Monthly Archives: December 2022

Counseling Today’s 20 most-read articles in 2022

Compiled by Lindsey Phillips December 28, 2022

The last few years have been filled with anxiety and stress about our physical, emotional and mental health, so it’s not surprising that the top articles for 2022 delve into those topics. Some other prominent issues in the counseling profession last year include the impact of legalized marijuana and the digital world on the profession, the need for financial change, clinical supervision and youth mental health.

Here are 20 most-read articles in 2022 at ct.counseling.org:

#1: Stress vs. anxiety vs. burnout: What’s the difference?

By Lindsey Phillips

People often view stress, anxiety and burnout as three interchangeable conditions, but understanding what differentiates them can help in addressing what lies at the heart of each. Read the full article.

#2: The emotional and social health needs of Gen Z

By Lindsey Phillips

Uncertainty and stress have left Generation Z feeling anxious, depressed and isolated and in desperate need of skills that counseling can provide. Read the full article.

#3: The impact of legalized marijuana on professional counseling

By Bethany Bray

With more states legalizing marijuana for medical and recreational use, counselors are being forced to consider the potential pros and cons in their work with clients. Read the full article.

#4: Counseling a broken heart

By Bethany Bray

Romantic breakups often come with a lot of painful feelings and loss, but when processed in counseling, they can also be an opportunity to connect with oneself and make meaning from the experience. Read the full article.

#5: It’s time for a financial change in counseling

By Derek J. Lee

The fact that counselors are, by nature, helpers and are often willing to give freely of their time does not mean that they should be treated unfairly as a labor force. Read the full article.

#6: Self-diagnosis in a digital world

By Lindsey Phillips

Thanks to the popularity of social media postings about mental health and the ease of searching for symptoms online, more people are being tempted to self-diagnose. This article explores if that is necessarily a troubling trend for counselors. Read the full article.

#7: Making every moment of clinical supervision count

By Tiffany Warner

A three-step method can help counselor supervisors use their limited time more efficiently while building strong competency in supervisees. Read the full article.

#8: Journeying through betrayal trauma

By Allan J. Katz and Michele Saffier

Individuals who discover a partner’s infidelity and deception must undertake a challenging journey to find healing for the mind, heart and soul. Read the full article.

#9: Behind the scenes with a counselor-in-training

By Allison Hauser

This article provides a glimpse into what life is really like for counselors-in-training. Read the full article.

#10: ‘Not a monster’: Destigmatizing borderline personality disorder

By Scott Gleeson

The stigma attached to borderline personality disorder can make both clients and counselors resistant to treatment, but by working together, they can sort through these misconceptions and help clients rediscover themselves. Read the full article.

#11: Disarming anger

By Bethany Bray

Viewing anger as a messenger rather than an adversary can help clients decouple it from shame, unpack its origins, explore related feelings and gain self-awareness. Read the full article.

#12: A cognitive behavioral understanding of social anxiety disorder

By Brad Imhoff

Once clients understand that anxiety is not something that is going to disappear altogether, they can turn their attention to managing it and loosening the grip it has on their lives. Read the full article.

#13: A beginner’s guide to alexithymia

By Jerrod Brown

People with alexithymia struggle to identify and express their emotions. This subclinical phenomenon is a known risk factor for a wide range of psychological and physical health problems, so it has significant implications for professionals working in the field of mental health. Read the full article.

#14: Sex-positive counseling

By Lindsey Phillips

Counselors must increase their own comfort and knowledge around sexuality before they can help clients navigate theirs. Read the full article.

#15: De-escalating conflict between parents and teens

By Bethany Bray

Friction between parents and teenage children is an inevitable part of adolescent development, but often the parents need as much — if not more — work in counseling as the teen to build the skills needed to navigate conflict. Read the full article.

#16: Getting triggered as a counselor

By Lindsey Phillips

Counselors will inevitably be confronted by countertransference, but by learning to recognize and manage it, an experience that has sometimes been stigmatized can become a tool for professional and personal growth. Read the full article.

#17: Building trust with reluctant clients

By Bethany Bray

Rather than labeling hesitant clients as “resistant,” counselors should check their assumptions, work to better understand the underlying reasons and barriers these clients face, and double down on unconditional positive regard. Read the full article.

#18: What’s new with the DSM-5-TR?

By Aaron L. Norton

This article answers questions counselors may have about the latest edition of the Diagnostic and Statistical Manual of Mental Disorders. Read the full article.

#19: Responding to the youth mental health crisis in schools

By Bethany Bray

A youth mental health crisis is rising to a crescendo in American schools, so now more than ever, school-based counselors need support and buy-in from school staff, parents and outside mental health professionals. Read the full article.

#20: Confidentiality comes first: Navigating parent involvement with minor clients

By Bethany Bray

Counselors must strike a balance between maintaining young clients’ confidentiality and accommodating parents who want to be kept in the loop about their child’s progress in therapy. Read the full article.

What was your favorite article of 2022? What would you like to see Counseling Today cover in 2023? Leave a reply in the comment section below or email us at ct@counseling.org.

Confronting client resistance

By Nancy A. Merrill December 27, 2022

Photo by Andre Hunter on Unsplash

In my years as a counselor in a college setting and in private practice, I found one of the most prevalent occurrences in the counseling process is resistance from the client. Counselors must first recognize that resistance has occurred before they can help the client confront it in order to progress in therapy.

In this article, I explain three different types of resistance and how to help clients confront their resistance in a productive way. I also provide suggestions for when counselors need to press clients to confront their resistance and when they need to leave it alone.

Types of resistance

Conscious resistance. Conscious resistance is deliberate avoidance of situations that may be unpleasant, frightening or goes against one’s gut intuition. Examples of this type of resistance include the displeasure of getting vaccinated, the fear of getting on an airplane, or dating someone you feel intuitively uncomfortable being around. This resistance is someone simply saying, “Thanks, but no thanks” or being honest with their feelings and saying, “I don’t want to do that.” It’s a matter of personal choice.

In any of these situations, a counselor might help the client overcome feelings of anxiety by asking probing questions such as:

“What makes you nervous about being vaccinated? Have you had adverse reactions to vaccinations in the past?”
“What frightens you with the idea of flying? Have you ever flown before? If so, what was that experience like?”
“How well do you know this person? What makes you feel uncomfortable being around them?”

Depending on the client’s answers, the counseling session may be brief or more deeply involved than this surface-level anxiety seems to indicate.

Stubborn resistance. Stubborn resistance is refusing to get help despite being asked or encouraged by others to discuss the problem with someone in a position to help. The following are a few examples:

A student with behavioral problems who causes major disruption in school is completely uncooperative, lies and may be belligerent when referred to a school counselor or principal.
A partner in couples therapy may deny there is any problem in the relationship and refuses to seek further help after the initial session.
A patient may reject a doctor’s advice to seek help from a psychologist or a sex therapist and deny any psychological basis for their sexual problems with their partner.
A troubled teenager who shows signs of depression and hints about suicide refuses to seek help.

The person who meets with the counselor in any of these situations is reluctant to cooperate, resents the process or refuses to answer any of the counselor’s questions truthfully. Progress cannot be made because the person doesn’t acknowledge there is a problem, blames someone else for causing the problem and won’t return for future sessions.

Unconscious resistance. Unconscious resistance occurs when a client unconsciously resists confronting problems on a deeper level. Sigmund Freud referred to this type of resistance as a defense mechanism in which the person’s ego opposes the conscious recall of unpleasant experiences. Examples include the following:

An incest survivor represses memories that are too painful to acknowledge.
A client of sexual abuse resists any discussions of painful thoughts or frightening events.

I once worked with a woman who had been the victim of incest by her father for many years from the time she was age 5. The woman, now in her 30s, came to me very troubled by her depression and her anxiety around men. She had never told anyone about the incest and had repressed the incidents.

After months of counseling, discussions would progress satisfactorily until she reached a certain point when she would suddenly stop talking because what she was going to say next was too painful to acknowledge. It was only after several sessions of relaxation therapy to the point of being in a hypnotic state that the client slowly remembered the incest incidents.

Confronting resistance in a productive way

A counselor must listen intently and remember the last thing the client said before the resistance occurred. In the case of unconscious resistance, for example, by paraphrasing the client’s last few sentences, the counselor may help the client understand that they just had an unconscious, spontaneous experience that prevented them from recalling unpleasant events that happened in their life. This explanation can be helpful to the client’s self-awareness. The counselor at this point has several options.

If rapport had been established at the beginning of the counseling sessions and if the client adamantly refuses to continue with the current session, allow the client to leave and return for the next appointment. This gives the client the freedom to feel safe and to be in control of the situation. Suggest that you can pick up the conversation at the next session if the client is willing.

Ask the client, “Do you know what just happened that made you forget what you were going to say?” or “Do you remember what you were going to say a moment ago?” Maybe the client knows the reason but refuses to pursue the discussion any further. Or maybe the client is vaguely afraid of something but cannot pinpoint it. The client may need time to process what just happened. With guidance and probing, the counselor may be able to help the client continue the discussion by going in a different direction (e.g., “We were talking about …”). This might help the client refocus on the problem.
The counselor might pursue the issue by probing, “You were about to tell me something but suddenly stopped. What were you going to say?” The counselor should be aware of the client’s body language and verbalize their observations, such as “You appear upset. What are you feeling right now?” and “Can you let those emotions out?” The counselor needs to determine if there is enough time left in the therapy session to continue or resume at the next session.

Handling resistant confrontations

Know when to press clients to confront their resistance. Clients are chiefly concerned with getting relief from their problems. When a client is open, honest and seeks solutions, then the counselor can press the client to confront any resistance encountered. If the counselor is successful in keeping the dialogue going, the client may be able to proceed with confronting emotions as well.

Sometimes, the client uncovers deeper issues on a conscious level only to resist the emotional aspect. The client may look away while trying to recall details of the story. Prolonged silence could indicate the client is contemplating something and is about to speak again. The ultimate goal is to help the client accept emotionally what they have thus far refused to accept.

Resistance may continue until the client can finally make a breakthrough and deal with the problem both psychologically and emotionally. The perceptive counselor will ask questions to help the client develop a better understanding of themselves and their ability to handle future problems.

Know when the client is pushed too hard and gets upset. It is best not to push a client too hard to the point where they get upset. The client may be heavily burdened with deep issues or feelings not yet expressed to the counselor. Signs of distress would include fidgeting while talking, smiling less, shrugging shoulders or crossing arms. The client’s lips may be tightly closed, and there may be less eye contact.

The counselor must not push a client too fast or too far. Remember to go at the client’s pace of self-acceptance so they don’t quit therapy altogether.

If there seems to be a real barrier to progress because of resistance or if the client exhibits deeper signs of emotional distress and is unwilling to pursue the matter, the session should end. Discussions can be resumed at the next appointment.

Know what to do when the client gets angry. A client may become irritated with the counselor’s directive approach and be reluctant to answer any more sensitive questions. They may speak very slowly or give one-word answers, or they may become argumentative.

It is vital for the counselor to pull back and address the issue of anger with the client: “You appear angry. Can you tell me why? Is it something I said, or are you angry for some other reason?” Listen to what is being said and what is not being said. The angry or hostile client must work through the surface to get down to what is hurting them and what they are fearful of.

Counselors as well as clients need to successfully confront verbal and emotional resistance head on. Only then can progress be made for clients to overcome their initial problems satisfactorily.

Remind your clients that they cannot change other people that seem to be the cause of their problems. The challenge for the client is to accept themselves and learn how to live in their environment in a healthy manner.

Nancy A. Merrill received her master’s degree in counseling from the University of Maine in 1974 and was licensed by the state of Maine. She worked in a college setting with private practice on the side until 2003, when she retired to care for her mother who suffered from dementia until she passed away in 2016.

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.

4 steps to refresh, recharge and reconnect

By Autumn Gonzalez December 22, 2022

tiles spelling self-care on table with two pink and white flowers

Image by Tiny Tribes from Pixabay

If you are anything like me, you find being a counselor very enjoyable and fulfilling. We regularly make positive impacts on the lives of people we serve, and we’re committed to help them heal and grow.

However, this endeavor can be emotionally demanding and challenging. We hold space for successes, but we also come face to face with various sufferings and human misery. Even an ordinary day can at times be exhausting.

Add in the personal responsibilities of everyday life, living amid a pandemic, daily acts of violence and inflation, and the potential implications can be prevalent and persistent for counselors. These implications include increased depression, anxiety, psychosocial isolation, loneliness, disrupted personal relationships, compassion fatigue, vicarious trauma, burnout and professional impairment, all of which can impact the quality of services for effective and ethical counseling and overall functioning.

While most of us have substantial knowledge about self-care and convey its importance to clients, there is a disconnect between knowing about and doing self-care. For many counselors, self-care is front and center yet so far away.

Defining self-care

What exactly is self-care? Simply put, self-care is intentional actions and experiences to enhance or maintain physical, emotional, mental and social well-being and balance in life.

Self-care has many benefits. It boosts well-being, builds resilience, increases self-awareness and self-esteem, prevents burnout and compassion fatigue, and helps us perform at our best. It is a form of prevention, an ethical responsibility and an imperative for counselors personally and professionally.

Most important, self-care is about choice and understanding what it means for you. Everyone has a unique definition of self-care. For some, it may be a spa day, a massage or weeks of vacation. For others, it may be curling up with a good book, taking a moment to breathe, establishing boundaries, being intentional or assertive, or holding oneself accountable. Self-care is what maintains and restores your sense of self and what nourishes you.

Making self-care routine

It can be challenging to integrate self-care into a daily routine, which is why I created a four-step guide and a few practical self-care tips and strategies for counselors that can be built into everyday life in a manageable and sustainable way.

Step 1: Complete a self-care assessment

The first step is completing a self-care assessment to help you learn about and become aware of where you are at with your needs. There are various assessments readily available on the internet, in books, etc. A common one is the Self-Care Assessment created by Therapist Aid, which helps people reflect on current self-care practices, explore areas of improvement and identify new practices.

Step 2: Create a self-care plan

The second step is to create a self-care plan. Create an inventory of personalized self-care strategies that cater to the whole self and include physically, mentally, emotionally and spiritually nourishing activities. This could be a list of the top five things you can do, or not do. Be specific. Don’t just write down “do a breathing exercise” — describe which exercises you foresee yourself doing and enjoy doing. Focus specifically on those you can do when you wake up or before you go to sleep, when you start and finish your day, and when you are between sessions.

Here are some possible self-care tips and strategies:

Set daily intention. Setting a positive daily intention can help you lead a purposeful and meaningful life. At the end of each day, think about how you lived your daily intention and how it impacted your way of being.
Live in the moment. Give yourself permission to just be and to be present in the moment. Scheduling short breaks throughout the day, doing one-minute meditations, breathing, noticing your surroundings, practicing gratitude, accepting things as they are, being mindful, taking a break from social media and technology, doing physical and mental grounding exercises, and focusing on one thing at a time can help you be in the moment and reset.
Fuel yourself. Truth is, you are what you eat. Eat balanced meals and drink plenty of water.
Move and exercise. A body in motion stays in motion. Engage in regular movement and exercise. Stretch to give your muscles a break to relieve tension and anxiety and pay attention to your posture. Take a brief walk between sessions, in the morning or after work.
Get enough sleep. Sleep hygiene impacts energy, concentration, learning and memory.
Set boundaries. Boundaries promote safety and security of self and others. Create and maintain professional and personal boundaries. At the workplace, this may mean saying “no,” delegating tasks, stopping a session on time, not answering emails from your family, not overloading your caseload with too many clients, asking for help, working within your competence, minimizing and avoiding dual relationships, and refraining from overidentification. At home, it may be taking breaks, being consistent in asserting yourself, not answering emails from work, not doing the “thing” that was planned or adjusting your schedule.
Connect with others. Spend time with family, friends or someone who brings you joy. Regularly meet with peers or colleagues for support, engage in clinical or reflective supervision, participate in personal therapy, or attend a mutual support group.
Practice self-reflection. Make time for self-reflection to gain an understanding of yourself, your motivations and your behaviors. Increase your self-awareness and examine your self-talk, window of tolerance, inner critic, strengths and weaknesses. This can help you better understand yourself and possibly others, assist in better decision-making, increase self-confidence, reduce assumptions and biases, build better relationships, increase emotional regulation, decrease stress, and reduce transference and countertransference issues. It can also help you pursue your purpose and live authentically. Reflective practices can include clarifying values, journaling, practicing mindful meditation, turning off autopilot, seeking supervision and completing a strengths assessment.
Use positive affirmations. Praise yourself for what you do. Positive affirmations promote positive well-being and lower stress. Try writing yourself a Post-it note or setting a daily reminder.
Have self-compassion. Honor and respect your feelings when you suffer, fail, feel inadequate or succeed. Allow yourself to cry and express your feelings. This can be one minute to one hour but take the time to release your emotions and all you hold on to.
Engage in enjoyable activities. Participate in activities you enjoy, such as group exercise, spending time in nature, listening to music, playing a recreational sport, reading for leisure or another hobby.
Practice relaxation. Relaxation is the lowering of tension in the mind and body. Relaxation improves coping abilities; decreases anxiety, depression and insomnia; lowers blood pressure and increases blood flow; decreases heart rate and respiration rate; provides a sense of calmness and confidence; relaxes muscles; promotes healing; and can reduce pain. Types of relaxation techniques include yoga, massage therapy, mindfulness meditation, progressive muscle relaxation, body scan, visualization/guided imagery, deep breathing and breath focus.
Use humor. Laughing feels good, can reduce stress, stimulates circulation, aids in relaxation and sustains resilience. Look up a joke, reframe or find humor in a situation, or watch something funny.
Treat yourself. Indulge in the things you enjoy, such as ice cream, a new book, etc.
Learn. Try learning something new. This can mean learning a new skill, building your strengths, gathering information or seeking out intellectual challenges personally and professionally.
Breathe. Just breathe.
Focus. You have the ability to intentionally choose what you focus your energy on.
Reduce stress. Aim to reduce stressors in your life.

Step 3: Commit to the plan

Commit yourself to intentionally use your self-care plan. You can share your plan with an accountability partner or someone encouraging. Just as you would ask a client to create a safety plan or relapse prevention plan, it is helpful to do the same for your self-care plan. This can be done in many ways, whether it is using your daily calendar, writing Post-it notes, or writing your plan on an index card to keep in your purse or wallet. Remember to start small and start where you are. Be realistic with your plan and implement activities that work for your life.

Step 4: Check in and monitor the plan

Check in with yourself regularly to review your plan and hold yourself accountable. The Professional Quality of Life (ProQOL) is a useful self-care tool developed by Beth Hudnall Stamm to help you monitor your self-care by seeing how you score on compassion satisfaction, burnout and secondary traumatic stress. Don’t forget to take the time to celebrate your success and evaluate where things did not go as planned.

Moving forward

The most selfless act we as counselors can do is to take care of ourselves actively, regularly and purposefully. Maintaining and enhancing our emotional, mental and physical well-being is a form of prevention as well as an ethical responsibility and a personal and professional imperative. It prevents burnout, assists in staying present with clients and enables us to provide the highest quality of care to clients while maintaining our well-being.

When we take time to care of and invest in ourselves, we are preparing ourselves to take care of others.

Autumn Gonzalez (she/her) is a licensed clinical professional counselor in Illinois and Iowa, a national certified clinical mental health counselor, and an advanced alcohol and other drug counselor certified by the International Certification & Reciprocity Consortium. She is a licensed mental health clinician and site supervisor for master’s-level practicum and internship counselors-in-training at The Project of the Quad Cities and residential and inpatient counselor at UnityPoint Health Robert Young Center. Contact her at agonzalez@tpqc.org.

This research was inspired by Gonzalez’s participation in the Refresh, Recharge, and Reconnect Retreat for Therapists funded by the Merlin W. Schultz Foundation Grant.

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.

Mental Health Access Improvement Act poised to pass in Congress

By Lisa R. Rhodes December 20, 2022

Image by JamesDeMers from Pixabay

The American Counseling Association’s lobbying efforts for Congress to pass the Mental Health Access Improvement Act (H.R. 432) may garner success before the new year.

As of this morning, the House version of H.R. 432 has been included in Section 4121 of the Omnibus released by the Senate, says Brian D. Banks, ACA’s chief government affairs and public policy officer. “This means the House and Senate have worked together to include our bill in the final vote to become law,” he explains. “Both the House and Senate have to vote yes for the bill to pass and make its way to the President’s desk for signature. We can expect a vote by the 23rd of this [week].”

If passed, H.R. 432 and S. 828, its companion bill, will allow licensed professional counselors and licensed marriage and family therapists to get reimbursed for providing mental health services to adults age 65 and older who access their health care through Medicare. This includes clients who are disabled and veterans.

This latest development is proof of ACA’s ongoing progress to make the bill a law. Earlier in the month, ACA was successful in its work with the Centers for Medicare and Medicaid Services (CMS) to help lower the cost of the bill to $902 million over a 10-year period.

“This is a big deal. Many Republicans were hesitant to support [the bill] because of the $1 billion plus price tag,” Banks says. “This gives us more momentum, right when we need it.”

Banks also notes that mental health is a “hot topic on the Hill.” ACA was competing for a vote on Congress’ legislative calendar, which is scheduled to end on December 21. Now it appears the House and Senate will vote on the bill before the start of the new 118th Congress in January.

The decadelong push of ACA and its stakeholders to bring a Medicare reimbursement bill this far on the Hill is bearing fruit, says Banks, who has focused on the effort for three years.

“This bill passing is a hand up to people in need, and that is bigger and better than any impact on the Hill,” he continues. “I will share this. Congress will look to ACA more when this bill passes because we will become equals with our needed colleagues in the social work and psychology professions.”

According to the national study ““Counselors’ Interest in Working With Medicare Beneficiaries: A Survey of Licensed Professional Mental Health Counselors,” conducted by ACA in April, an estimated 115,000 current licensed professional counselors would enroll in the Medicare program with the passage of this legislation, including counselors in the CMS Medicare Program. The ability for licensed professional counselors to treat Medicare clients also provides them with a way to earn additional income.

Danielle Monroe, a licensed mental health counselor at Southwestern Behavioral Healthcare in Indiana, has been helping with lobbying efforts in her state. “There is a lot of excitement and anticipation amongst counselors to finally have access to this population and to provide services to meet their needs,” she says.

The passage of the bill is necessary because licensed professional counselors and licensed marriage and family therapists can only provide mental health services to clients up to age 65, when they become eligible to enroll in Medicare. Older Americans on Medicare who are working with these counseling professionals must then find a new provider who accepts Medicare so they can continue their treatment.

According to Banks, passage of the Mental Health Access Improvement Act will help older adults who must often wait as long as three to four months for an appointment with other mental health providers who accept Medicare, such as social workers or psychologists.

As of now, Monroe explains, older adults must decide whether to pay out of pocket for care, which is an added burden since many live on a fixed income, or to discontinue treatment because they don’t want to start over with a new provider who takes Medicare.

“Passage of this legislation means that older Americans will be able to keep working with providers that they connect with and trust regardless of their age,” notes Monroe, an ACA member. “This seamlessness of treatment makes completion of treatment more likely.” Making it possible for older adults to continue mental health services with licensed professional counselors is an important preventative measure against future negative outcomes.

If older clients don’t receive consistent clinical help, they may begin to rely on medication to treat their mental health symptoms, Banks adds. “Some of the medications contain opioids, which can be addictive and lead to substance use issues, or worse,” he says. This includes suicide attempts, thoughts of suicide and self-harm. Many psychologists and social workers are not accepting Medicare, which, as Banks notes, gives licensed professional counselors the opportunity to treat these clients.

Monroe says that there is an important lesson to be learned in the dedicated effort to pass the Mental Health Access Improvement Act. “We have to continue to be organized and to have our voices heard,” she stresses.

Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.

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.

Voice of Experience: Home visits

By Gregory K. Moffatt December 19, 2022

front porch of house with a a green chair and swing

Image by Gretta Blankenship from Pixabay

It was early in the 1990s. I had been in practice maybe six or seven years. I’d paid my dues in general practice, hoping one day to focus exclusively on family and children. At that time, nearly all my clients were children or families with children.

Most of my clients were either single-parent families, divorced and blended families, or families in the middle of divorce. It was heartbreaking for me to observe the pains of broken families — lost dreams, heartache, the unknown, financial devastation, and the many other factors that can make divorce so painful. These are things we have all seen many times even for those just starting out in the profession.

One family was limping along trying to salvage their 10-year marriage. I’d seen them and their three children several times in my Atlanta office, but most of my clinical work focused on the marriage.

The couple faced many challenges in finding times to meet with me. They both worked full time; he was a postal worker and she was a nurse. Their home was 35 miles from my office through heavy Atlanta traffic. For each appointment, they had to pick up children at daycare, scurry home as quickly as possible, change clothes, meet the babysitter and head north to my office to make our 6 p.m. appointment.

To arrive on time, everything had to go as planned — no car troubles, no late days at work, no late or no-show babysitters. The stress of a long day at work, coupled with the rush to get out the door on time, often led to arguments in their 45-minute drive to my office. If this happened, they were so harried when they arrived that it took several minutes for them to recenter before we could get down to business in our session.

Despite all of that, we were making progress until one day I got a call just 30 minutes before they were supposed to arrive. Everything had gone wrong that day, and they were not only canceling the appointment but also withdrawing from therapy.

That is when I had an idea. I suggested we have a final session the following week, and I would help them find a referral. But this time, I offered to meet them in their home. They heartily agreed.

Their dimly lit living room was full of commotion: Pets were running around, and I could hear young children in a nearby bedroom. But I realized the only one who was uncomfortable was me. They were more relaxed than I’d ever seen them. Although it was a less-than-ideal environment for therapy, they were comfortable in their own space. I saw them in a way I’d never seen them before.

It was then that I realized that I was unintentionally adding to their marital challenges by the very nature of my practice. They had to spend extra money on babysitters — money they didn’t have. And before each appointment, they spent the entire day dreading the potential problems they might encounter trying to make it to my office by 6 p.m. — my latest appointment option.

After this realization, I offered to meet with them twice a month in their home and they agreed. Six months later when we terminated, their marriage was much healthier. Just a year or so ago, I received an email from the wife. They are still married, their children are grown, and life has settled.

Home visits create numerous challenges for us as counselors. Most obviously, boundary crossing is an issue, but in the home visits I’ve done, I’ve never had any problems arise from these boundary crossings. Until about 50 years ago, half of all physicians made house calls without any issue. And some still do!

Safety, of course, is a concern, but social workers have made home visits for decades demonstrating that safety issues can be managed.

Instead of making a home visit, I could have offered a later appointment time or one on the weekend, but that would have compromised my own family life boundaries. Finding a closer referral could have worked, but that would have required them to start over.

While I admit these challenges, among others, need to be considered, if we really want to pursue diversity and consider cultural issues, shouldn’t that include the challenges I faced with this family? I am confident that I opened my mind to alternative methods of delivering clinical services in an ethical and responsible way.

Just like telehealth, there is no one-size-fits-all approach. For example, I couldn’t meet alone with an individual client at their home. Although there are many limits to offering in-home services, I’ve never regretted making that decision.

Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

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.