Monthly Archives: April 2022

Considerations for athletes in counseling

By Jessie Huebner April 11, 2022

“I have to do what’s right for me and focus on my mental health and not jeopardize my health and well-being.” 

Hearing those words from Simone Biles, the epitome of talent in the world of gymnastics, and witnessing her personal battle in deciding to remove herself from competition at the Summer Olympics in Tokyo was eye-opening, to say the least. 

As the world prepared to observe the talents of the athletes in the 2022 Winter Olympics this past February, it made me reflect on all of the groundbreaking disclosures by elite athletes concerning their personal challenges with mental health leading up to, during and after the conclusion of the prior year’s Summer Games. These challenges had never previously been disclosed and discussed to such magnitude.

For example, following the U.S. Olympic team trials, swimmer Simone Manuel disclosed that she was experiencing depression, anxiety and insomnia resulting from overtraining syndrome. Liz Cambage, a Women’s National Basketball Association player who was scheduled to compete for Australia in Tokyo, identified anxiety symptoms as the reason that she pulled out of the Olympics a week before the opening ceremony. She has since described how daily medication helps her manage her anxiety symptoms so that she can continue competing. 

Throughout the broadcast of the Summer Games and following the conclusion of competition in Tokyo, numerous brave, elite-level athletes shared their prior or current difficulties with mental health symptoms. U.S. shot-putter Raven Saunders shared her experience with depression and prior suicidal ideation and her need to continually monitor and focus on her mental health. Cross-country mountain biker Jenny Rissveds of Sweden disclosed that a year after winning gold in the 2016 Summer Olympics in Rio de Janeiro, two deaths in her family triggered depression symptoms that she has been addressing since that time. U.S. sprinter Sha’Carri Richardson qualified to run the 100 meters in the Summer Olympics in Tokyo, but a positive test for marijuana resulted in a temporary suspension, causing her to be ineligible to compete in the race. Richardson acknowledged using marijuana to cope with and avoid negative emotions following the death of her birth mother and the stress connected with elite performance expectations. American gymnast Sam Mikulak revealed that swimmer Michael Phelps’ openness about his mental health journey encouraged Mikulak to seek treatment and experience the benefits of therapy. Phelps’ disclosures about his own struggles with mental health continue to be highlighted through his endorsement of an online therapy service provider.

Not just Olympic athletes

Olympic athletes’ willingness to openly discuss their mental health seemed to spark discussions in the Olympic community about the need for increased support and mental health interventions for athletes. Because of concerns regarding the impact of stigma on discussions about mental health, the U.S. Olympic & Paralympic Committee in 2020 suggested administration of the Sport Mental Health Assessment Tool during routine physicals for athletes. The tool was first administered with a group of 165 USA Swimming and U.S. Soccer athletes; 58% of participants tested positive for a mental health issue, and four athletes were found to be potentially at risk for self-harming behaviors or having suicidal ideation.

Difficulties with mental health are not limited to athletes at the Olympic level. This suggests the need for counselors working with elite athletes at any level to be prepared to offer services that take into consideration this unique client population. 

A 2019 meta-analysis by Vincent Gouttebarge and colleagues identified that mental health symptoms and disorders for current elite athletes ranged from 19% for alcohol misuse to 34% for anxiety/depression. Symptoms for former elite athletes ranged from 16% for distress to 26% for anxiety/depression. Some studies noted that while athletes in general may be at comparable risk for these mental disorders in distinction against the general population, some subgroups of athletes (e.g., those in retirement, those experiencing performance failure) may be at elevated risk. 

Common sources of tension identified by elite athletes include stress, injury, errors on the sporting field, fatigue, and their club’s or organization’s climate. Athletes experience increased stress related to factors including restricted social and occupational opportunities, pressure to maintain superior fitness and performance, scheduling and time constraints, social isolation, demands of multiple relationships, lack of energy and motivation due to physical fatigue, limited funds due to restricted financial opportunities, public criticism, injuries, and fear of career-ending injuries. While some elite athletes endorsed employing active coping strategies in their everyday lives, athletes were more likely to use less adaptive (avoidance) strategies when faced with unexpected stressors. 

Seeking to learn more about the mental health of student-athletes, in 2015, Andrew T. Wolanin and colleagues implemented multiple measures with 465 college athletes during yearly physicals across three consecutive years of their athletic careers. Clinically relevant levels of depression symptoms were exhibited by 23.7% of the sample, with 6.3% exhibiting moderate to severe levels of depression symptoms. Significant gender differences were found, with females exhibiting 1,844 times higher risk of clinically relevant symptoms than males. Prior studies have also identified gender differences, with female student-athletes scoring significantly lower than males on sense of self-worth, stress management and leisure. 

With athletes being channeled into specific sports at younger ages and with the associated changes in sport and life demands, mental health symptoms for athletes may begin even earlier. This is especially concerning because young athletes possess even fewer psychological coping skills. Among the identified stressors connected with mental health symptoms for youth athletes are pressure to perform and perfectionism, maintenance of academic and social balance, interpersonal conflict or abuse, injury and concussion, body image and weight pressures, and disrupted sleep. These stressors have been correlated with burnout and overscheduling, bullying and hazing, and risk-taking behaviors (e.g., early use of tobacco, misuse of prescription drugs, the restriction of calories, weight-dropping behaviors, use of performance-enhancing drugs). 

Student-athletes, in particular, have to endure the constant demands of intense practices, competition schedules, and the need to maintain or improve upon their strength and physical skills, all while maintaining passing grades to remain eligible for athletic competition. Additionally, student-athletes often have difficulty making time for leisure activities and may be less satisfied with such activities. 

Areas of focus for athlete clients

Counselors who work with athletes can assist these clients by focusing on personal and social issues that athletes commonly experience. Counselors can also help these clients in their development as individuals separate from their identity as athletes. Specific approaches might include relaxation training, solution-focused techniques, time management, cognitive behavior techniques, decision-making techniques, life management and career planning, coping skills strategies, and crisis intervention. 

Perfectionism

Athletes experience both personal and external expectations of perfection. Professional skateboarder Nyjah Huston has shared about the pressure of being an elite athlete and how he is often “really hard” on himself when he does not win. Counselors can support these clients by communicating understanding and empathy regarding the exceptional standards for athletes. 

Counselors can use psychoeducation to explain that extreme self-criticism can affect clients’ well-being and athletic performance and to encourage clients to identify the positive and negative aspects of perfectionism. Additionally, counselors can assist clients in setting their own realistic expectations of performance. 

Incorporating the topic of perfectionism is especially important because of the potential for athletes to turn to risk-taking behaviors to achieve perceived perfection in their sport. 

Burnout

Athletics is an environment in which psychological symptoms are often downplayed by the individual, likely exacerbating risk for continued symptoms, overtraining and burnout. In addition to mental health symptoms, overtraining is often connected to poor eating and sleeping patterns and increased risk of injury. Counselors should ask athlete clients about their current sleep habits or sleep disruptions. Counselors might consider offering sleep hygiene, psychoeducation and cognitive behavior approaches to promote healthy sleep behaviors. 

Student-athletes may experience burnout due to the constant need to balance sport, academic and emotional demands. Counselors should communicate understanding of the totality of clients’ commitments and assess for symptoms of burnout, including physical and emotional exhaustion, sport devaluation and reduced sense of accomplishment. 

Counselors can assist athletes experiencing burnout by opening discussion of what the client enjoys or previously enjoyed about involvement in their sport and what may have changed. Counselors can also encourage the reframing of clients’ (and, possibly, caregivers’) expectations of sport participation, foster fun and enjoyment both inside and outside of athletics, and explore clients’ overall values and nonathletic interests to expand their identity and promote balance between athletic and nonathletic identity. 

Interpersonal needs

Athletes may be perceived to have frequent peer interactions due to constant interactions with other athletes in sport, but many athletes have been found to lack interpersonal skills in everyday social interactions. Often, athletes are isolated from peer interactions and social opportunities outside of their athletic community. 

Counselors can guide these clients in assessing their schedules and time management techniques to identify nonathletic social opportunities and offer psychoeducation on the importance of interactions and connections that are not connected to their athletic world. Additionally, counselors should assess for signs of bullying or harassment (e.g., hazing; body shaming; encouragement to dope, cheat or play when injured) occurring for clients, especially for those identifying as being in a minority group at higher risk for negative interpersonal experiences in sport.

Injury

Athletes’ mental health can be affected by the fear of, and actual experience of, injuries that could affect their future athletic careers and, potentially, their overall life plans. Injured athletes have been found to exhibit greater depression and anxiety symptoms and lower self-esteem than controls, both immediately and in the months following their injury. 

To best guide treatment interventions, counselors should assist clients in identifying specific sources of distress related to the injury (e.g., physical pain, trauma of injury incident, isolation, irritation with rehabilitation, fear of reinjury, fear of not returning to sport). Counselors can support their injured clients by being mindful of the significant distress that often accompanies injury for elite athletes, offering compassion-based and acceptance-based approaches, and reframing the injury as an opportunity for growth and development. 

If the client’s injury involves a concussion, counselors should be knowledgeable about the psychological symptoms (e.g., irritability, anger, depression, anxiety, impulsivity) commonly associated with concussion injuries and the risk that clients may minimize symptoms or not present with awareness of the connected symptoms. 

Vulnerabilities

Athletes have been identified as vulnerable to disordered eating and risk-taking behaviors such as hazardous drinking, unprotected sex, driving while intoxicated and doping. 

Counselors can potentially assist in early detection of eating disorders in this at-risk population. Techniques identified to address disordered eating among youth athletes include interventions targeting motivation to change, dialectical behavior therapy skills training to develop ability to tolerate subjective distress and improve emotion regulation, and interpersonal skills development. Preventive measures to target disordered eating may include cognitive distortion psychoeducation, groups targeting improved self-esteem, and techniques to target negative coping strategies and encourage positive coping mechanisms. 

A 2020 study by Stephen P. Bird and Benjamin D. Rushton found that elite youth athletes generally lack fundamental nutritional knowledge, specifically information related to dietary reference intakes and supplementation. Therefore, nutrition education with this population is crucial; however, counselors should be aware of any specific requirements of the sport to support trust building and credibility with the athlete and to align treatment goals accordingly. 

Doping is also a prevalent problem among elite athletes (across all ages). Counselors should educate themselves on signs of doping and ask clients if they are currently using performance-enhancing drugs or have been pressured to use such drugs by coaches, parents or peers. Counselors are encouraged to address doping by implementing interventions that match the specific needs and readiness of the client. Counselors may begin by helping the client identify and discuss their desire to change their behavior and offer support and alternative views or behavior options for the client. If the client presents with resistance to changing their behaviors, counselors should avoid arguing and instead work with the client on improving their self-efficacy. 

Fostering the whole self

Elite athletes tend to identify themselves as athletes early in life. Individuals who exhibit this strong athletic identity can be at greater risk of emotional and social challenges, physical injury caused by overcommitment, and difficulties with transitions and future career identity development. 

In 2007, Clint Galloway separated athletic identity into three separate factors: social identity, exclusivity and negative affectivity. An athlete’s social identity involves the degree to which the individual identifies as an athlete from a social perspective. In some instances, an athlete’s success in sport and their connection to this identity, status and preferential treatment may result in a sense of entitlement, permissiveness and dependence. When this is shattered by the athlete’s injury or retirement, deficits in tasks such as independent decision-making, planning, organization and time management are evident and potentially detrimental.  

According to Galloway, exclusivity involves the degree to which an individual’s self-worth is determined based solely on their success in the athletic role. Elevated exclusivity can be especially detrimental when an athlete is injured or ages out of their athletic career because they may not have explored other career, educational and lifestyle options outside of their sport. 

Galloway’s final identified factor, negative affectivity, relates to how the individual experiences negative emotional reactions to poor outcomes in sport. Dutch professional cyclist Tom Dumoulin highlighted the impact of an athlete’s identity conflicts when he commented about needing to leave a training camp to clear his head, noting that he was finding it “very difficult … to know how to find my way as Tom Dumoulin the cyclist.” 

Counselors can support their athlete clients in developing and fostering their whole selves, expanding perspectives about their entire identity, and visualizing aspects of the self beyond their role as an athlete. Available measures to assess a client’s athletic identity include Britton W. Brewer and colleagues’ Athletic Identity Measurement Scale and Suzanne A. Nasco and William M. Webb’s Public-Private Athletic Identity Scale. Separately or in conjunction with formal measures, counselors can encourage clients to process past important experiences in their life and identify values, skills and roles that they used in these moments. Clients can then be asked to envision important experiences for their future, using their past experiences and skills as the foundation and starting point for their future life plan that may or may not be related to sports. 

Counselors can play an important part in highlighting and supporting other roles in the client’s life. Counselors can assist the client in seeking balance by incorporating friend and family life, education, and activities outside of their sport. In 2011, Natalia Stambulova suggested that counselors encourage clients to sort information and life experiences into separate categories (e.g., client as person, client as athlete, client’s social roles and environment, client’s near past, client’s present situation, client’s perceived future) to visualize the role or impact of their athletic identity. Additional interventions include assisting clients with time management, fostering motivation to establish other aspects of their self and life, and reviewing their schedule to offer opportunities for experiences and social interactions unrelated
to sport. 

Incorporating athletic skills

wavebreakmedia/Shutterstock.com

Elite athletes are unique. For athletes to reach their level of performance and skill, they depend on mental qualities (e.g., responsibility for self, adaptability, self-aware learning, determination, confidence, optimal performance state, game sense, attentional focus, mental toughness) and strategies/skills (e.g., physical preparation, process orientation, routines, self-talk, visualization, commitment, flexibility, creativity, problem-solving, decision-making) that can be applied in other areas of life to foster success.

Counselors might consider using solution-focused techniques to assist athletes in identifying what resources they have developed in the past that can be used in their future life. In general, counselors should assist in preparing the athlete for success for their whole self. This includes incorporating discussions of how the interventions or techniques offered to address current athlete-specific needs can also be used for other stressors that may present for the client outside of their athletic world. This mindset will support the client in recognizing aspects of their life outside of their athletic identity and prepare the client for when they are no longer an athlete due to injury or retirement (whether planned or forced). 

Planning for the future

When faced with the end of their athletic careers, athletes are at increased risk of experiencing mental health symptoms. This risk is exceedingly higher when the transition was not expected (e.g., as the result of injury). These symptoms are often connected to the athlete’s losses of their athletic identity, their sources of satisfaction, their identification as a sport hero, and their daily routines and connections associated with sport. 

Counselors can assist clients through this transition from life as an athlete to their new path, whether academic or professional. Clients with a strong athletic identity may have experienced disempowerment and the loss of personal autonomy, which may have resulted in limited opportunities to reflect on their personality or sense of self outside of their athletic identity. Counselors who are working with athletes can play a role in reducing the risk for problems during transition times by engaging in academic advising, life management techniques and career planning with clients while they are still active in their sport. 

Most athletes will not make it to the professional or Olympic level in their sport, so they would benefit from interventions that focus on skill development and life planning across the life span. Career development for athletes can incorporate discussions about the client’s knowledge, abilities and opportunities that can be transferred to areas outside of athletics. In helping clients develop coping strategies to use when dealing with unexpected and unforeseen life events in general, counselors might also be preparing these clients for future events that may occur in their athletic careers.

Be prepared for resistance

Athletes have been raised within a community and a culture that emphasizes the importance of being not only physically tough but also mentally tough. At elite performance levels, this may result in athletes being resistant to seeking or engaging in mental health services. Additional barriers to athletes seeking counseling include time limitations, a lack of problem awareness, a difficulty or unwillingness to express emotion, fear of the potential impact of help seeking, and concerns that their high degree of visibility may be a threat to their confidentiality and privacy. 

Counselors should be familiar with the culture of sport and the specialized needs of athletes and how these factors may affect athletes’ service engagement. Identified preferences when athletes seek counseling have included the counselor’s familiarity with sport; the counselor’s race, ethnicity or gender; and counselors who offer expanded operating hours to accommodate athletes’ schedules. 

Final thoughts

Athletes are a special client population. When counselors are working with a client involved in, or previously involved in, elite sport, consideration should be given to the client’s unique experiences, presentations and needs. As is the case with all clients, the diversity of client athletes (e.g., race, ethnicity, socioeconomic status, age, ableness, sexual orientation) must also be considered. Also be aware that there are many differences in athletes’ motivations for being involved in sport, their preparation or development for sport, their academic needs, and the perceived importance of their athletic role in life planning. When working with current or former athletes, counselors should consider their client’s athletic identity, pressures for perfectionism, time and physical commitments, and elevated vulnerabilities to problematic behaviors. 

The openness of Olympic athletes has sparked new awareness of the potential mental health needs of all athletes. It is now our turn as counselors to promote the need for mental health services for athletes at all levels of sport and to adjust our assessments, techniques and treatment planning for this unique client population.

 

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Jessie Huebner is a licensed clinical social worker and a doctoral candidate at Northern Illinois University in counselor education and supervision. Jessie’s current professional role is as a clinical screener for children and adults involved in child welfare. Prior professional experience includes counseling, supervision and administration for children and adolescents receiving residential treatment and juveniles with sexually problematic behaviors. Contact Jessie at jhuebnerlcsw@gmail.com.

 

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

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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.

Rev. Tutu delivers a message of hope and connection after crisis

By Lindsey Phillips April 8, 2022

The Rev. Nontombi Naomi Tutu delivers the keynote address at ACA’s 2022 Conference & Expo on Thursday, April 7. Photo by Lindsey Phillips/Counseling Today

Race and gender justice advocate Rev. Nontombi Naomi Tutu told the audience at the ACA 2022 Conference & Expo in Atlanta that a lot of her education stemmed from the wisdom and advice gleaned through African proverbs. Proverbs are not literal truths; they require people to consider the underlying meaning — something a literal-minded child like herself often found challenging to do, she joked.

The Rev. Tutu is the daughter of the late Archbishop Desmond Tutu, who resisted and helped end South Africa’s apartheid. She has served as the program coordinator on topics related to race relations and gender violence in education at both the African Gender Institute at the University of Cape Town and the historic Race Relations Institute at Fisk University in Nashville.

She delivered the keynote address on Thursday, April 7 to open ACA’s annual conference, held through April 9 at the Georgia World Congress Center.

During the first in-person ACA event in three years, Tutu shared with the assembled crowd an African proverb that deals with how one reacts during a crisis: “In the time of flood, the wise build bridges and the foolish build walls.”

She said her first thought when she heard this proverb as a child, of course, was, “Why would someone take the time to build anything? Why wouldn’t they just move away from the flood?” But eventually she learned that the true message is about how we need to build alliances and find new ways of doing things when faced with a crisis or challenge, she explained. Only the foolish cut themselves off from others and simply cling to what they have.

She then proceeded to connect this proverb to the current “flood” of crises that we face, including the COVID-19 pandemic and racial injustice. She told the audience she hoped these crises would provide us with an opportunity to do something different, to rethink how we approach situations and to forge a new path in the midst of the floods.

To successfully build these bridges, she said we must do two things. First, we have to accept and celebrate the fact that we are all different. For instance, she noted that her identities as an African, a woman and a first-generation immigrant to the United States differs from someone whose ancestors came over on the Mayflower. So, she urged those in attendance to create space for and welcome conversations around this diversity.

Second, we have to recognize one another’s humanity. “The truth of the crisis right now, our social crisis, our racial crisis, even our crisis around COVID has been truly based on some people questioning the humanity — the full humanity — of others,” she said. “In order to reach that place where we acknowledge and work from a basis of our shared humanity, we have to be willing to hear the other’s story, hear their story in their own voice, hear their story from their own perspective, hear their story in a way that makes sense to them.”

She acknowledged that recognizing this shared humanity is something that counselors are taught early in their career, but she reminded the audience that it’s also something that is so easy to forget.

She then underscored the importance of this second point by sharing a personal story about a presentation she gave at Vanderbilt University in the late 1990s on the potential dangers and opportunities of the 21st century. During her presentation, she spoke with enthusiasm about how this would be a century where women and people of color would be included and heard, which would reshape how we looked at the world.

When she finished, a white man raised his hand, and her first thought she admitted was, “Oh no, an angry white man!” And she was right: He was angry, but not for the reason she assumed, she told the audience. She discovered this man had spent a large part of his life homeless and in and out of mental health institutions, and he was a political activist. He was angry and wondered why she was having this conversation in a privileged white space, one where most of the people she was talking about would not feel welcome.

She then explained to the audience that this story illustrates how we often make up our mind about people before we allow them to share their humanity. We assume who the person is based on external factors such as what they’re wearing, where they worship or how they speak, she said.

“We decide that our knowledge of them is enough to make decisions about them and often for them. But if we allow ourselves just even for a minute to stop the tape that we have had playing in our heads, … to allow ourselves to stop and say, ‘Let me hear about you, from you,’ … then our whole process starts from a completely different setting,” she said. “We become open to actually learning something [not only] about the other but also from the other. And then we can think more about the bridges that we want to build.”

She concluded by reminding the audience that the current crises we face present an opportunity for us to listen to others and really forge connections and communities for all. “If we acknowledge that we are indeed in a time of crisis, that we are indeed facing a time of major challenge,” she said, “we could choose in this time of flood to build walls that separate us from those who think differently from us, separate ourselves from those who look differently, separate ourselves from those who speak differently.”

But “we are [also] given the opportunity in this time to build real bridges,” Rev. Tutu told the audience, “to open ourselves to sharing our stories, and hearing and taking in the stories and perspectives of those” who differ from ourselves.

Everyone in the room left that space a little wiser and filled with the hope that we can work together to build bridges, not walls.

The Rev. Nontombi Naomi Tutu delivers the keynote address at ACA’s 2022 Conference & Expo on Thursday, April 7. Photo by Lindsey Phillips/Counseling Today

 

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Find out more about the 2022 ACA Conference & Expo at counseling.org/conference, and follow the hashtag #Counseling2022 on social media.

See more photos from conference at flic.kr/s/aHBqjzKfUB

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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.

Preparing for private practice

By Katie Bascuas April 6, 2022

For many counselors, making the leap into private practice can feel like something of a stab in the dark.

As Logan Williamson, a licensed professional counselor (LPC) in New Orleans, points out, most graduate counseling programs don’t teach aspiring clinicians how to run a business. “It’s unfortunate because universities seem to think that the only thing you’ll be doing for the rest of your professional life as a therapist is talking to people and writing notes,” he says. 

So, while many counselors are well-versed in theory and techniques, they often find themselves learning the administrative side of running a private practice as they go. But there are lessons to be learned from clinicians who have already blazed a path and established successful practices. 

That’s how Williamson learned much of what he needed to know to get started with his practice, New Orleans Counseling, nearly 12 years ago. “I just talked to people,” says Williamson, who was unafraid to approach other therapists and even other business owners for advice. “There is time that goes into figuring it out, and I guess that’s an animal unto itself, and you really have to put the work into it.” 

Erin M. Moss, an LPC based in Buffalo, New York, had a somewhat similar experience to Williamson when she started her practice, Erin M. Moss Mental Health Counseling, six years ago. “I had no road map or role model to look to,” says Moss, who struggled to find other African American clinicians in her area whom she could relate to and who had already established private practices. “There were about two other people that I knew of that looked like me,” Moss says. “I didn’t realize that I was filling a void in my community.”

Meanwhile, for Duncan Price, an LPC in Washington, D.C., launching a full-time private practice seemed like the next step in his career after working in community mental health and managing a part-time practice on the side for several years. Yet the shift to full-time private practice still provided Price with some surprises, from working through the administrative side of running a business to confronting issues that challenged his personal and ethical beliefs.

In reflecting on their experiences, Price, Moss and Williamson all have invaluable advice to offer other counselors who are hoping to go out on their own. While all three clinicians faced similar challenges on their road to establishing private practices, they also encountered some unique experiences and opportunities that helped to shape not only their practices but also their identities as mental health professionals. 

As Moss acknowledges, there is no one way to do private practice. And that may represent one of the most important pieces of advice about running a business as a counselor.

Prepare for insurance hurdles

One of the biggest learning curves associated with starting a private practice involves dealing with insurance. Navigating the insurance landscape can be intimidating and may even keep some counselors from maximizing the potential of their private practice.

“The good thing about taking insurance is that it keeps you very busy,” says Price, who admits that he sometimes questions his early decision to accept insurance because of the added work and responsibility that accompanies it. “I don’t think I was quite aware of the level of administrative duties, particularly with electronic filing and all the entities that are involved to get a claim processed. It took a while to get it working smoothly.”

Price adds that he has sometimes grappled with the idea of whether to take insurance at all. “It would be nice to make more money, but I can’t see myself only seeing clients who can afford to pay out of pocket or to wait for an out-of-network reimbursement,” he says. Price’s practice, DC Recovery Counseling, accepts both private insurance and Medicaid so that he can maintain a connection with the clientele he worked with in community mental health. 

Meanwhile, for Williamson, fear of the insurance world kept him from establishing a full-time caseload of private practice clients as soon as he would have liked. “I felt that there was always a sense that I wasn’t going to get paid by the insurance company for the work that I would do,” Williamson says. “So, I didn’t want to put in time to not get paid.”

After his initial hesitation, however, Williamson eventually began accepting insurance and says his practice grew substantially. “I would say that after I started taking insurance — and I only take two [providers] — it took me six months, maybe, to get a caseload where I was at 20 patients a week.”  

Williamson advises those who are interested in taking insurance to start the credentialing or paneling process early, especially if they are jumping into private practice full time as opposed to building it up on the side. The entire process can take several months — possibly longer with errors or oversights in the application process — and it can turn into a frustrating waiting game with financial consequences. 

“Insurance companies will put you through a process and after three months, they’ll kick something back to you, and they’ll say, ‘You didn’t initial on page 12 at the top,’” Williamson relates. “Now you’re kicked back another month at least or two. That’s really deflating when you’re trying to build up a business.”

Dealing with administrative headaches, which can often be insurance related, was also a bit of a shock for Moss. “There are kinks in every organization — you hear that everywhere you go,” she says. “What you don’t realize is that when all of that is under you, there are a lot of fires that you have to deal with.” 

For example, despite outsourcing her billing, Moss still encounters issues where an insurance company disputes or retracts a payment. When that happens, the onus of fixing the issue falls on her, whether that’s rectifying the problem herself or spending the money to have someone else fix it. “When you’re working for someone else, you don’t have to worry about those things,” says Moss, who acknowledges that managing the operational side of her practice has been one of her biggest challenges.

Tap prior experience

Moss, Price and Williamson all note that the realities of the administrative side of running a private practice can come as a shock. At the same time, all three point to the value of previous work experience in helping them navigate the process of establishing a practice.

Williamson, for one, acknowledges that his path to full-time private practice was a windy one, with several pit stops along the way. After leaving a thriving group practice in Colorado to move to New Orleans to be closer to family, Williamson worked several jobs in the mental health field before returning to private practice full time. He credits those jobs, which included a stint at a university counseling center, time running an applied behavior analysis clinic at a local school, and a position at a major insurance company doing inpatient psychiatric reviews, with providing him good insight into business management. 

“It was on-the-job training that I was able to take with me,” says Williamson. For example, the firsthand experience of managing billing and credentialing for an organization gave him greater confidence and understanding that he could do it later on for himself in private practice. “I think that was helpful to understand — knowing that if I needed to, I could do it, that it’s not impossible.”

Moss similarly credits jobs earlier in her career with giving her a strong foundation in not only business skills but clinical skills. “I worked everywhere, and my case management background has always been strong,” she says. “There was a client sitting with me yesterday, and she said she wanted to open a business, and right away, I gave her the contact for the Canisius Women’s Business Center. It was those early years of going into homes and linking people with services — I can still go back to that stuff.” 

Price advises counselors interested in starting a private practice to not underestimate the importance of developing strong clinical skills. “I think it takes more experience than people think it does,” Price says of clinical readiness. “I’m not saying you have to be a master, but I think it helps doing it on a part-time basis with supervision while also getting really solid training in different modalities.”

Price recommends that clinicians, especially those just starting out, seek additional training at local schools or workshops to continue expanding their skill sets and keep pace with evolving techniques. “I would strongly suggest if someone is thinking of starting a private practice, to make sure that they’re ready clinically and that they’re also investing in continued education,” he says.

Create a support network

Seeking out continuing education can also be an avenue for counselors to expand their professional networks, which can in turn be a valuable resource for private practitioners who are working solo. 

“It’s tempting to think of it as it’s only on you, but if you don’t have a professional network of people that you trust to help you make decisions, then invariably you’re not going to make the right one and put yourself at risk,” Williamson says. 

He gives the example of working with a client who was going through a divorce and having his clinical notes requested by the client’s attorney. Not wanting to be involved in a legal matter, Williamson called a clinical colleague who specializes in client issues related to divorce and asked for advice. “He helped me write my note for that session so that I could send it to the lawyer and not be called into court,” Williamson says. He also provided the client with several therapy referrals that he received from another professional contact who had a wider network in the New Orleans area. “So, I was able to take care of the patient, protect my license and also protect my time because I didn’t have to go through all of that,” Williamson says.

A solid professional network is not only a good place to turn to for advice and consultation. It can also provide socialization and collegiality, which can be lacking in private practice.

“There’s no one next door to say, ‘Hey, girl, what are you eating for lunch?’” says Moss of the lack of office camaraderie that can come with running one’s own business. She adds that she recognized the solitary nature of private practice early on. Over the years, she has actively created opportunities to build in socialization, whether that takes the form of doing administrative work occasionally at a coffee shop where she can be around other people or serving on boards and joining associations and groups where she can volunteer. 

“I’m always at the table learning from like minds in the mental health community and groups that represent some of things that speak to me and my clients,” says Moss, who currently serves on the boards of two mental health organizations in her area. “Even though I’m my own boss, I have always had my foot in the community.”

Williamson also recommends the idea of board membership and suggests that it can be a good way to give back to the community, especially if a counselor’s private practice is less community oriented. “It’s super rewarding, and it’s a low barrier for entry,” says Williamson, who served for six years on the board of a local public service provider. “The commitment is only what you want to put into it.”

Establish boundaries

Given the time commitment that comes with running a business and managing one’s professional network, and then balancing all of that with one’s personal life, setting and sticking to boundaries is another invaluable strategy to implement early on when starting a practice.  

“I used to take clients as they came,” Price says. “And just emotionally, physically, mentally, you can only work with so many clients, especially if some have difficult cases. Trying to find that balance has been hard for me.” 

It can be challenging to turn clients away, especially given the current climate of high need, but prioritizing boundaries and work-life balance is key to avoiding burnout, Moss says. “We’re processing trauma, so it’s so important to have space to not do that,” she emphasizes. “It’s important to have space and time that is just yours, whether you’re connecting with your family or friends or just yourself.”

Moss credits her early years of working for organizations and agencies with helping her realize the value of establishing a healthier work-life balance. “One of my first clinical jobs right out of grad school, they gave me a laptop and a BlackBerry, and I was so excited — like, ‘Who has a BlackBerry?’ Little did I know that was the beginning of my phone never stopping ringing,” says Moss, who now implements a hard stop for herself at 6 p.m. every day. “There’s never enough time, and there’s always something to do, so you literally have to say, ‘I’m done working.’”

Structure for the long term

Although managing a private practice — like any job — may come with certain headaches, it can also afford counselors the opportunity to create and build their dream business. 

“Essentially, private practice is what you make of it,” says Moss, who knew early on that she wanted to create a “super practice” while also developing a professional identity as a mental health advocate. “This is really your show.” 

As part of a small community of African American counselors in Buffalo, for example, Moss realized while building her practice that her scope of practice might not resemble that of other counselors, especially white counselors.

“For me, building a practice and gaining clients, it wasn’t as simple as opening the doors,” she says. “Black people needed to know that it was OK to come to therapy. I had to do a lot of work breaking stigma and free speaking to let people know that this is normal and this is a good thing.” Through that early groundwork, Moss realized a desire to become an advocate and public speaker on mental health issues. That goal has become part of her larger business strategy for her practice and her work as a mental health professional, which she hopes to continue to expand. “I’d love to do more outreach to the Black community,” Moss says. “It’s so needed.”

While having a personal brand or specialty can set private practitioners apart in the market, so can good customer service skills and transparency, says Williamson, who employs a strategy of fostering long-term relationships with his clients from the outset of their work together. 

“I set up the expectation that this is more like a primary care visit for their mental health and they’re developing a relationship with me that can last a lifetime,” he says. “So, we work on the problem at hand and get that taken care of, and they feel good and are discharged, but they always have the ability to come back and talk to someone who knows them and cares about their experience.”

Establishing strong relationships with clients is not only good for business but can also help remind clinicians of their reasons for entering the field or starting a practice, which often lead back to being of service and helping. That sense of purpose can be a source of motivation and encouragement when weathering the more challenging times of business ownership, Moss says. She advises other clinicians wanting to step out on their own to avoid too much overthinking and lean into the process. “Relax and rely on why you got into this in the first place,” she says.

Branislav Nenin/Shutterstock.com

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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.

Writing guidelines for CT Online

April 5, 2022

Who can submit an article?

Any mental health professional can submit an article for CT Online.

What kind of articles do we publish?

We publish mental health articles, including news articles, case studies, how-to articles, columns and public-facing pieces, that offer practical advice and personal experiences about mental health and the profession of counseling. The article length can range from 700 to 2,500 words.

What do we not publish?

We do not publish literature reviews, academic articles, product reviews, and research or project summaries.

Who is our audience?

We write articles for mental health professionals (e.g., licensed counselors, counselor educators, social workers, psychologists) and those interested in learning more about mental health (i.e., the public). When you write, assume that your reader is either a knowledgeable peer or a future client. Practical advice comes from real experience as well as well-researched ideas.

What’s our style?

CT Online articles adhere to Associated Press style (article authors do not need to be familiar with this style to submit an article but understand that articles accepted for publication will be edited to conform to Associated Press style). Articles should be written in a reader-friendly manner rather than relying on jargon and academese.

CT Online articles do not contain citations, footnotes or reference lists. Instead, if a particular idea, thought, quote or theory needs to be attributed to a specific person or organization, include that attribution within the natural flow of the article (for example, “According to a study published by researcher Susan Smith of the Substance Abuse and Mental Health Services Administration in 2003, nearly 50 percent of people who seek counseling …”). When citing a source’s name within an article, provide the person’s first and last names on the initial reference; after that, it is fine to use only the last name.

What will we ask of you?

  • Your article is an original piece of work written for CT Online, not something published elsewhere (including blogs or social media).
  • You will verify the accuracy of the quotes, facts, figures or names in your article. (CT Online does not assume responsibility for any inaccuracies. If information is inaccurate, the article will be subject to rejection.)
  • You will collaborate with the editor assigned to you and be open to their feedback. (Please note that articles are subject to editing to meet space, grammar and style requirements. Headlines and section headings may be rewritten by Counseling Today.)
  • You will establish a timeline for delivery with your editor and communicate with them if something changes.

What will CT Online do for you?

We appreciate all the work you are doing to help us create great content. While publication in CT Online is unpaid and voluntary, we will support you in the following ways:

  • Give you full credit and a byline with your photograph and biography so readers can find out more about you and your work.
  • Promote your article on Facebook, Twitter and all our other channels.

How do I submit an article?

Please send all articles as a Word attachment via email to Lindsey Phillips, Counseling Today editor-in-chief, at lphillips@counseling.org. There is no need for fancy formatting. A single-spaced draft with a suggested headline and section headings will suffice.

 

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Also readTips for Getting Your Article Accepted by Counseling Today.”

For additional questions regarding submitting articles to CT Online, email Lindsey Phillips at lphillips@counseling.org.

CEO’s Message: Hey, counselors: This month is all about you

Richard Yep April 4, 2022

Richard Yep, ACA CEO

April is Counseling Awareness Month (CAM). That means we want to do whatever we can at the national, state and local levels to let your colleagues, communities and constituencies know about the positive impact professional counselors make on the lives of millions of people. Given what society has experienced over the past few years, I truly believe that the work of those who identify as professional counselors has made things much better than what might have been. I know it isn’t always easy to see that, especially if you listen to the news, but your work does matter, and you are making a difference.

So, dear counselors, do not let up! Continue doing your good work. And if you need permission to “toot your own horn,” consider CAM the vehicle for doing so. CAM isn’t about bragging; it is about celebrating your education, your experience and your ability to literally change the trajectory of the lives of children, adolescents, adults, couples and families. 

Call me an eternal optimist, but I think the counseling profession has achieved even greater status over the past few years. The public and the media are recognizing that the services counselors provide should not be seen as an “addition” to the priority applied to one’s physical health. Rather, social-emotional well-being and mental health are part and parcel of a person’s overall health maintenance. I was so pleased to hear President Joe Biden reference mental and physical health parity during his State of the Union address last month. ACA has advocated for this type of parity for decades, so having ostensibly the “most powerful person in the world” make that statement was yet another milestone for the counseling profession. 

This month, approximately 1,700 people will gather for ACA’s first in-person conference since 2019. The event will look quite different from what previous conference attendees experienced, but there will still be more than 150 education sessions, an inspirational opening keynote speaker, and numerous networking and social gatherings. All of this will be done while we strive to keep attendees, staff and vendors as safe as possible by observing post-pandemic meeting protocols. Although I wish we could be back in “full force” with the thousands who previously attended the ACA Conference & Expo, this will be a first step toward that realization. In addition, ACA will be holding its second annual Virtual Conference Experience in the fall, during which additional education sessions and presentations will be featured. 

In the same way that your clients and students face challenges, we must all learn to deal with obstacles, adapt to new situations and then work toward results that bring fulfillment, satisfaction and joy. I implore you to stay focused on why you chose to be a professional counselor. As I have said many times, given the increases in strife, violence, brutality, racial injustice and inequity over the years, our society needs counselors now more than ever. But with all that you do for your clients and students, I will continue to encourage you to build self-care into your week. We cannot afford to lose even one counselor to burnout. You deserve to be recognized.

April is when we celebrate your work, your commitment and your role as an advocate for clients and students. Think about the power that 58,000 ACA members harbor, especially if they come together and focus on a message that lets the world know about what they do. In addition to checking out the CAM resources we have made available at counseling.org, get together with your colleagues and plan how you will celebrate this special month. 

Many of you are very creative, and I have loved seeing and reading about what you did during previous CAMs. I hope you will again share with me what you and your colleagues decide to do to celebrate CAM this year.

As always, I look forward to your comments, questions and thoughts. Feel free to call me at 800-347-6647 ext. 231 or to email me at ryep@counseling.org. You can also follow me on Twitter: @Richyep.

Be well.