how the dartboard has different rings, which represent different levels of friendship, and how not everyone in the client’s life can fit in the inner circle or bull’s-eye — that area is reserved only for close, personal relationships. She finds this exercise particularly helpful with teenage clients, who are typically still figuring out these relationship dynamics.

Johnson encourages clients who are struggling with social anxiety after returning to in-person education to find a club or group that caters to their strengths. One client she worked with enjoys watching indie movies, so they joined a movie club at college. The group isn’t large — just four or five other students — but it’s a great way to meet others with similar interests and safely practice social skills, Johnson says. 

Relationships can be hard enough without adding in the complications of social media. One negative social media post can sometimes ruin a person’s day, so Bellenbaum often teaches clients how to cope and handle distress when things are outside their control. 

If someone made a rude comment about the client on social media that caused them to have an automatic negative thought such as “It’s true; I am a horrible person,” then Bellenbaum would use cognitive behavior therapy (CBT) to help the client identify, challenge and replace the negative thought with a healthier, more realistic one. But if the client is upset, angry and embarrassed about the mean comment, then Bellenbaum might teach them distress tolerance and distracting skills using DBT. This strategy allows them to tolerate difficult emotions and feelings so they can get through the rest of their day until they are in a space where they can get help or process their feelings. 

Samson, a therapist at Choice Clinical Services in College Park, Maryland, works with Gen Zers, millennials and people of color. She observes that members of Gen Z often struggle with interpersonal boundaries, largely because they have grown up in a digital world where they are constantly connected and expected to communicate with others. She advises her clients to take breaks from social media and engage in activities they find relaxing. Samson has noticed that if her clients dedicate some of their day to relaxing by themselves, then they typically feel better and have the energy to be available and interact with others. 

Some Gen Z clients may find it difficult to start a conversation with their counselor, Samson adds. They may not know how to explain or even identify what they are feeling, so she goes back to the basics and helps educate her clients on identifying feelings by using the feelings wheel. The wheel contains words identifying basic emotions in its middle and branches out to more complicated aspects of these feelings on the outer perimeter of the wheel.

Being authentic 

DeMoya, a certified child and adolescent trauma professional, stresses the importance of being authentic with this generation. “As therapists, we have to move away — as I think we are — from the disconnected, Freudian approach where we just put on our glasses, have our clipboards … and don’t engage in a more relational way,” she says. “You have to be willing to put the clipboard down.” Although there is nothing inherently wrong with taking notes in session, DeMoya says, it can sometimes be a barrier to developing a closer connection with Gen Z clients. 

This generation often wants to know more about the counselor they are working with, and as Bonfini points out, they are likely to have Googled the clinician before the first session. Bonfini recalls being taught as a counseling graduate student not to self-disclose with clients, but she has learned that some limited disclosure helps build rapport with this population. Her clients often ask if her high school or college experience was similar to theirs. She shares with them the ways it was different, such as not having a smartphone and having to make sure that she showed up on time to meet friends or else she would miss them. But she also normalizes and validates common adolescent experiences such as feeling uncomfortable in one’s own body, navigating romantic relationships and being unsure of what’s next after graduation. 

Being authentic also includes working collaboratively with this population to determine their treatment plans and therapeutic goals. Bonfini likes to use motivational interviewing to build rapport and let her clients know that she is working in partnership with them. She often requests that they rank and rate various mental health issues they may want to work on in session. And she asks them, “When will you know therapy is over? What does that look like for you?” This process not only lets the client know that counseling is a partnership but also provides her with useful information about the client’s core issues and treatment goals. 

Today’s counselors must also be willing to learn more about the world these digital natives inhabit. “If you want to be an effective therapist and connect with youth, you have to know social media,” Bellenbaum asserts. Bellenbaum familiarizes herself with current social media trends and has Instagram, YouTube, TikTok and Facebook accounts to help her better understand this culture and what her clients reference. She doesn’t play the video game Minecraft or games such as Dungeons & Dragons or Magic: The Gathering, but she’s aware of what the games are because younger populations often play them. Knowing about current social media trends will help clinicians better understand the challenges this generation faces, she says. 

But counselors don’t necessarily have to be familiar with all the latest trends to build rapport with this population. It’s great if you are, DeMoya says, but what’s more important is showing up authentically in session. 

Making counseling more friendly for Gen Z 

Counselors can also adjust their clinical environment to make it more welcoming for Gen Z individuals. One simple change is to offer electronic communication options for making initial contact with the counselor or setting up an appointment. Bonfini has found that Gen Z clients are less likely to reach out via phone, and when they do call, they don’t say much beyond “I want to make an appointment” or “Call me back.” Secure messaging platforms, text messaging and online forms allow clients to go into more detail and explain why they are seeking counseling, their current schedule and the best way to get in touch with them, she says. 

Bellenbaum uses the app Talkroute, a virtual phone system, for her business because it allows clients to call and text her business line for scheduling purposes. Bellenbaum can also access this app on her laptop or phone, which makes it convenient for her as well. In her client intake packet, she stresses that texting is only for scheduling issues because she cannot guarantee confidentiality through text, but she likes having this option because she knows Gen Z clients are more likely to text than to call. 

Bellenbaum mentions the importance of counselors having office décor that clients can relate to. She has tailored her space to the Gen Z age group by having modern décor with comfortable chairs, blankets, pillows and inviting colors. She also keeps fidgets and snacks in her office in case clients want them. Bellenbaum says her clients often notice and comment on how they like her wall color or décor.

DeMoya’s goal is to create a therapeutic environment that feels like two friends hanging out in a living room. She invites clients to bring in their own coffee or snacks, and she also keeps drinks and snacks in her office. She tells clients to sit where they feel most comfortable — whether that’s on the couch with their feet up or on the floor — and DeMoya will join them in sitting on the floor if they ask her to. 

Bellenbaum also knows that, as digital natives, Gen Z clients prefer electronic forms over paper ones, so she has made all her paperwork electronic and uses an electronic health record. In fact, she doesn’t even keep a filing cabinet in her office. “A big piece of working with Gen Z [is using] … what works for them,” Bellenbaum says. 

If clinicians use a lot of paper worksheets and homework assignments, there is a good chance the forms will be lost or not filled out, Bellenbaum says, so she finds electronic copies more useful. She also suggests counselors get creative in how they incorporate electronic therapeutic techniques. For example, she may ask clients to keep a thought journal on a note app on their phone, and she often recommends that they use apps such as Calm or Headspace when they are working on mindfulness techniques. When she has assignments for clients, Bellenbaum may give them an electronic worksheet, have them take a picture of a worksheet on their phone or email them a link to a counseling exercise because she says they are more likely to engage with the activity if it can be accessed electronically. 

Samson also uses therapeutic apps with her clients. For instance, she sometimes recommends that clients who are struggling with obsessive-compulsive disorder use the GG OCD app, which converts CBT techniques into short games that challenge intrusive thoughts and promote positive self-talk. 

DeMoya has learned that many Gen Z clients prefer counseling approaches such as mindfulness and eye movement desensitization and reprocessing (EMDR) that allow them to be in the moment targeting specific issues. When doing bilateral stimulation as part of EMDR, DeMoya gets creative to keep these clients engaged. For example, she gives clients who are musically inclined drumsticks, sets a metronome and has them drum to the beat, or she may have a client use boxing gloves and punch left and right for bilateral simulation.

“Generation Z is all about experiences,” DeMoya says. “If you can make the counseling [process] … something that touches all of their core senses — sight, sound, touch, taste, smell — and you can create something that is an experience in the counseling room, that’s how you’re going to get a whole lot of momentum from them.”

“They’re so stimulated in every area of their life,” she adds. So, “the counseling session has to be something that engages them in multiple, different levels.”

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Considering developmental and generational factors

Counselors know Erik Erikson’s stages of psychosocial development well, and they often think about how a client’s life stage (say as a teenager or emerging adult) might be affecting their mental health. But should counselors also consider the generation that a client belongs to? 

Amber Samson, a licensed clinical professional counselor in College Park, Maryland, thinks counselors should consider both. From a life-stage approach, counselors can reflect on what it was like to be an adolescent and emerging adult and how they are thinking about issues socially, she says. And from a generational perspective, counselors “can see the unique challenges that Gen Z clients face with communication and the constant access they have to their peers, which heightens the judgment and pressure they feel at this age.” 

Jayna Bonfini, a licensed professional counselor in McMurray, Pennsylvania, and a counselor educator, agrees that it’s important for counselors to be aware of how generational factors affect clients’ mental health and development. Drawing from psychologist Urie Bronfenbrenner’s bioecological theory of development, which argues that human development is a transactional process in which surrounding environmental context shapes an individual’s development, she points out that one’s sociopolitical time influences one’s development. Every generation faces different environmental and societal factors, and Bonfini argues that with increasing technology and climate change, Gen Z is dealing with a lot of issues and crises that previous generations didn’t have to think about in the same way.

At the same time, counselors must guard against pigeonholing clients based on “membership” in any particular generation. “A big hurdle that we can all get into as humans is looking at the next generation and automatically putting them in boxes [e.g., boomers are selfish, millennials are entitled, Gen Z is antisocial], and it [often] comes into the counseling session,” says Nichole DeMoya, a licensed mental health counselor in Jacksonville, Florida.

DeMoya encourages clinicians to be aware of their generational biases and to make sure that they do not intrude on their work with clients. It’s easy to criticize, blame and label, she notes, so Gen Z clients often want to know if they have credibility with their counselor and if their worries and concerns are going to be taken seriously.

 

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@counseling.org.

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