Tag Archives: Counselors Audience

Counselors Audience

Bringing evidence-based processes into the therapy room

By Boyd Eustace and John Donahue June 5, 2019

By way of introducing ourselves as the co-authors of this article and providing a little context for what follows, John Donahue is a clinical psychologist, an assistant professor at the University of Baltimore, and a practicing psychotherapist. Boyd Eustace is a licensed counselor and a lead therapist at a hospital-based outpatient mental health clinic in Baltimore, in addition to maintaining a private counseling practice in the city. The University of Baltimore’s graduate program in counseling psychology and the outpatient clinic in which Boyd works partner in the training and professional development of the university’s graduate students. Colleagues on both sides of this partnership share an interest in fostering collaboration between graduate-level training programs and clinicians in practice settings. A primary focus of the partnership is bridging the gap between academia and clinical practice.

At this point, it has been well-established that a science–practice gap exists in the field of mental health. In 1996, in an article for BMJ, David L. Sackett and colleagues suggested that evidence-based practice reflects clinical decision-making on the basis of three components:

1) Research evidence

2) Clinical expertise and judgment

3) Client values, preferences and characteristics

Later, the American Psychological Association adopted this “three-legged stool” approach when it defined evidence-based practice in psychology as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.”

One way the separation between science and practice can be witnessed is in the varying weights that mental health practitioners tend to apply to the different legs of the evidence-based practice stool. For example, research has found that prior clinical experiences exert the strongest influence on treatment decisions. Additionally, mental health practitioners almost universally report incorporating client expectations and values into treatment planning and strive to establish strong working alliances with their clients. However, when it comes to the first leg of the stool, clinicians have frequently reported hesitancies about factoring in empirical research findings when assessing and treating their clients. This contrast may in part stem from negative perceptions toward empirically supported treatments (ESTs) (see Michael E. Addis et al., 1999) and from confusion among community mental health providers concerning the differences between ESTs and evidence-based practice (see Michelle A. DiMeo et al., 2012).

The EST movement has expanded our understanding of many psychotherapy protocols that are efficacious in the treatment of specific diagnostic categories. With that said, ESTs certainly have not become a panacea for treating distinct disorders, and a few serious issues have hampered widespread dissemination of research-backed treatments to community-based clinics. Among these issues are concerns that:

  • Efficacy studies generally include samples that are not representative of the modal, multiproblem patient/client with several comorbidities
  • Treatment manuals result in rigid and mechanistic applications of psychotherapy
  • Studies often fail to attend to mechanisms of change that underlie variance in outcomes
  • Primary outcomes of randomized controlled trials (i.e., symptom reduction) are not necessarily the primary outcomes of interest for patients/clients in the community

In addition to these stated concerns about treatment protocols, there is substantial evidence that the targets of ESTs — individual Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses — are themselves invalid. Since the DSM introduced the categorical model of psychopathology in 1980, research has generally supported the conclusion that the diagnostic system is plagued by comorbidity, heterogeneity of symptoms within diagnoses, lack of adequate symptom coverage (resulting in excessive “not otherwise specified” diagnoses), and diagnostic thresholds that appear quite arbitrary.

Given these findings, the National Institute of Mental Health has stated that it is moving away from DSM-based diagnoses as its outcome of interest and has instead introduced the Research Domain Criteria (RDoC) initiative, which articulates a group of putative mechanisms of psychopathology that can be studied at varying levels of analysis. However, the RDoC approach, which is still in its nascent stages, has been critiqued for its emphasis on the biological level of analysis. It is currently a framework for research rather than a classification system that demonstrates clinical utility.

Fostering evidence-based care in light of obstacles

Although ESTs have been helpful in furthering scientifically informed mental health practice, the preceding section demonstrates that they possess numerous limitations and do not represent the compendium of effective counseling methods or stand for our full understanding of evidence-based practice in clinical settings. They have also too often contributed to the proliferation and endorsement of brand-name treatment approaches and trademark interventions, creating further divisions between orientations and increasing resistance to evidence-based practice. Moving beyond the era of prescriptive treatment protocols for specific disorders may therefore be helpful in expanding the use of evidence-based practice in the clinic.

In this spirit, we embraced a recent book by Steven Hayes and Stefan Hofmann titled Process-Based CBT: The Science and Core Clinical Competencies of Cognitive Behavioral Therapy. Rather than outline yet another protocol, or describe the techniques important for x disorder, the purpose of this text is to describe the “core processes that are common to many empirically supported treatments,” regardless of tribal theoretical identities and disregarding the confines of illusory diagnostic boundaries. Because of this approach, we thought it might be a particularly valuable vehicle in disseminating evidence-based practice into the community clinic.

As a lead therapist at this particular outpatient clinic, Boyd organized five monthly seminars focused on evidence-based practice and process-based cognitive behavior therapy (CBT) during the summer and fall of 2018 with the hospital’s mental health staff. We (John and Boyd) collaborated on curriculum content and co-led the seminars. The goals of these meetings were to increase the participants’ overall knowledge related to clinical research, broaden their understanding of evidence-based decision-making, and help identify various ways for them to incorporate science into their everyday practice. Participants included licensed practitioners, students-in-training and clinical supervisors.

Each monthly seminar was approximately 90 minutes in length, was offered around midday during a period that would conflict less with client sessions, and focused on specific chapters and topics from Process-Based CBT. Specifically, topics included:

1) The history of ESTs and problems with the “protocols for syndromes” approach

2) Evidence-based practice and some drawbacks with over-reliance on clinical judgment

3) Benefits and obstacles implementing ESTs in the clinic

4) Core cognitive, behavioral and emotion regulatory processes

5) Cognitive restructuring, cognitive defusion, exposure and psychological acceptance

Each seminar included brief didactic presentations on agenda items followed by group discussion. In essence, we did not want to teach another protocol. Instead, we sought to engage the mental health team in a discussion about specific processes and techniques that are empirically validated.

What did we learn?

At the conclusion of the seminar series, team members were offered an opportunity to complete a questionnaire designed to provide feedback concerning the pertinence and usefulness of the information presented in the educational workshops. The questionnaire included three items rated on a Likert scale ranging from strongly disagree to strongly agree, plus one open-ended question. Eight of 12 practitioners chose to complete the questionnaire. All of these practitioners were either licensed clinical social workers or licensed professional counselors with prior clinical experience ranging from four to 18 years. General outcomes were as follows:

  • All practitioners either agreed or strongly agreed that the seminars provided information that might help them integrate science into their everyday practice in the clinic.
  • Most practitioners either agreed or strongly agreed that the seminars broadened their understanding of counseling outcome studies, ESTs, randomized controlled trials, and some of the problems related to treatment-construct validity and generalizing findings to practice settings. (Two participants responded that they were undecided.)
  • All practitioners either agreed or strongly agreed that the seminars delineated the advantages and challenges of using evidence base to inform
    clinical decisions.

Additionally, practitioners were asked about the ways in which the seminar modified their views on evidence-based practice. Illustrative of the possible benefits of this program, several practitioners noted that evidence-based practice is beneficial because it helps clinicians select interventions that have been proved to work. One respondent wrote, “The seminar made me aware of the disconnect between research and practice … that we are still trying to find ways to connect research and practice.” Another wrote, “It is important to also consider clients’ preferences and values along with research.”

In conducting this seminar, we also arrived at some revelations. One is that, sometimes, clinicians are regularly using evidence-based techniques but are unaware that they are doing so. For example, in our discussion on exposure procedures, one clinician noted that she did not conduct exposure therapy, and this statement was then endorsed by several other members of the group. However, when the clinicians were prompted to consider ways in which their work with clients facilitated emotional willingness and tolerance of difficult experiences, it became clear that this procedure was a significant part of their practice. When the emphasis is on protocols, we may be more inclined to say, “I don’t do that.” But when the conversation shifts to processes, we can more easily notice the instances in which specific empirically supported procedures are useful, thus bringing additional intentionality to the use of these techniques.

In connection to our own work, this seminar series has reminded us of the importance of assessing and monitoring changes in processes, not just changes in outcomes. When we track a process in session and use procedures in the service of modifying that process, we should also close the loop and assess this change (or lack thereof). This can be done in a variety of ways, including self-report, behavioral tests and self-monitoring. It is important that we share these findings with our peers and continue to test and refine our practices.

This seminar series also helped solidify our view that practice-based research may be critical in reducing the science–practice gap. Information must flow in both directions — from the laboratory to the clinic, and from the clinic back to the laboratory. We hope that our discussions over these five months have helped lay the groundwork for practice-based research that will contribute to this noble task.

Concluding comments

We (John and Boyd) practice acceptance and commitment therapy and rational emotive behavior therapy, respectively. Both of these evidence-based models are theoretically grounded in the CBT tradition and are transdiagnostic, and they overlap substantially in their approaches. Our view of counseling is aligned with the process-based approach advocated by Hayes and Hofmann, which highlights the advantages of therapists using testable models to employ a versatile range of evidence-based interventions. This approach reflects the complexity and situational specificity of presenting problems and implies a nondogmatic, nuanced, multimodal strategy.

The process-based approach takes to heart Abraham Maslow’s cautionary observation: “I suppose that it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” In other words, with a predetermined armamentarium in hand, we might be tempted to rigidly and reductively treat diagnostic labels instead of treating our individual clients/patients and their idiosyncratic problems.

Similarly, Arnold Lazarus, cognitive therapist and founder of multimodal therapy, advised therapists to have a variety of tools in their toolbox so that they could “offer a broad-spectrum versus narrow-band treatment approach.” Taking this broad-spectrum approach improves outcomes and prevents future behavioral and emotional problems for our clients.

In keeping with the aforementioned frame of reference, our goals in this seminar series were to:

  • Use Hayes and Hofmann’s influential text as a method of engaging an eclectic group of mental health practitioners on the topic of evidence-based practice
  • Begin to move away from the specific protocols and techniques linked to brand-name therapies for diagnostic syndromes
  • Initiate a conversation about how to effectively target the precise processes that appear to be important across different psychotherapy orientations

Given the overall good receptivity to the seminar series across clinicians, we believe we took steps toward those goals.

Furthermore, we think that this approach is one that is transportable to other clinics. Reflecting on the successful aspects of this seminar series, we recommend:

  • Organizing sessions at a time that is minimally disruptive to the busy schedules of mental health practitioners (for us, that was around lunchtime, but this will vary across settings)
  • Tailoring each session to a specific topic or set of topics
  • Including out-of-session readings that participants can review prior to
    each session

We also hope to extend this work with further trainings, which then may stimulate research questions and encourage practice-based research relevant to the process of therapy. In this effort, we may plant the seeds for the upward dissemination of evidence that will help to answer Gordon Paul’s great question: “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances, and how does it come about?” Or, as is stated in the Process-Based CBT text, “What core biopsychosocial processes should be targeted with this client given this goal in this situation, and how can they most efficiently and effectively be changed?”

 

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Boyd Eustace, a licensed clinical professional counselor and clinical supervisor, sees clients and supervises therapists in a hospital-based mental health clinic and in his private counseling practice in Baltimore. He received training in rational emotive-cognitive behavior therapy at the Albert Ellis Institute and specializes in brief solution-focused individual and couple counseling at LB Counseling Services. Contact him at lbcounseling90@gmail.com or via his website at pcc-mentalhealth.com.

John Donahue is a licensed clinical psychologist and assistant professor of psychology at the University of Baltimore. His clinical and research interests involve mechanisms underlying psychopathology that cut across traditional diagnostic boundaries and the application of mindfulness and acceptance-based approaches to psychotherapy. Contact him at jdonahue@ubalt.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.

Healing from multiple personalities

By Todd E. Pressman May 28, 2019

In April 1996, I began a course of psychotherapy with a woman named Angela. She came to the first session with vague feelings of anxiety and the need to “find a safe place.” This seemed usual enough for me after 20-some years in practice. Little did I know that our first meeting was the beginning of one of the most extraordinary therapeutic journeys I would ever encounter.

Although Angela had always suspected something was different about her, she did not realize that she had multiple personality disorder (now called dissociative identity disorder). She only knew that she was filled with fear much of the time and that there were large gaps in her memory.

Early in our work together, Angela had a dream of being in a bicycle repair shop — a wondrous place with huge escalators carrying bicycles here and there to be repaired. After watching many bicycles come in damaged and leave repaired, Angela asked the owner of the shop (me) if all bicycles could be repaired. In the dream, I answered “Yes.” When Angela showed me her own bicycle, which to her seemed hopelessly damaged, my response in the dream was, “There are no bicycles beyond repair.”

This was the message Angela needed to begin her therapeutic adventure. Through the course of her recovery, in which she integrated more than 70 personalities and opened up into one of the most spiritual people I have ever met, I deepened my own conviction that, truly, that are no “bicycles” beyond repair. In other words, there are no souls that cannot be healed and no injuries that cannot transform into a higher level of understanding and peace.

 

Angela’s story

The early part of our work together was simple and straightforward: Angela needed to know that there existed such a thing as “a love that didn’t hurt.” It was hard for her to trust that our therapeutic relationship could be the safe place she was looking for, that she could dare to start whispering family secrets without reprisal, that, together, we could be bigger and stronger than her fears.

Angela began her life as the victim of extreme abuses, as is true for most people with multiple personalities. From the time Angela was 4, her father, whom she trusted like any innocent child would, began sexually abusing her, while her mother stood by in passive compliance. When Angela resisted, her father threatened her, saying the devil would take her away if she did not agree to what he wanted to do and, in fact, if she did not enjoy it. At such a vulnerable age, Angela managed to do the impossible — she held in her screams and learned to say “thank you” and “I love you” in response to these abuses.

As these kinds of extreme torments continued, Angela forced her natural expression of self deeper and deeper down until, one day, she found a new solution: She would “project” herself into a certain picture that was hanging on the wall, a picture of a beautiful angel protecting a little girl and boy. Angela would make herself the little girl and her brother the little boy and bring the angel to life in her mind. She would do this so thoroughly that, for a time, she could live in that picture and escape her torture.

At a certain point in her therapy, Angela felt compelled to chronicle and perhaps publish her story. This served two purposes. First, she would be able to reach out to others — those with multiple personalities and those who simply needed to find their way through emotional struggle. She wanted to offer the help she was finding in her own recovery. Second, sharing her story would be a powerful way to take a stand against the thought that she needed to preserve the family secrets and stay victimized by them. That book, The Bicycle Repair Shop: A True Story of Recovery From Multiple Personality Disorder as Told by Patient and Therapist, became a reality.

In notes that Angela shared with me after the book was published, she provided the rarest of accounts of how the first moment of splitting off (dissociating) occurred:

 

One day, my father’s touches were worse than ever. His huge body pressing against mine was more than I could bear. … The pain grew greater until [the point of] what I thought was my last breath. I felt as if my arms were being yanked, pulling my body from its skin — my insides were separating from my outside to pull my body from the spot where I sat. My legs felt as if they were bolted to the ground. It was as though someone was trying to pull me from the other end out of my skin.

I was surprised to find myself standing in a picture that hung in my bedroom. A picture of a Guardian Angel watching over two children. Where was I? Who was it that was still with my father? I was not aware of what was going on. All I knew was that I was safe. The memory of what was happening before was successfully erased. That was how “four” was born, my first personality of many.

 

This remarkable description shows the adaptive function of multiple personalities: When one personality could no longer stand the circumstance of the moment, a new one would take over. This was the strategy Angela would use to grow her “family within” to help her navigate the abuses she was being exposed to.

 

Meeting Angela’s personalities

Through her therapy, Angela came to understand how each of these personalities was created to fulfill a specific role, protecting her from some unique threat that she could not handle by herself. In this way, she would simply stop “being” Angela and become someone who could better handle the situation.

First, there were “the little ones” — all children — including Four, Six, Schoolgirl and Crystal. Four was the first one I met, an absolutely adorable, sweet little girl who wanted nothing but to feel safe and loved. She was clearly terrified and felt solace only in my presence. When I would go away on vacation, for instance, her pain was so great that she could not tolerate it and would go “underground.”

Crystal, on the other hand, was immune to such pain. She was a beautiful little girl with curly blond hair and bright blue eyes (different in physical appearance than the others). Her strategy was to imagine that she was not, in fact, part of this family. She fully expected that she would be rescued by her “true” family any minute and taken away from the abuses.

Then there was Patrick. He was one of only two male personalities whom I met. In creating Patrick to be gay, Angela was imagining a model of a male who could be gentle, nurturing and safe.

The Boss was the other male personality, and his function was to “control” the children. In manner and even appearance (Angela’s face would change dramatically whenever the Boss showed up), he was like a classic Chicago mob boss. I must confess, I felt rather intimidated by him at the beginning. Later, however, I managed to convince him that I was an ally, someone who could help him find a better way to keep the children in place through understanding and meeting their needs. You can imagine his resistance, but in the end, we became a great team. (At one point, after we became “friends,” the Boss confessed to me in a hushed voice, “I’m working on getting rid of these.” He was referring to Angela’s breasts.) This was one of the rare occasions in which Angela’s external reality and the inner life of her creation did clash. Still, she was working on a “solution” that would enable her to keep her constructed world intact.

Eventually, three personalities came forth as those who would stand “out front”— those who would interact with the world — while the rest stayed inside to manage Angela’s inner experience. Angela, of course, was the primary personality, and she was the one who would take responsibility for handling the affairs of everyday life. Angie, on the other hand, was a party-loving, sexually profligate personality whose purpose was to have a good time and forget all troubles. She was especially skilled at “knowing what men wanted” and used these wiles to get men to do her bidding. At the other extreme was Angel, a spiritual personality who would remind the rest that they were safe and loved in God’s care. Angel would become a most important presence in Angela’s recovery because this spiritual aspect led the way to her final experiences of forgiveness.

At a later point in therapy, a personality was needed to “house” the others in a more neatly integrated whole. This was one of the few times in which I actually witnessed the creation of a new personality. The personality wanted to choose a name for itself that would bring it to life, so to speak, and it came up with Tang — a combination of Todd (my name) and Angela. This, she explained, was the result of my saying to the family, “I need you not to make any decisions without me because I am part of the family” — a necessary prevention against Angela trying to hurt herself or sabotage the therapy in some way.

Tang was a fascinating entity, representing the point at which Angela was 99% integrated. Angela described this sensation as if there were a body inside of her body that almost completely filled her up. There was just “1%” of space between them inside.

She also allowed the little ones at this point to create a magnificent collage. They knew they were about to “disappear” into the one personality that was Tang, and they wanted to be remembered this way. The collage showed what they felt inside: a single body with many faces, some happy, some sad, some shy and some covered with bugs who had been very afraid. Angela once told me that upon my calling Tang’s name, all the eyes of these faces opened up at the same time to look in response.

One by one the personalities came forth to express their need and tell their story. As Angela and I understood their core message, we were able to find a way to meet the need that was more adaptive. This required that Angela bravely face the fears that had been too horrible to withstand in childhood, trusting that it was safe to do so now. Borrowing my strength and trusting my words — that the people and circumstances of these memories could not stop her from standing up to them with my support — she did what she couldn’t dare do back then.

With a new and profound belief in her right to be free, she stood up to the abuses and said “Enough.” One personality even took on the name Shark to show her teeth and “devour” the fear that they represented. As Angela looked at her fears this way, always in manageable doses, she gave herself the message that she was no longer at their mercy, and one by one, the personalities that had been born to manage these fears would fulfill their purpose and integrate back into Angela.

 

Facing fears

With the right combination of safety and support, Angela was able to discover the great secret of all healing: When we face our fears, they lose their power over us. At worst, we find a problem that now can be managed. Often, the fear disappears completely because it can no longer scare us into running away from it. In this way, we find ourselves to be “bigger” than the fear, and so its illusion is exposed. It was but an imagination, given power by our refusal to look at it, with no actual ability to harm our true Self.

This was the freedom that gave Angela the  power to forgive her abusers (there was nothing left to forgive), integrate the personalities (they no longer had a function), and live in a world she now knew to be safe, manageable and, in the end, sometimes even fun.

In writing the book, Angela wanted others to hear the message that facing our fears is the key to freedom, that nothing can rob us of our ability to choose how we respond to life and to declare our right to be who we truly are. With this, we integrate the fractured parts of our own personality and find our own sense of wholeness, completion and fulfillment.

Throughout our work, Angela would repeat to me, “I want to be one of your success stories.” Many times, she felt the way was too difficult, but as I continued to hold a safe place for her, she developed the courage to face her fears one by one, dismantling the entire structure of her constructed “personality” and reclaiming her original innocence and wholeness.

In the end, she discovered that facing her fears made it possible to forgive, not in the sense of merely accepting those who had abused her, but in the much more profound sense of realizing that they, too, were in need of love, and that holding onto her anger and pain simply kept her a perpetual victim of their abuse. Only with this realization was she free to ask for the love she had once known as a little child of 4, and in asking, find that it was, in fact, still available in the world. With this, she was able to integrate that love and become whole again, to replace the path of disintegration into many fragments that she had chosen before. This integration of love, “a love that doesn’t hurt,” awakened a profound sense of spirituality within her. She is now, in fact, one of the most peaceful, loving and spiritual people I know.

 

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Todd E. Pressman has been a licensed psychologist for the past 32 years. He is the founder and director of Pressman and Associates at Logos Wellness in Voorhees, New Jersey. An author and speaker, he co-wrote The Bicycle Repair Shop: A True Story of Recovery From Multiple Personality Disorder as Told by Patient and Therapist with Angela Fisher, who, during the course of her recovery, felt the need to share her story so that it might be of help to “anyone who wants to get free.” Pressman’s forthcoming book, Deconstructing Anxiety: The Journey From Fear to Fulfillment, will be available in August. Contact him at toddpressman@comcast.net or through toddpressman.com.

 

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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.

A script for socialization to the cognitive model

By Brandon S. Ballantyne May 14, 2019

Cognitive behavior therapy (CBT) is an evidence-based treatment approach that has statistically been shown to be effective in addressing a variety of mood disorders and psychological problems. It is my belief that a key component to successful cognitive behavioral treatment is counselor-to-client socialization of theory and concept.

It is essential that clients become socialized to the cognitive model — understanding the rationale behind CBT’s effectiveness — to gain maximum benefit. For that reason, I have developed a script that counselors can use with the clients they serve. This script aims to provide a blueprint for live, in-session socialization to the cognitive model and provides a platform to transition into routine practice of cognitive behavioral technique in future sessions.

 

Script introduction

If I were to ask you to think of a palm tree, what do you think of? You probably just imagined a palm tree. If I were to ask you to think of your very first car, what do you think of? You probably just imagined yourself either in or next to that memorable first automobile. If I were to ask you to think of your favorite food, what do you think of? You probably just imagined your meal of choice.

Now, if I were to ask you to feel anxious, what do you have to do? Most people say they need to imagine a stressful scenario to feel the emotion of anxiety. The point is that we can instantaneously produce any thought. However, when it comes to producing an emotional state, we first need to think of something in order to feel something.

The formation of emotions is a biological process, meaning that it is impossible to shut off or terminate from human experience unless we suffer serious medical injury that leads to such complications. With that being said, there is a specific sequence of internal and external events that not only create, but contribute to, the emotional experiences of you, me and everyone else with whom we share this wonderful planet.

 

Situation

For an emotion to be formed, one must first encounter a situation. A situation is anything that an individual becomes aware of. It can be an external event such as a person, place, thing or activity. It can also be an internal event such as a particular thought or emotion.

Let’s say that tomorrow, I wake up, get in my car and start my drive into work. I encounter a traffic jam, which I anticipate might make me late to my destination. As I approach, I become aware of the traffic jam itself. Both the awareness of the traffic jam and the traffic jam itself become the situation at hand.

 

Thought

Our brain is like a thought warehouse. It has a job of producing thoughts throughout the day — every second, every minute, every hour.

What is a thought? A thought is a sentence that our brain produces about the situation at hand. Thoughts have sentence structure. Each thought has punctuation. It can also take the form of an image or movie that we experience in our mind.

On some occasions, we verbalize our thoughts out loud. Sometimes they stay silent. Regardless, they affect how we feel. If I am driving to work and become aware of the traffic jam, my brain might produce the thought of, “Oh no! I am going to be late. I am going to be behind all day, and I will get reprimanded by my boss. This happens all of the time!”

The first thoughts that our brain produces about a situation at hand are automatic. We don’t really have control over them. But as I mentioned earlier, these thoughts affect how we feel, so they are important to accept and to understand.

 

Emotion

Once our brain produces a thought about a situation at hand, there is the onset of some kind of emotional experience. How is an emotion different from a thought? Emotions can be categorized into mad, sad, glad and fearful. Any emotion that we have at any given time will likely fit into one of these categories of primary emotions.

There is also a subtle category that some identify as “neutral emotions.” However, we are rarely taught about what neutral emotions are. Throughout our life experiences, we are given the message that there must be a way to feel and that emotions need to be either pleasant or unpleasant. Therefore, if we aren’t particularly happy, sad, fearful or mad, we tend to say that we are feeling “nothing.”

Emotions are a biological process. And because our thoughts are automatic, we never really have an absence of emotions. So, when we are feeling “nothing,” we are actually feeling “neutral.” Descriptors such as “content” and “OK” best describe a neutral emotional state.

Now, let’s refer back to the traffic jam scenario. While sitting in the traffic jam, I am having the thought, “Oh no! I am going to be late. I am going to be behind all day, and I will get reprimanded by my boss. This happens all of the time!”

Because of this thought, I am most likely to be feeling anxious. Anxiety is most closely related to the primary emotion of fear. Some emotions occur parallel to physical symptoms as well. For example, if I am sitting in my car feeling anxious from the thought about being late to work, I may also notice that my hands have started to sweat. Physical symptoms help us to identify and label emotions.

So, it is important to pay attention to your patterns in your physical symptoms as you experience emotional states. In general, emotions give us information about the situation at hand. However, it is then our job to examine that information accordingly.

 

Behavior

Our behaviors are influenced by the emotions we experience. Behaviors can usually be observed by others. Based on the specific characteristics of the behaviors — and the specific characteristics of the reactions that the behaviors provoke in others — these behaviors can help us to get closer to our goals, push us further from our goals, or neutralize the pursuit of our goals.

What does it mean to neutralize the pursuit of our goals? Well, some behaviors neither get us closer to nor push us further from our goals. These behaviors can be referred to as “neutralizing behaviors.”

In the example of sitting in the traffic jam and feeling anxious, I may react to the intense anxiety by engaging in behaviors such as beeping my horn and yelling at other drivers.

 

Result

Results can be defined as a set of benefits or consequences that are produced by one particular behavior or set of behaviors. Results can be desirable, undesirable or neutral.

Desirable results are outcomes that take us closer to our goals. Undesirable results are outcomes that push us further from our goals. Neutral results neither take us closer to our goals nor push us further away.

In the traffic jam example, the behavior indicated was beeping the horn and yelling at other drivers. We can anticipate potential results that those behaviors may produce. As a reminder, the goal in that scenario is to get to work on time, or at least not too late, and safely.

One possible result of beeping my horn and yelling at other drivers is that other drivers may begin beeping their horns and yelling at me. This additional conflict may cause my anxiety to intensify further. At the same time, everyone beeping their horns and yelling at each other will not change the fact that I am sitting in the traffic jam itself. Therefore, this outcome can be categorized as an undesirable result.

 

Wrapping it up

The goal of this type of cognitive behavioral style work is to identify where in the process above an individual may have personal control or personal choice of changing the problematic patterns or tendencies. By examining the above scenario in that way, individuals will be able to conceptualize aspects of personal choice and change that can help them reduce intense emotional distress, engage in healthier behaviors, and achieve more desirable results — first in the above scenario and then with the real-life stressors that have brought them into treatment.

Use the following reflection questions to get started with application of this skill:

1) If you were stuck in a traffic jam similar to the one described above, what would be going through your mind? What are some of the automatic thoughts you would be having?

2) What kinds of emotions would your automatic thoughts produce? Would you be noticing any symptoms of those emotions in your body?

3) What type of automatic behaviors might you engage in based on the influence of those emotions or physical symptoms?

4) What type of outcomes or results would those behaviors likely produce? Would those results be desirable, undesirable or neutral based on your goal of getting to work on time, or not too late, and safely?

5) Is there anything else you might be able to say to yourself in the scenario about the traffic jam that would produce less intense distress? If so, what are those thoughts? Remember, thoughts come in the form of sentences or images.

6) If you were able to insert those new thoughts the next time you experience a traffic jam, what types of emotions would those thoughts likely produce? If they do not produce less intense distress or new emotions comprehensively, try identifying new thoughts (sentences) until you find one or two that either reduce the distress or produce new desirable emotions.

7) With less intense distress or new desirable emotions, what are the new behaviors that likely would be produced as a result?

8) Given the likelihood of those new behaviors, what would happen next? In other words, what would be the results of those new behaviors? Would those results be desirable, undesirable or neutral based on the goal of getting to work on time, or not too late, and safely? If those results are desirable or neutral, then you have successfully completed examination of this scenario. If the results are undesirable, repeat steps 1 through 8 until you are left with desirable or neutral results. If a neutral result does not make the situation worse, then it is desirable in itself.

9) What are some situations in your life that have caused stress?

10) What were the automatic thoughts running through your mind at the time?

11) Given those life situations, what were the undesirable results that were occurring?

12) Given those life situations, what were the behaviors that were contributing to those undesirable results?

13) Looking back, could you have said anything different to yourself in those moments to reduce the level of stress? If so, what would those coping thoughts be?

14) Given those life situations, what are examples of healthier behaviors that you want to be able to engage in?

15) Given those life situations, what emotions would be needed to make those healthier behaviors easier to achieve?

16) Given those life situations, what results would you want to be able to achieve, experience or receive?

17) With those desired results in mind, what can you say to yourself about those life situations that might help to produce healthier emotions and healthier behaviors?

18) Copy down those thoughts. Put them on an index card. This will serve as your coping cue to take with you. It will be a reminder that although we may not be able to fix a stressor at hand, we do have the opportunity to access alternative thoughts. It is those alternative thoughts that kickstart the process of reduced distress, healthier behaviors, and the satisfying experience of more desirable results. Thus, we are creating an opportunity for achievement as we assist ourselves in getting closer to our goals, even if certain stressors stay the same. With consistent practice, we teach our brains that we control our thoughts, emotions and behaviors. We give power to ourselves in knowing that we do not need situations to change in order to feel better and do better.

 

 

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Brandon S. Ballantyne has been practicing clinical counseling for 12 years. He is a licensed professional counselor and national certified counselor who specializes in the treatment of anxiety and depression. He currently practices at a variety of different agencies in eastern Pennsylvania. Find him on the web at https://thriveworks.com/bethlehem-counseling/our-counselors/, and contact him at brandon.ballantyne@childfamilyfirst.com.

 

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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.

Remembering Martin Buber and the I–Thou in counseling

By Matthew Martin and Eric W. Cowan May 8, 2019

Counseling research designed to measure therapeutic efficacy has increasingly focused on empirically validated methods and interventions. On the other hand, counselors have long understood the therapeutic relationship to be the most powerful meta-intervention for fostering client change and transformation. Carl Rogers’ No. 1 rule — that the counselor and client must be in psychological contact — is the precondition for all therapeutic movement. As counselors, we must “be someone with” rather than “do something to” the client.

However, the interpersonal process that occurs between counselor and client is difficult to quantify because it possesses intangible qualities that slip through the fingers of measurement and scientific scrutiny. The relationship between counselor and client seems to transcend any particular intervention strategy. The maxim “it is the relationship itself that heals” is an organizing principle to which most counselors subscribe and yet still sometimes forget. In the search for empirically validated methods, are we in danger of losing touch with what matters most in counseling?

Another consideration is the cultural shift that has altered how people communicate, with interpersonal contact becoming increasingly digitized, objectified and packaged in virtual platforms. Will the next generation of counselors still give primacy to the sense of “presence” in the therapeutic relationship that is the heart of counseling? From our perspective, it seems that a counselor’s enhanced capacity for meaningful interpersonal contact is more important than ever.

Philosopher Martin Buber detailed the qualities that characterize a real “encounter,” or I–Thou meeting, between two people. His ideas remain as relevant today as when they helped to shape the humanistic movement in psychology and counseling.

The I-Thou encounter

According to Buber, an interpersonal encounter contains wonderful potential that far exceeds two separate people in conversation. This potential becomes apparent when two people actively and authentically engage each other in the here and now and truly “show up” to one another. In this encounter, a new relational dimension that Buber termed “the between” becomes manifest. When this between dimension exists, the relationship becomes greater than the individual contributions of those involved. This type of meeting is what Buber described as an I–Thou relationship.

The I–Thou relationship is characterized by mutuality, directness, presentness, intensity and ineffability. Buber described the between as a bold leap into the experience of the other while simultaneously being transparent, present and accessible. He used the term “inclusion” to describe this heightened form of empathy. It is a far cry from the now-familiar scene of a group of friends sitting around a table at a restaurant, all gazing into their smartphones.

Buber saw the meeting between I and Thou as the most important aspect of human experience because it is in relationship that we become fully human. When one meets another as Thou, the uniqueness and separateness of the other is acknowledged without obscuring the relatedness or common humanness that is shared. Buber contrasted this I–Thou relationship with an I–It relationship, in which the other person is experienced as an object to be influenced or used — a means to an end. Regrettably, the I–It relationship requires little explanation for anyone living in a cultural frame of absent-mindedness and technological materialism.

The world of I–It can be coherent and ordered — even efficient — but it lacks the essential elements of human connection and wholeness that characterize the I–Thou encounter. The I–It attitude is increasingly depersonalizing and alienating as it becomes structuralized in human institutions. When an extreme I–It attitude becomes embedded in cultural patterns and human interactions, the result is greater objectification of others, exploitation of people and resources, and forms of prejudice that obscure the common humanity that unites us.

Although Buber saw the I–It as an essential pole of human existence, he thought humanity was losing its ability to orient toward the Thou. He emphasized the important balance required between the two poles if humanity was to survive the dangers inherent in the possibility of mutual destruction.

Counselors view the client–counselor relationship as the foundation of all therapeutic growth because it is fundamentally affirming of human connection, validation and participation. In our own small sphere of influence, we are a force for promoting a more compassionate and humanized world. Counselors should keep this in mind even as we strive toward greater technical organization and efficiency within a mental health “service delivery system” that is not entirely compatible with our broader aims.

To exist is to be in relation

Buber rightly understood that human development occurs in a relational context. Human beings are highly social creatures who need love and care from others to survive through infancy and beyond. An absence of these relational needs almost always leads to psychological injury.

Buber called this deep participation with, and acceptance of, another’s essential being “confirmation.” He believed that one’s innate capacity to confirm others, and to be confirmed in one’s own uniqueness by others, is the source of our humanity. The innate subjectivity that unfolds within every human being can begin to be actualized only when it is accurately mirrored in the eyes of another. Confirmation is at the heart of the I–Thou meeting, of human flourishing and of counseling.

Confirmation is similar to the concept of not imposing “conditions of worth” in the relationship. However, confirmation goes a step further by acknowledging the person’s potentialities — what one may become. For example, a child experiences the tension between growth and fear along each step of the developmental path. The parent can either accept the child’s reluctance in the moment or encourage the child to take the leap. At all ages, human thriving is found in these continual moments of confirmation of potentiality from person to person. As a client struggles with making the “growth choice” or the “fear choice,” the counselor invites the client to greater participation, yet expects to bump into the old fears that make such participation fraught for the client.

Unfortunately, we aren’t always as mindful and present as we’d like to be with others, and we ourselves have not been affirmed in the eyes of others as often as we would like. Even the best of us can fall into an I–It orientation with the world, failing to see the other person at all. Buber believed that these “missed meetings” were the ultimate failure of human relationships and resulted in us losing a part of ourselves.

We all desire to be confirmed in our uniqueness, but when we realize that confirmation is not going to happen, we seem to sacrifice true confirmation for mere approval in hopes of preserving our attachment to others. We cultivate the ability to “seem” a certain way to others to elicit approval, but such approval does nothing to nourish our “being.” A person would rather be confirmed in that which he or she is not than chance the possibility of not being accepted at all.

Unfortunately, this “seeming” mask tends to get stuck, and as one hides one’s being in fear, the possibility of an I–Thou relationship is lost. As Buber cautioned, “To yield to seeming is man’s essential cowardice, to resist it is his essential courage.” When the I of the I–Thou relationship is sacrificed for the It orientation of abstracted relation, authentic human growth and connection are lost, and the I begins to wither away.

Healing through meeting

How can we as counselors foster and model I–Thou relationships with our clients and help them avoid the temptation of “seeming” like someone they are not? Buber thought the answer could be found in a process of active imagination that he termed “inclusion.” In this process, the barriers and constrictions that prevent one from being fully present to an I–Thou encounter indicate where the work is to be done. In what ways must the client stay hidden from others and protect his or her own inner thoughts, feelings and fantasies?

In inclusion, one imagines what another person is feeling, thinking and experiencing while standing in relation to them as a Thou. Rogers’ concept of empathy and Buber’s concept of inclusion are similar (in fact, the two of them debated about it). However, inclusion places greater emphasis on the unique subjectivity of the person attempting to understand the other.

The attempt at understanding the subjective inner world of the person is not a one-way street because the counselor must account for his or her own influence upon the client as both participants come into psychological contact. The I–Thou is a relational event that is co-created; it does not fully reside in one participant or the other. The counselor’s ability to mine the riches of the present encounter and wonder “what is happening between us in the immediate moment” expresses Buber’s notion of inclusion.

We as counselors have the ability to confirm our clients through the process of inclusion, providing them with a relationship that can heal the wounds of their past missed meetings. We must stand in relation to our clients as an I to a Thou to successfully inspire them to move from a “seeming” stance to one of greater authentic participation and “being.”

Although empirical methods and interventions are critical in guiding our understanding of best practices, we must not forget that the single most predictive variable in whether counseling is effective is the client’s experience of the counseling relationship itself. Clients deserve to be seen as a Thou. As Buber once said, “In spite of all similarities, every living situation has, like a newborn child, a new face that has never been before and will never come again. It demands of you a reaction that cannot be prepared beforehand. It demands nothing of what is past. It demands presence, responsibility; it demands you.”

Every moment is an opportunity for “healing through meeting.”

 

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Matthew Martin is a graduate of James Madison University’s clinical mental health counseling master’s program. He is currently completing his residency in counseling at the university’s counseling center. Contact him at matthewmartin.rva@gmail.com.

Eric W. Cowan is a professor in the Department of Counseling and Graduate Psychology at James Madison University. He is the author of Ariadne’s Thread: Case Studies in the Therapeutic Relationship. Contact him at cowanwe@jmu.edu.

 

Letters to the editor: ct@counseling.org

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

 

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

Culturally competent end-of-life counseling

By Ashley C. Overman-Goldsmith May 1, 2019

End-of-life counseling is an important area of our profession. Unfortunately, it is also an area of the profession that is underdeveloped and seldom researched. Consequently, few resources are available to professional counselors that specifically address multicultural competence in end-of-life counseling.

I first became interested in end-of-life counseling while working as a bereavement program manager and counselor in a private hospice setting. As a bereavement counselor, I worked not only with the families of patients receiving hospice services but also with higher risk patients (those who struggled with psychological and physical pain). The private hospice organization provided social services for patients, but our social workers had large caseloads and found it difficult to meet the emotional and psychological needs of patients and family members who required ongoing therapeutic intervention. To meet those needs, I developed an end-of-life counseling program in which I personally worked with patients and family members deemed medium to high risk.

I currently practice counseling at Sea Change Therapy PLLC, where I help individuals who are struggling with life transitions, including the end of life. In addition to my clinical practice, I am conducting research in end-of-life counseling under the advisement of my dissertation committee at North Carolina State University.

The list of reasons for counseling at the end of life can be similar to the reasons that individuals seek out counseling earlier in life. The largest difference, of course, is that with end-of-life counseling, the client is facing his or her death. This makes this area of counseling all the more challenging. Because these clients die at the end of counseling, counselors are responsible for so much more than just helping clients pursue improvements in a relationship or changes to an existing issue. Counselors are helping these clients achieve goals that may improve the possibility of them experiencing peace before they die. This is a major undertaking.

As an end-of-life counselor, I have witnessed the impact that clients’ lived experiences and aspects of their identity have on their end-of-life experiences. These experiences are personal, unique events that require counselors to be skilled in addressing a multitude of issues regarding both a client’s identity and the dying process. Multicultural and social justice competence is key to counselors being able to provide effective end-of-life counseling and help clients navigate end-of-life experiences successfully.

The Multicultural and Social Justice Counseling Competencies (MSJCC) endorsed by the American Counseling Association are a set of guidelines for developing and maintaining multicultural and social justice competence as counselors. The MSJCC framework aids in understanding the complexities of the counseling relationship, specifically with counselor–client interactions. The MSJCC support counselors in addressing issues that are often not well-recognized but that have a significant impact on the client. These issues include power dynamics, privilege and oppression. The MSJCC are well-supported by our profession and are a very useful tool for promoting cultural competence for counselors.

The Handbook of Thanatology, a resource created for practitioners by the Association for Death Education and Counseling, provides detailed, thought-provoking suggestions on how to be culturally competent when working with clients at the end of life. The handbook includes a combination of research findings, practical implications and recommendations for end-of-life practice.

Using the MSJCC and suggestions from the Handbook of Thanatology, counselors can ensure that they are providing culturally competent and effective end-of-life counseling services to their clients. Using these references, along with information from my professional experience as an end-of-life counselor, I have developed a simple framework for culturally competent end-of-life counseling practice.

Education

Education is an important component of culturally competent practice. Continuing our education beyond the completion of the master’s degree requirement is necessary for growth and effective practice in this field.

As professional counselors, we are required to complete a specific number of continuing education credits yearly to maintain state and national licenses. For many of us, a certain number of these continuing education credits are required in the area of multicultural competence. Continuing education in end-of-life practice is increasingly available, and there are many opportunities for growth across disciplines in this specialty area. For example, there are distance learning programs that provide thanatology coursework, including multicultural competence in end-of-life care. During my personal search for continuing education, I have come across numerous courses or sessions that are outside of the university setting. Professional memberships, local funeral homes, palliative care programs and medical facilities all offer continuing education opportunities, sometimes at little to no cost.

In addition to the more formal avenues for advancing your education, there are ways to learn and grow in the understanding of other cultures through observation, immersion and self-education. The Handbook of Thanatology says that if we want to better understand the beliefs and practices of a particular cultural group, immersing ourselves in that group can aid in this quest. Obviously, that approach is time-consuming and not feasible for all counselors. However, I would recommend, at minimum, that counselors observe and investigate the beliefs and practices of the clients (and clients’ family members) with whom they are working. Don’t fear asking questions that will improve your knowledge.

We are encouraged as counselors to be well-informed about what is going on in the world around us and to consider the ways in which events may affect our clients. For example, changes in health care coverage and policies can impact terminally ill clients and their families. Seeking out details on these changes and working to stay informed not only can help us to prepare for what our clients may be facing but can also provide us with information that could be important to pass along to our clients. Social, cultural and political developments may also influence our clients’ emotional and psychological states. It is important that we maintain an awareness of how these developments could affect clients from varying groups in different ways.

Possessing knowledge of both historical and current events — particularly those resulting in the oppression of a group of individuals due to their race, ethnicity, socioeconomic status, gender or sexual orientation — can help us better understand the lived experiences of our clients. Linking historical and current events can provide us with a clearer perspective on the adversities that our clients and their families continue to face. These adversities are woven into their personal narratives and are often revisited at the end of life. Our clients may want to remember the happy experiences they have had, but they may also recall the adversities they have confronted. Our clients’ worldviews, values, beliefs, and marginalized or privileged statuses (lived experiences) all have an impact on their perceptions of death and dying. In turn, their perceptions of death and dying have an impact on their end-of-life experiences.

Education is the foundation of culturally competent end-of-life counseling. Developing knowledge of the impact of history, events, culture, religion/spirituality and other influencers on our clients’ lived experiences can help us reach a better understanding of their end-of-life experiences. Possessing a solid knowledge base — and continuing to expand that base by seeking out educational opportunities — has a direct impact on the effectiveness of our practice as counselors.

Practice

This section of the framework is designed to be used in addition to the approaches and interventions that end-of-life counselors are already trained in and currently practicing. Like other areas of the counseling profession, end-of-life counseling is not limited to one single approach or a specific set of interventions.

Culturally competent end-of-life counselors embrace the fact that multiculturalism and social justice are central to end-of-life counseling. In culturally competent end-of-life counseling, counselors work to be aware of the many identities that counselors and clients possess, as well as their privileged and marginalized statuses. These identities and privileged or marginalized statuses enter into and influence how each individual will experience interactions that occur during the counseling relationship. Culturally competent end-of-life counselors skillfully facilitate discussions about these identities and statuses. They share information about their own identities, allow clients to explore their personal identities, and work to identify and overcome any barriers that may arise in the counseling relationship.

The knowledge that culturally competent end-of-life counselors possess and continue to build upon (addressed in the education portion of the framework) aids them in better understanding clients’ identities. Open dialogue about these identities can help counselors gain insight into an individual’s unique background. Through this work, clients may even come to recognize their diagnosis or terminal illness as a new identity or way in which they see themselves. When this happens, counselors can help clients examine this new identity and use interventions that are helpful in exploring clients’ perceptions of what this new identity means to them.

Occasionally during this time in the counseling process, clients will discuss experiences that led to their understanding of these identities. These experiences and others that are shared during counseling are the clients’ lived experiences, which may influence how they view themselves and their end-of-life experience. Making space for these discussions (or even initiating them) and asking questions to better understand our clients helps us to become more culturally competent counselors. As a result, trust is built between the counselor and the client, and the counseling relationship is enhanced.

In end-of-life counseling, these discussions usually take place early on in the counseling relationship. In fact, faster development of the counseling relationship can be more critical in end-of-life counseling than in other areas of counseling practice. Allowing opportunities for these discussions early on may greatly enhance the client’s comfort in sharing with the counselor and may aid in achieving the goals of counseling in the limited time available.

The ultimate goal of end-of-life counseling is to facilitate psychological and emotional healing that will allow clients to experience peace. Counselors and clients work together to identify sources of stress or any psychological disturbances (e.g., depression, anxiety) that are preventing the client from achieving peace. Reasons behind the presence of disturbances such as depression or anxiety may vary. Clients might express fear of death, a sense of isolation, a loss of purpose or meaning, struggles with feelings of guilt, conflict in relationships or other concerns. Occasionally, struggles in relationships, personal regrets, feelings around a loss of independence, feelings of loneliness, or emotions connected to experiences with racism, sexism, religious oppression or other forms of oppression may also surface at the end of life.

Culturally competent end-of-life counselors understand that clients’ lived experiences (inclusive of issues such as oppression and discrimination) are unique and personal and should be handled delicately. Providing a safe space for clients to express their feelings surrounding these experiences is an important step in helping them achieve peace at the end of life. This safe space is created early on in the counseling relationship through structure, support, encouragement and unconditional positive regard. It is enhanced when counselors effectively and openly discuss identities, privileged or marginalized statuses, and issues such as oppression and discrimination. Allowing space for the anger, frustration, sadness and other feelings that clients may feel when sharing about these experiences is very important.

The MSJCC emphasize the need for counselors to work outside of the office, meeting directly with the client’s family members and friends (with permission from the client) to determine what relationships exist that will either support the client’s progress in counseling or present barriers to change. With end-of-life counseling, counselors are more likely to work with the client outside of the office. This might include meeting in hospice facilities, nursing facilities, assisted living facilities, hospitals or clients’ homes. As a result, end-of-life counselors are occasionally afforded opportunities to observe interactions that clients have with their family members and friends. If clients have identified resolution of conflict in a relationship as a goal of end-of-life counseling, then counselors are able to intervene.

By facilitating these discussions early on in the counseling relationship, counselors can create the solid foundation necessary for various counseling approaches and interventions. Counselors should ensure that they are using approaches and interventions that are culturally appropriate and that empower clients.

Advocacy

Advocacy at the end of life can be complicated, but it is important that we make sure our clients’ voices are heard. End-of-life counselors often are responsible for updating the interdisciplinary team about the client’s emotional and psychological well-being and the progress being made in counseling.

The interdisciplinary team (sometimes referred to as the multidisciplinary team) generally consists of medical professionals (doctors and nurses) and a group of supportive services professionals that can include some combination of social workers, counselors, psychologists, and clergy or spiritual care counselors. These teams are usually organized and assigned through hospitals and palliative care/hospice organizations. Team members work together to ensure that they are meeting the needs of individuals enrolled in services. Team meetings can vary in approach, but in my experience, each team member is asked to provide an update on the services for which they are responsible, along with any concerns they have about the needs of the individual who is facing end of life.

As counselors, we are often uniquely cognizant of the emotional and psychological needs of our clients. This gives us the ability to identify additional issues that are affecting our clients’ well-being. We can share these concerns and challenges with the interdisciplinary team in many ways. For example, we can relay information about the progress our clients are making in sessions by tracking their levels of depression or distress via simple assessments and then presenting our data during team meetings. We can also bring up any concerns that our clients have voiced during sessions regarding their care or interactions with other team members.

Our role on the team also gives us opportunities to educate the other team members on cultural considerations. The cultural insights we provide may influence discussions that these other team members have with our clients and their family members. Because of our greater level of understanding of the lived experiences of our clients and the impact these have on our clients’ end-of-life experiences, we can provide guidance to the team on how best to provide individualized care to clients.

In our role as advocates, we can also give voice to our clients’ end-of-life wishes. This may sometimes require us to relay difficult and sensitive information (again, with the client’s permission) to family members, team members and caregivers. This might involve the client’s desire concerning the presence or absence of certain individuals during the end-of-life experience, the environment in which the person wishes to die, requests for final meals, the kind of medical care or interventions the person would like to receive, and so on. As advocates, it is important that we relay this information in ways that are sensitive while also being true to our clients’ voices.

In addition to our responsibility to give our clients voice, it is also important that we work to improve the understanding of the attitudes, beliefs, biases and prejudices that exist in our communities, not just in our places of work. Among the ways we can do this are advocating for policies and procedures that rectify existing inequities, offering additional support to marginalized clients, and collaborating with others to address issues of power, privilege and oppression in advanced care settings. Some examples of how these issues arise in advanced care settings include the ways in which information is relayed to marginalized clients and assumptions that all clients have strong support systems, the same knowledge of or experience in health care settings, and similar perspectives on the end of life. Providing education on culturally competent practice to others who work in end-of-life care can also serve as advocacy. Advocacy is a part of cultural competence, and it is an important role that end-of-life counselors can play for clients.

Summary recommendations

Key considerations for providing effective, culturally competent end-of-life counseling are as follows:

  • Seek out educational opportunities that challenge and expand your understanding of multicultural and social justice issues in end-of-life counseling settings.
  • Treat the “whole” client and not just the parts of the client with which you are comfortable.
  • Integrate discussion of both the client’s and counselor’s worldviews, beliefs, attitudes, and marginalized or privileged statuses.
  • Help clients explore their lived experiences and the impact these have on their end-of-life experiences.
  • Advocate for clients by giving them a voice and pursuing social justice in end-of-life policies and practices.

Conclusion

Counselors should continue to strive to be culturally competent to provide the best services possible to our clients. Being culturally competent involves not just our professional selves but also our personal beliefs, values and worldviews. As we become more culturally competent and actively engage in multicultural and social justice advocacy, we will become more well-rounded, effective counselors.

 

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Ashley C. Overman-Goldsmith is a licensed professional counselor, a national certified counselor, and a doctoral student at North Carolina State University. She is the owner and lead therapist at Sea Change Therapy PLLC. Her current research centers on honoring the lived experiences of terminally ill clients while helping these clients resolve issues that affect their end-of-life experience. Contact her at seatherapychange@gmail.com or through her website at ashleyoverman-goldsmith.com.

 

Letters to the editor: ct@counseling.org

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

 

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