Tag Archives: Counselor Educators Audience

Counselor Educators Audience

Past trauma in counselors-in-training: Help or hindrance?

By Bethany Bray May 20, 2018

Counselors are not immune to trauma — in fact, far from it. Many practitioners say that personal or familial experience with trauma or mental illness actually spurred them to become professional counselors.

The connection between personal experience and the pull to become a counselor is something that is hard to quantify, but “in my personal experience, I encounter it pretty frequently,” says Allison Pow, a licensed professional counselor in North Carolina and adjunct professor at both Wake Forest University and the University of North Carolina at Greensboro. “For a lot of people, past experience draws them into the counseling field, and trauma can play such a pivotal part in someone’s life. It’s a common thing that we see as supervisors and counselor educators.”

Past trauma can be either an impairment or a kind of “benefit” for counselors-in-training, depending on how much the person has worked through and processed the effects of trauma, say Pow and Amber Pope, a licensed mental health counselor and program chair of the clinical mental health counseling program at Hodges University in Fort Myers, Florida.

Counselor educators and other professionals in the field who have close contact with counselors-in-training should keep an eye out for red flags that may indicate that a person’s past trauma is interfering with their growth as a counselor or, in a worst-case scenario, has the potential to cause harm to clients.

“Just because you’ve been through trauma doesn’t mean you can’t become a counselor. You can become a great counselor if [your trauma] is processed correctly,” Pope says.

Pow and Pope co-presented a session, “Wounded healers: How to support counselors-in-training who have experienced trauma,” at the 2017 ACA Conference & Expo in San Francisco. The term “trauma” can encompass a wide variety of experiences, from an acute event to yearslong, developmental trauma, Pow explains.

People who have processed the effects of past trauma — often with the help of a therapist of their own — can become excellent counselors, Pow says. Posttraumatic growth and healing from the experience can foster empathy and strengthen coping skills.

“Going through trauma is a very unique experience [through which] you understand the way your brain works and your body reacts. That is hard for someone to understand who hasn’t gone through that,” Pow explains. “I have had some students who were very resilient because they have been forced to cope [in traumatic situations] in the past.”

“The reason a lot of people become very, very good counselors is their life experience,” Pow adds.

However, people who haven’t fully processed the trauma in their backgrounds can run into trouble as professional counselors. For example, in client sessions, they risk becoming triggered by topics that clients bring up and may be unable to regulate their own emotions or other behaviors in response. These reactions can harm the delicate balance of trust between practitioner and client.

“They may unwittingly be using their role as a counselor to work through their own unprocessed material or to recapitulate an unhealthy power dynamic to feel that they’re in control,” Pow says. “Control is often something that people seek after going through trauma. It may come from a lack of self-awareness.”

 

Red flags

Interactions with classmates and colleagues might be one of the best indicators of whether counselors-in-training have a trauma history that still needs to be worked through. During moments of vulnerability, do they become aggressive or reactive or express other strong emotions? In general, a lack of self-awareness, such as oversharing in class or being unaware of how the people around them are feeling, can be an indicator of unprocessed trauma, says Pow, who has a private practice in Greensboro, North Carolina.

Also watch for attachment issues or signs of avoidance, such as skipping classes or evading one-on-one contact with a professor or authority figures, Pow says. It can also be indicative of a trauma background if students do not generally have themselves together, including missing assignments or being late to class repeatedly, Pope says.

Other indicators can include:

  • Poor boundary keeping: This may manifest as oversharing, attention-seeking or disruptive behavior in the classroom, or an unhealthy preoccupation with relationships with classmates or colleagues.
  • Low self-confidence: Students with unresolved trauma may demonstrate low belief in themselves regardless of past successes. They may feel like they can “never do enough,” Pope explains. These students may lack motivation or even self-sabotage, such as missing a deadline even though they are capable of meeting it.
  • Rigidity in thinking: If students aren’t open to receiving feedback and unwilling to take constructive criticism, it can be a major indicator of past trauma that hasn’t been resolved. This attitude can stem from a black-and-white way of thinking in which the student categorizes things as “all good” or “all bad” with no in between, Pope says.

Everyone has bad days now and then that can set them off. However, if a student is repeatedly unable to regulate their emotions, such as becoming reactive or upset in class, it is a red flag, Pope says.

“When a student is so set in their values or way of thinking that they try and impose it on others, that can stem from trauma. If they can’t become more flexible in their thinking process or relationships with others, then they’re going to have a difficult time with clients,” she explains.

 

When it’s time to intervene

It is beneficial, for any number of reasons, for counselor educators to get to know and connect with the students in their program, Pope says. If a particular student seems to be struggling with challenges that could keep them from becoming a proficient counselor — such as issues related to unresolved trauma — it is better to intervene sooner rather than later.

Be prevention-focused instead of reactionary, Pope suggests. The longer a student continues in a graduate counseling program, the harder it will be to check their behavior or make decisions about their future.

“Don’t let students waste time and money if they’re not going to be a good fit,” she says.

Counselor educators who identify students raising red flags should pull them aside after class or ask them to stop by the counselor educator’s office, Pope advises. The first interaction with the student should be kept informal and light. Let them know that you have noticed some patterns and indicators in their behavior that require some attention, and ask them what supports they need to help them make improvements, she says. If appropriate, other professors or colleagues who know the student can sit in on this initial informal meeting to offer support, Pope says.

Check in with the student frequently during class breaks, supervision meetings and other opportunities. Ask how the student is doing and how they are practicing self-care. This conveys to the student that the professor wants them to succeed and grow, Pope says.

Pope emphasizes that this method should be applied only to counseling students who haven’t committed an egregious offense or intentionally gone against the ACA Code of Ethics. In those cases, a swifter and more formal response is necessary.

If a student does not begin to change their behavior after a first informal meeting, consider meeting with the counselor-in-training again to create a formal written behavior agreement. Spell out which behaviors aren’t acceptable, why those behaviors aren’t acceptable and what they need to do to continue in the counseling program. Be specific and include a timeline of when the expectations must be met, Pope advises.

If the student meets the requirements in the behavior agreement, they should be allowed to continue on with graduate school. If not, suggest that they take a semester or other time off to get the help they need, or leave the program entirely.

“When a student is given feedback and continues in their behavior patterns and doesn’t make any changes, that’s showing me that the student isn’t ready to change or do what they need to do to grow professionally,” Pope says.

Throughout the process, Pope says, she would recommend that the student attend counseling. There is some debate within counselor education as to whether it is ethical to require students to attend personal counseling . In the case of recommending a student to personal counseling, a counselor educator can request the student to provide proof, in the form of written letters from a provider, that they are attending therapy sessions and making progress to demonstrate their willingness to comply with their professors’ recommendation.

“We’re very open, telling students that we [their professors] have all attended or are attending counseling, and that it’s important to be as healthy as you can be, [to] take care of yourself mentally and emotionally,” Pope says.

Although sometimes uncomfortable, this process is also an opportunity for counselor educators to model what a healthy professional relationship should look like, Pope notes. It shows students that you can give critical feedback while caring and maintaining empathy.

“You can give suggestions and guidance while keeping professional boundaries. They may not have had that [example] in their life before,” Pope says.

“In my classes, I make a point of being very transparent with my expectations and predictable. I have a standard of which behaviors I respond to and which I don’t,” Pow agrees. “For a student who has gone through trauma, it’s not our job to be their counselor. But a lot of times their lives haven’t been predictable, and they haven’t had a safe base. We can be that predictable, safe base. We can talk openly about their struggles, getting help and that it’s not a bad thing that you’ve had some challenges in your life.”

 

Gatekeepers and guides

Counselor educators must strike a fine balance between acting as gatekeepers for the profession and serving as mentors and guides for those who need extra support, Pope says.

“When it comes to student trauma and challenges, for me, an ideal situation is when I can have enough conversations with a student so they can come to their own conclusions on whether the field is right for them or not,” Pow says. “Part of effective trauma treatment is creating choice and putting decision-making back into the person’s hands. That may be the choice to take some time off and return to the program. Emphasize where they have agency in things.”

It’s OK for a student to come into a graduate counseling program with unresolved trauma issues. They just have to be willing to work on it, self-process and accept help, Pow says. Students who are open to self-reflection and constructive feedback can experience a tremendous amount of growth, she says. “It’s unreasonable for us to expect, as educators, that people are going to come into these [graduate] programs having processed everything that has happened to them and be completely self-aware,” she affirms.

Processing and rising above trauma builds skills that are the hallmarks of a good counselor, including a strong sense of self-awareness, empathy and sensitivity. Counselors who have successfully processed their past trauma can become models for clients struggling with similar issues, Pope says.

“If you heal from a trauma, you really have to engage with the most vulnerable parts of yourself. It’s a depth that people who haven’t been through trauma may not fully understand,” Pope says. “That’s what creates really great counselors — [to be able to] engage with others at that level of vulnerability and intimacy. Knowing that going through something so challenging, you can become more whole, and in turn become a safe place for others. As a counselor, you’re better able to serve your clients.”

 

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Related reading

  • For more on supporting counselors-in-training through the supervision process, see the feature “Guiding lights” in the June issue of Counseling Today.

 

 

Suggested resources

Want to learn more on this topic? Pow and Pope suggest these titles:

 

 

 

 

 

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org

 

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

 

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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.

 

 

Integrating mindfulness interventions in counseling courses

By Allison Buller October 2, 2017

As a professor of counseling, I am invested in helping students develop the necessary and sufficient skills to become effective psychotherapists. There is a plethora of evidence to support mindfulness as a tool for fostering these skills. Integrating mindfulness training can:

  • Improve how counselors-in-training relate to self and others with more acceptance, genuineness and empathy
  • Help counseling students develop a deeper connection to clients’ experiences and be more present to clients’ suffering
  • Help decrease stress, negative affect, rumination, and state and trait anxiety, and increase positive affect and self-compassion
  • Help students become more aware, patient, mentally focused, empathic, compassionate, attentive, responsive and able to handle strong emotions
  • Help students cultivate therapeutic presence

With all of the good data to support mindfulness in counselor education, I chose to describe a few of my favorite mindful interventions and how I implement them in my counseling courses.

 

Mindfulness interventions

Breathing techniques and guided mindfulness practices are among the key interventions I include in all of my counseling classes. The interventions are secular; therefore, I do not use terminology that would be considered religious or unusual for the university context. I ask students to close their eyes while I guide them through a mindfulness practice of attending to a specific focus for several minutes, such as paying attention to each breath or sending out positive energy to self or others (i.e., stress breath and compassion meditation).

The movement, breathing and mindfulness components of the class are designed to enhance the students’ capacities for sustained attention, promoting greater awareness of cognitive, physiologic and bodily states and how to regulate those states. In addition, I include a brief period of discussion prior to the guided mindfulness practice in which I offer didactic information about such topics as identifying stressful events, using mindfulness techniques to respond to difficult people, cultivating positive relationships with others and keeping one’s mind and body healthy. This information is often woven into subsequent guided mindfulness practices (e.g., using the breath to relax if something stressful has happened). Students are encouraged to practice these skills outside of class and reflect on their experiences in writing.

I often receive positive feedback from students participating in mindfulness practice. Among the reflections I have received are:

  • “I felt relaxed.”
  • “Calming … I wish we could do this every time.”
  • “Tired in a good way.”
  • “It helped me to feel something different.”

In some cases, students may experience open displays of emotion during meditation (i.e., crying, runny nose, shortness of breath). The generalizability for students happens when they can use these techniques outside of class time. Examples reflected by students using the stress breath technique include:

  • “I used it before seeing my client”
  • “I use it all the time now”
  • “I never knew I didn’t know how to breathe!”
  • “I catch myself using it before tests or presentations.”

Many students acknowledged that the “stress breath” was one of the most useful interventions they learned in class.

Although the majority of student reflections have been positive, some students struggle with the concept of mindfulness:

  • “I don’t know how to clear my mind.”
  • “How do I stop thinking?”
  • “I can’t think about nothing.”

Comments such as these need to be explored, and extended discussions on barriers to mindfulness can offer clarification. Before every practice, I give students the option to “pass or play,” meaning they can choose whether to participate in the mindfulness activity. If they chose not to participate, they are asked to sit and engage in a quiet activity.

 

Integrating mindfulness training

One of the biggest challenges I face in implementing mindfulness training is believing in myself as an experienced practitioner and qualified teacher. Although I have practiced mindful meditation for almost a decade, I am not certificated in yoga or meditation. For all intents and purposes, I am an ordinary professor with a personal practice.

The majority of researchers and practitioners agree that teaching mindfulness requires a dedicated personal practice. In fact, Jon Kabat-Zinn advised, “Don’t turn mindfulness into a commodity.” He believes that mindfulness needs to become a way of life, not just a skill, an intervention or an outlook.

In a 2012 article (“Teaching mindfulness to create effective counselors”) for the Journal of Mental Health Counseling, Jennifer Campbell and John Christopher described it as the sort of teaching that cannot be done from a manual. Instructors must be able to dive deep and connect with themselves through a kind of altered state. The authors recommended that those who do not yet have years of personal experience co-teach with experienced meditation teachers.

Another challenge is finding time during class or in the curriculum for mindfulness training. Time constraints and the pressure to cover course material is an ongoing concern in higher education. At times, implementing mindfulness practice can feel like an indulgence or an overwhelming addition rather than a useful tool. Taking time to implement mindfulness requires discipline and planning. I chose specific times throughout the semester to implement mindfulness training (i.e., before role-play activities, midsemester wellness day, finals week). Every course is different, and the needs of the students vary. Choose what works best for you.

The greatest challenge and best motivator for implementing mindfulness is helping students understand how mindfulness can be used to manage emotional reactivity. Incorporating research literature to support mindfulness as a tool for emotional and mental health is necessary to gain students’ trust. Mainstream information about mindfulness can be overwhelming and confusing. My job as a professor is to clarify the facts and demonstrate the tools.

 

Take-home lessons

I choose to incorporate mindfulness practice in my courses based on positive outcomes relevant in the literature. Many of the students in my counseling courses have never practiced mindfulness or had any training on how to breathe. I find it both humbling and exciting to introduce this practice to students. I am humbled to share the art of meditation and excited to introduce mindfulness to students for the first time. The insights and changes that come with studying and practicing mindfulness carry over into life and work.

My self-efficacy as a mindfulness educator stunted my motivation and confidence to do this kind of work. I erroneously believed that I lacked the qualifications and information required to help others learn to meditate. In essence, I was standing in my own way. Therefore, I conclude this article by appealing to the reader for brazen courage. If implementing mindfulness practice is your intended goal, commit to your own practice, align with like-minded and experienced faculty, and get out of your own way.

 

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Allison Buller is a licensed professional counselor and an assistant professor of counseling and psychology in the Department of Arts and Sciences at the University of Bridgeport. She is also a staff counselor for the university’s counseling center. Contact her at abuller@bridgeport.edu.

 

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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.

Developing trust in your effectiveness as a helper

By Peter Scheer September 12, 2017

As a newly minted counselor, I sometimes remember back to my early days in the program when my classmates and I shared some deep concerns about “doing it right.” Our heads were full of theories and dos and don’ts, and we really struggled to understand how we could possibly help anyone as we stumbled around during our practice sessions with other students during the prepracticum course.

While reviewing tapes of our sessions in class, we questioned ourselves: Were we doing anything to help this client? Were we just wasting their time? What the heck were we doing as counselors?

Many months later, after completing our required internship hours under the supervision of a licensed practitioner, we then had to supervise students in their early stages of counseling during prepracticum. I was actually very glad for this experience and quite surprised at how much it reminded me of where I had been at the beginning of the program. I observed my supervisee and recognized many characteristics that I had at that stage: self-doubt, setting high standards for myself, wanting to control the session.

It made me realize how far I had come. I was surprised at my ability to empathize with my supervisee and to find words to ease their concerns while providing some guidance and hope that they too could make it one day. I saw how much my internship hours had changed me and helped me develop some degree of confidence.

While reviewing tapes one week with my supervisee, I noticed that they were struggling significantly with self-doubt and wanting to see improvements quickly. The supervisee felt that because they had not managed the counseling session well enough, the client had not been well served. The supervisee took on a lot of pressure to get an outcome and ended up feeling very inadequate.

A few days after the session was over, I thought of a personal experience that had been significant in helping me to see how therapy works. It was a single session that was so helpful, although neither I nor my therapist knew it at the time. Over the course of about 20 years, I went to 12-step meetings to work on my codependency, went to therapy off and on, read many books and discussed mental health with others who were also in emotional recovery. I explored spiritualty and many forms of alternative healing modalities. Many times I encountered the concept and benefits of forgiveness and would remember my therapist’s story. Like water dripping on a rock, over time, my stubborn anger softened and yielded.

I want to share my journey to wholeness and how that first encounter with forgiveness was foundational in my eventual release of anger, even if that therapist is unaware of how she helped me. I share that with you now using an excerpt from an email to my supervisee.

 

Email to supervisee

I did have something else that I wanted to share with you to support you with this new skill that you are developing.

I recall your desire to steer and to control the session and hope to see some results, or at least some change in the client fairly quickly. Also, your desire to rate and assess your personal helping skills during a session. This mental health therapy is quite different than other professions, as we have discussed. I too came from a problem-solving profession where we assess, diagnose, make a plan, implement it and reassess … and try something new if that does not work. It is quite action-oriented and “managed” by us. We rely on feedback of some sort to assess progress.

However, mental health therapy is quite different. It has some similarities in that we may try different approaches until we see progress. However, the feedback we get from the client can range from direct and clear to none at all. Many times it is vague and sometimes even evasive. It is really hard to work with this kind of self-reporting as feedback.

Also, a reminder that counseling is a collaborative activity. We may forget that desired change in the client requires action and effort by both counselor and client. It is not realistic to think that we as counselors are solely responsible for client outcomes.

Finally, you may recall I mentioned that a client may actually be helped even if they do not show it in session. We may say something that triggers an awareness that proves helpful, but we, as the therapist, do not know of it. I want to share a personal experience I had to illustrate this point.

Many years ago, I saw a therapist. This was my first experience with counseling. It was possibly our third or fourth session, and I was struggling with unresolved anger at my father. She sensed that I needed help to forgive him and release the emotional burden I was carrying. She told me her personal story of forgiveness. How she managed to forgive the DUI driver who killed her only child, and how she found emotional peace after that. I was both stunned and impressed by her ability to forgive and her calm and peaceful demeanor while recounting it. Clearly, she walked the talk of emotional wellness.

While I found it impossible to forgive, I was deeply affected by her story and thought of it many, many times over the years. I returned to that story many times as I worked through my anger with my father and as I learned how to forgive.

Her story did not “fix” my problem with my father, but it certainly did give me a new awareness about forgiveness, what it means and the benefits of forgiveness for me. It has taken 20 or more years to forgive my father. However, I worked on it and am now at peace with that relationship.

To illustrate how a therapist may help a client but not know at the time, and how the collaborative nature of counseling should work, I offer the following questions and answers for you to consider:

Did that therapist “cure” me in that session? No.

Was that session helpful to me? Yes.

Did I tell the therapist at that time this was helpful? No (because I was just processing this information).

Did that therapist lay a foundation for a positive change in me? Yes.

Does she know today how that one session helped me? No.

Who had the choice to work on changing me? I did.

Who did the actual work to change me? I did.

I think what I carry with me because of this experience is the awareness that I may be helping this client in front of me, but I may never know it. I may be adding one brick to this client’s efforts to rebuild his/her house of emotional health. I may never see the finished house. It may never be finished. But I know I tried to help the client in the moment. I am not sure I can do more than give it my best effort and keep learning and stay focused on the client.

This all feeds into the notion of “letting go” of the outcome of a session. To accept that we just do not know in many cases what effect, if any, we may have on a client. Sometimes, it may be enough to just sit there and be present and caring as they tell us painful and personal stories.

This can be quite difficult to accept; to allow ourselves to believe that if we make an honest effort to help each client, that this may actually be enough. Improvements in mental health require a collaboration and involve a client being both willing and trying to change, along with a supportive therapist to help them change. It is complex and time consuming. It is vague and uncertain most times. This is what we are getting into.

I offer all this and ask you to reconsider your definition of what a “successful” session looks like. I offer this to allow you to reconsider how you judge your performance in this profession. Your heart is in the right place. I believe that you will help people by just having patience and persistence (with the client and with yourself), along with caring and empathy, ongoing practice and continual learning.

My best wishes to you!

Peter

 

 

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Peter Scheer conducts a private practice, Heartbeats to Wellness, offering private counseling with a focus on adolescents, major life transitions, and grief and loss in Harrisburg, Pennsylvania. He is a national certified counselor (NCC) and Health Rhythms facilitator offering drum-based group therapy. Contact him at peter.heartbeats@gmail.com.

 

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Related reading on practitioner self-doubt, from the Counseling Today archives: “Facing the fear of incompetence”

 

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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.

Healthy conversations to have

By Kathleen Smith July 26, 2017

In the United States, 1 in 6 adults has a prescription for a psychiatric drug. That ratio only increases among individuals who walk into counselors’ offices, leaving many counselors feeling that they must perform a special type of tightrope act to talk about medications with their clients. Given that licensed professional counselors don’t possess prescription privileges, some counselors feel that they lack the training to carry on such discussions. Other counselors fear letting their own beliefs and biases show. Regardless of the reason, some counselors are quick to refer clients back to their doctors or psychiatrists rather than engaging clients in a thorough conversation about medication management themselves.

Because primary care physicians write almost 70 percent of antidepressant prescriptions, counselors may find that new counseling clients who are on medication have yet to have an extended conversation about medication management and their overall mental health. These clients may not have given much consideration to how long they want to stay on medication, or they may be uninformed about the possible risk of growing dependent on sedatives, anxiolytics and other medications.

Several counselor educators are taking up the charge of encouraging more informed and comfortable conversations in the counseling room about client medications. American Counseling Association member Dixie Meyer presented with colleagues at the association’s 2016 conference in Montréal on adjunctive antidepressant pharmacotherapy in counseling. Meyer dedicated her dissertation research to the sexual side effects of antidepressants and their effects on romantic couples. As her research expanded, she grew more and more fascinated with exploring the relationship between psychopharmacology and counseling.

Today, as an associate professor in the Department of Family and Community Medicine at St. Louis University, Meyer educates many primary care physician residents, and she notes that counselors sometimes forget that they have a unique ability to conceptualize clients. “Primary care physicians are expected to be able to know pretty much anything, but they do not have the same level of depth in their mental health training,” she says. “Counselors need to really think about what kind of information they can share with a primary care physician, and the answer is, a lot.”

Meyer explains that counselors may have a greater understanding of the impetus for the client’s condition, the specific symptoms the client has experienced, which of a medication’s potential side effects might be more of a challenge for the client and what additional resources the client may need to maintain medication adherence.

Biases and fears

Professional counselors carry their own biases and values related to psychiatric medications, often based on their individual experiences and training. It is easy to see how the counseling profession as a whole might feel threatened by the statistics, however. For example, nearly $5 billion is spent every year on TV ads for prescription drugs. Then there is the fact that more than half of all outpatient mental health visits involve medication only and no psychotherapy.

A physician assistant with a second master’s degree in counseling, ACA member Deanna Bridge Najera is frequently invited to talk to counselors about improving dialogue between medication prescribers and counseling professionals. She gave a presentation at the ACA 2017 Conference in San Francisco titled, “Medicine Is From Mars and Counseling Is From Venus: How to Make It Work for Everyone.”

Najera has heard skeptical counselors make many statements about psychopharmacology, including that such medications turn people into “zombies,” alter their personalities or simply produce placebo responses. As a master’s counseling student, she also heard many comments from fellow students about their negative relationship with medication or their family members’ negative experiences.

“We have to make sure that we have these conversations out loud,” Najera says. “We have to ask counselors what their concerns are. The way I explain it, the medicine is supposed to allow you to be who you’re supposed to be. It doesn’t change who you are; it just makes it more manageable to learn and grow.”

Although there is still no clear winner in the medication versus therapy debate, researchers are learning more about who might respond to one treatment better than the other. For example, a 2013 study in JAMA Psychiatry found that patients with major depression with low activity in a part of the brain known as the anterior insula responded well to cognitive behavior therapy and poorly to Lexapro. Those patients with high activity in the same region did better with medication and poorly with the therapy. Researchers have also concluded that patients who are depressed and have a history of childhood trauma do better with combined therapy and medication than with either treatment alone.

“We chose our profession because we believe in our profession,” Meyer says, “but the research is going to report no differences between counseling and medication. I do see a lot of bias, and one of my concerns is that our No. 1 goal should be to help the client. So whatever the client’s perspective is, whatever the client thinks is going to help them is probably what will help. They are the experts on their own life.”

Erika Cameron, an associate professor of counseling at the University of San Diego and an ACA member, presented with Meyer in Montréal. When they were enrolled in the same doctoral program, Cameron found herself sharing Meyer’s interest in psychopharmacology and considering how she could respond to the general wariness of school counselors around the topic of medication.

“There can be a bias that that’s not part of their role. They are not diagnosing or prescribing, so they don’t need to know about medication,” says Cameron, who once worked as a school counselor. “But by not talking about it, we might be harming the client. Or if you don’t know that a student is on a medication, then you don’t know what behavior sitting in front of you is normal or atypical for that particular student.”

Another common trepidation among counselors is the fear of stepping outside their lane when it comes to talking about psychiatric medication. Clients often ask for advice about certain medications or when starting any type of drug, but there is a temptation among some counselors to avoid the subject or simply to refer all questions in that vein to a psychiatrist or doctor.

Franc Hudspeth, associate dean of the counseling program at Southern New Hampshire University and also a licensed pharmacist, says that counselors should serve as educators and advocates when it comes to client medications. “We should never cross that line of telling a client what to do with that medication,” he says. “We have to refer back to the foundation of our profession. We help individuals overcome problems, and we don’t give them the solutions. It’s saying to the client, ‘If you have concerns, we can present this to your prescribing physician, and I will support you in any way, but I’m not going to tell you how to do it or what to do with the medication.’ I wouldn’t even do that as a pharmacist. We have to help people make the best decisions based on the best information.”

Hudspeth also says that he observes more of a general hesitancy at work than a fear of liability among counselors. “If someone advocates for their client and their voice gets squashed by a physician or a psychiatrist, there may be some hesitancy to get involved. But it never hurts to voice concerns and to be the advocate for your client,” he says. “[Still], I do think that some counselors fear the repercussions of helping a client speak up.”

Having the conversation

How exactly should counselors respond when clients want to talk about psychiatric medications? In an effort to provide effective psychoeducation, Meyer says, counselors shouldn’t be shy about asking thorough questions upfront concerning clients’ beliefs and ideas related to medication. She suggests asking questions such as, “How do you know that you want to be on a medication?” and “Are you likely to have another depressive episode?” Questions such as these can provide valuable insight into the client’s knowledge (and knowledge deficits) about medication. For example, a client who wants to take an antidepressant might not realize that half of all individuals with depression will not experience another episode.Most frequently prescribed psychiatric medications in the U.S.

Najera also encourages counselors to ask clients where they obtained their knowledge about particular medications. “Many people have the idea that newer is always better, which study after study has shown is not true,” she says. “A client might see a commercial for a new medication and ask if it will work. I’d rather them not break the bank for a new medication when there’s a $4 medication at the local pharmacy that’s just as effective.”

Hudspeth suggests that counselors do a medication check-in with clients at every session. He says the best question counselors can ask clients who are already on medication is, “How is your medication treating you?” This kind of general question can help counselors gather information without overeducating clients in a way that predisposes them to having side effects, Hudspeth explains.

Cameron agrees that the simplest approach is often the most empowering for clients. “Sometimes [it’s simply] asking, ‘Did you read the really long paper that came in the bag with your pills? What is the medication really treating? What are its side effects? What would be considered not normal for you?’ [It’s] educating clients to be critical consumers of their medication,” she says.

Cameron also encourages counselors to role-play conversations that clients could have with their prescribing doctors. Counselors can assist their clients with compiling a list of questions to ask and also encourage them to track their symptoms, thoughts and feelings while on a particular medication. Data can be a powerful tool for holding doctors accountable for connecting clients with the best medication options, but sometimes clients need to learn what to observe while on their medications, Cameron says.

Counselors may also need to have conversations with clients about the impact that their physical health can have on their mental status. Meyer encourages counselors to take time to consider how nutrition, physical illnesses, medications and other substances could potentially influence the mental health of their clients. Anything from high blood pressure medication to birth control pills to low iron could be a culprit, and Meyer worries that individuals who don’t provide their doctors with detailed information about their health are at risk of being prescribed medications that don’t fit their particular symptoms.

“If a client has not had a physical in a long time, then you do not know if there are cardiovascular concerns, hormonal concerns, cancer symptoms or one of the many other disorders that can have depressive side effects or present as depression,” Meyer points out.

Counselors are also charged to have open and honest conversations with parents who are worried about putting their children on psychiatric medications. When Hudspeth worked as a pharmacist in the early 1990s, he began noticing that many children were being medicated without solid reasoning to back it up. Thinking there might be a better approach, he went back to school to become a counselor and later a counselor educator. In his counseling work with children, he has fielded many questions from parents about whether their child should be evaluated for the need to take psychiatric medication.

“My perspective is that the evaluation isn’t going to hurt anything,” Hudspeth says. “I tell parents that they don’t have to make the decision to choose medication, but if the child is medicated, he or she will also do better if they’re in therapy. The two treatments are synergistic, and our goal as a team is to find the [right] balance of different components.”

Cameron adds that school counselors are presented with the complex task of advocating for developing kids who are on medication. “Because there’s so much hormonal change and physical growth, medication may need to be adjusted more frequently,” she says. “School counselors have the ability to see these students on a daily basis, and if we’re not paying attention to these changes, there could be a downward spiral before something
is corrected.”

Psychopharmacology in counseling classrooms

Counselor educators are tasked with preparing their students for the increased use of psychiatric medication among their clients. The 2016 CACREP Standards require clinical mental health counseling students to be educated about the “classifications, indications and contraindications of commonly prescribed psychopharmacological medications for appropriate medical referral and consultation.” Similarly, the CACREP Standards say that counselor education programs with a specialty area in school counseling should cover “common medications that affect learning, behavior and mood in children and adolescents.”

Hudspeth is of the belief that every master’s program in counseling should require a psychopharmacology course. “When 50 percent of our clients are on medication, we should have a basic foundation for understanding psychopharmacology,” he says. “New practitioners need to be better prepared for what they’re going to face in internship or post-master’s work, so they should be familiar with what medications are used for what disorders and what kind of side effects pop up.”

A 2015 article in the Journal of Creativity in Mental Health by Cassandra A. Storlie and others explored the practice of infusing ethical considerations into a psychopharmacology course for future counselors. The authors argue that counselor educators should engage students in talking about how their own values and perceptions about medication use could potentially affect the quality of counseling service they provide. The authors tracked the success of one psychopharmacology course that asked students to complete a variety of creative assignments, including reporting on a legal or ethical issue in the field of psychopharmacology, interviewing an individual who takes a psychotropic medication and discussing fictional client scenarios. At the end of the course, students reported greater confidence in how they understood their role related to discussing medication with clients.

Cameron agrees with the benefits of offering a psychopharmacology course to counseling students. She also sees value in inserting medication conversations into her supervision work with students. When her students bring in case conceptualizations during their internship work, she asks them to list what medications the client is taking. She then asks them to educate their peers about what each medication is treating, what the dosage is and any typical side effects.

“I have to model being comfortable bringing up the topic of medication so that my students get more comfortable,” Cameron says. “Often they don’t talk about medication because they feel that they don’t know it all. They don’t want to give bad information. But they can learn to take a proactive role by sitting with a client and saying, ‘Hey, let’s look this up. Let me get this resource guide or a consult on this.’ There’s this fear, especially with student counselors, that you have to know everything to be able to be helpful.”

Areas for growth

Of course the work of medication education doesn’t end with graduate school. New medications are steadily being introduced, and over time researchers will learn more about the long-term effects of popular ones. Cameron recommends that counselors keep a copy of the Physicians’ Desk Reference, a compilation of information on prescription drugs, in their office. “They update it pretty regularly, so when you have clients come in, you can open the book and figure out what’s going on,” she says.

Hudspeth says counselors should stay informed but also avoid the subtle ways in which they might give advice about any medication, including over-the-counter ones. “A client may come in and say, ‘I’m having difficulty sleeping,’ and a counselor says, ‘Have you tried melatonin?’ They just stepped over that line,” Hudspeth says. “Just because you can buy it at Target or Walmart doesn’t mean you should be asking those questions.”

Meyer suggests that counselors who feel overwhelmed with the breadth of information on medications begin with the client population they serve most frequently. “What information can help your particular clients?” she asks. “Start there and seek out information, depending on who’s coming in and how you can treat them to the best of your ability.”

Above all, Meyer recommends that counselors never forget to take the topic of medication seriously in their work and training. “When you are choosing to take a medication, you may be choosing to have potential side effects. You are choosing that you will alter your neurochemistry. That is not a decision that should be taken lightly. It is not an easy decision,” she says. “When a client makes a choice about whether to take a medication, they need to make it from a place where they are well-informed.”

 

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Kathleen Smith is a licensed professional counselor and writer in Washington, D.C. She is the author of The Fangirl Life: A Guide to All the Feels and Learning How to Deal. Contact her at kathleensmithwrites@gmail.com.

Letters to the editor: ct@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.

Teaching counselor education curriculum in a ‘new reality’

By Suzanne A. Whitehead May 19, 2017

I love my job, my calling, as a counselor educator, and I take my role and passion as a graduate student advocate, public innovator and social justice change agent to heart every single day. As Mahatma Gandhi once said, “Be the change you wish to see in the world.”

His words are my mantra in life. Each one of us touches the hearts of so many others and, thus, the very future.

But teaching in these uncertain, turbulent times has been challenging to say the least. A powerful, yet almost silent and unspoken subtle change has occurred in my classrooms. It almost feels like a gray mist or cloud that is not seen but clearly felt.

I have never tried to be political with my students or to discuss politics in the classes that I teach. I don’t believe in it. Just because a professor has a “captive audience” in a class and CAN speak his or her mind doesn’t mean that one should. I don’t shy away from state, national or global issues because they are often pertinent to the material we discuss. Still, I don’t offer my own political opinion on these issues, mostly out of respect, but also because I feel it’s the right thing to do.

I care a great deal about my students. I can see the concern and worry in their eyes. They are more unsettled than normal, and the mood is palpable. Approximately 80 percent of my students are Hispanic and bilingual. They share an immense pride in their heritage, culture and family systems. I honor their commitment to their communities, their livelihoods and this country that they dearly love.

My students bring in reports of their own counselees in schools and agencies who share stories of intense fear, anxiety and pain at the idea that they, or their parents, could be deported. We have a lot of “Dreamer” students (children of undocumented immigrants) at my university and many of these children and families in our surrounding communities. Their understandable angst is powerful, heart-wrenching and compelling.

 

Teaching in these challenging times

And now we are asked to continue to teach our students as though nothing has changed in our world. No matter how one voted (or chose not to vote) in our nation’s most recent election, one thing is for certain: It has been an incredibly acrimonious, divisive and challenging time for our entire country. I have my opinions, but they are not for me to share them with my students. Yet they share theirs, every day. They have to because it affects their lives, their families and the clients they serve.

Other counselor educators who are struggling with these same issues may be wondering: How do we respond in a caring, empathic, yet ambiguous, way and not take sides?

The danger in “taking sides” is that even if I find great personal solace in doing so, I may also inadvertently destroy a student’s belief that each person has a right to free speech and to believe as he or she sees fit. In my bully pulpit ramblings, I could possibly (even if unintentionally) insult or even scar a student who may hold vastly different opinions from my own. That would be inexcusable. That serves no one except for my own selfish gain.

 

What we can do

It tugs at my heartstrings, but the only conclusion I can see is to treat this situation as a counselor would with any client. We must be confident, genuine, caring and willing to listen. We need to share that we understand students’ (and their clients’) fears and concerns. We express great empathy for what they are experiencing and model, summarize and validate their honest emotions, using an overall person-centered approach from Carl Rogers.

This isn’t always easy with a large number of students on one’s caseload. I never want to appear disingenuous. I just keep telling them, and myself, that their feelings, and those of their clients, are real, significant and truly matter. I will not judge; that is not my purpose as an educator. And I will not just gloss over everything with the proverbial, “It will all be just fine” message, to assuage their fears and my own discomfort.

All we can do is let them know how much we care and then use our own therapeutic orientations that we hold dear to help them and their clients. For example, in using a brief solution-focused therapeutic approach (Steve de Shazer), they can explore their options and what they believe IS within their power to influence, and develop effective ways to cope and move forward. These are all productive ways of handling and making sense of difficult times. The basic tenets of Viktor Frankl’s logotherapy seem useful here as well — finding purpose and meaning, even within one’s suffering and turmoil, and a reason to keep going.

 

Wellness for counselor educators

It is also more evident than ever that we as counselor educators need to take the time for wellness and coping strategies for our own mental well-being. It is one thing to conduct site visits and observations to see each of my students working with children, adolescents and adults. I too hear their stories firsthand and feel great empathy for their situations. But now, we also hear the same concerns from our students in our classes, and it is hard not to feel their pain intensely.

I reach out to my professional colleagues for feedback and interaction. I value the unwavering support of my family and friends and cherish their input now more than ever. And I have become intensely aware of where my own “head” is at — and my emotions — and utilize my coping strategies to the fullest. I consciously try to “check my ego and attitude” at the door before I step into the classroom and hold fast to the belief that I am here to instruct, teach, lead and inspire. The American Counseling Association’s values and code of ethical conduct are bedrocks of sanity to hold dear.

I am guessing that things will continue to be tricky for many of us in the coming months and years. As educators, we need to help each other through these very different times and circumstances. Knowing that the counseling profession is strong, and that our colleagues are always there for us, brings great comfort and resoluteness. My fervent hope is that it brings the same to each of you.

“Carpe diem,” dear colleagues.

 

 

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Suzanne A. Whitehead is a licensed mental health counselor and assistant professor of counselor education at California State University, Stanislaus. Contact her at sawhitehead7@gmail.com or swhitehead1@csustan.edu.

 

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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.