Tag Archives: Counselors Audience

Counselors Audience

Counseling clients into new territory: Five steps to redefine a foundation

By John Wheeler March 30, 2020

As professional counselors, we are often faced with challenging clients who express the desire for their life to be different yet continually make the same choices. We do not fill the role of advice givers as counselors, but if we’re not asking questions that encourage our clients to explore what’s true for them, then we are doing a disservice to them and to ourselves.

It is important for every counselor to have some pragmatic tools to assist in the counseling session. As clients explore “new territory,” it is not uncommon for them to face new challenges, feel like quitting or even decide to no longer seek counseling. With the steps below, I invite counselors to explore five easy ways to encourage “change” and facilitate clients toward redefining the foundations of their lives.

When we say “foundation,” we are talking about the fixed points of view that someone has either been taught or discovered from their own life experience and from which they create their basic belief system. Foundations give us a false sense of security while constantly providing us with information to make decisions. Although we must have a way to form our decisions and make choices, it is important to allow for a flexible foundation. When the foundation your client is using becomes too solid or too fixed, it does not allow them to make changes in the systems that govern their beliefs.

Step No. 1: Acknowledge what is no longer working. The first thing in redefining the foundation of clients’ lives is to get them to acknowledge what is no longer working. By simple definition, acknowledgment is the acceptance of truth or accepting that something exists. It is the ability to see that something is simply what it is — no more and no less. Acknowledging choices that have been made without placing a judgment on them (i.e., making them “right” or “wrong,” “good” or “bad”) creates a safe space for clients to explore their life stories.

Facilitating clients’ acknowledgment of everything that isn’t working also creates more flexibility in their understanding of different life events, such as having a parent leave or the ending of a marriage. Although this concept is existential, in its basic nature, this tool empowers clients to see the choices they have made, recognize the role they have played in every situation, and practice nonjudgment of themselves in a way that begins to unravel the barriers they have built.

What if acknowledgment of what is no longer working was the most freeing concept that your client had encountered?

Step No. 2: Determine the points of view in place. Once clients have acknowledged what is no longer working, it is time to determine the points of view they are using to create their lives. One of the fundamental beliefs in psychotherapy is that the way something or someone is perceived determines the likelihood of creating patterns, judgments and fundamental beliefs on which future choices are based. For example, if we perceive an individual as being rude, we may make every effort to avoid that person in the future.

By processing the points of view clients have taken around the events in their lives, we are inviting them to determine what is known to be true versus what they think to be true. Exploring a point of view about any area of their life can result in new insights, new awareness, new choice and new possibilities that clients may not have imagined previously.

How different would your life, business and practice look if you had no points of view on which you based your decisions?

Step No. 3: Explore the possibilities. Think of this step as a giant brainstorming activity in which clients and counselors welcome every possibility and do not label anything as impossible. Although it is important to be realistic and have measurable goals, counselors have to allow their clients to explore the new foundations being formed. At this level, counselors have challenged clients to be open-minded and flexible in their beliefs. To turn down ideas as dumb or to discount clients could create mistrust and new judgments.

What if you were willing to explore the infinite possibilities of the new foundation being formed?

Step No. 4: Make a new demand. Considering the possibilities that have been discovered, it is time to acknowledge what is reachable at the time of the session. Keep in mind that what is available now may be different in future sessions as clients get more comfortable. Making a demand is about clients accepting “what is” and then committing to doing, being or having something different in their life. This is the stage at which they get to choose whether to continue in the same pattern they have been repeating or begin to create something new. It is about taking responsibility and playing an active role in the creation of their life.

How different would things look if you made a different demand in your own life?

Step No. 5: Encourage clients to create for themselves. A risk of individual therapy is that relationships can change as clients change. It is important to discuss with clients that they can change only themselves and their own roles in their lives. Clients are the experts in their lives, so they must learn to choose what their lives will be like. Many factors play into the success of clients beginning a new chapter, but the most important thing they must learn is to do it without the counselor.

How can you encourage your clients in every session to explore something new for themselves?

 

Conclusion

In closing, please note that it is not a counselor’s place to push clients to change their foundations. As counselors, we do not have the right to push our agendas or beliefs on our clients. The pragmatic approach I have outlined will work best with clients who have a high motivation to change, express a strong desire for something different, and demonstrate a willingness to be more flexible with their views on life. This is a more directive approach to counseling, and counselors should always use their best judgment in determining whether this approach might best suit their clients’ needs.

 

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John Wheeler is a licensed professional counselor in Dayton, Ohio, and a certified facilitator of Access Consciousness. His focus in therapy is on providing a space that allows clients to be the experts of their own lives and encouraging them to take a proactive approach to fostering lifestyles that work for them. Contact him at johnrwheelerlpc@gmail.com or visit john-wheeler.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.

Hearing voices: A human rights movement and developmental approach to voice hearing

By Laren Corrin March 12, 2020

In 2016, shortly after I entered a CACREP-accredited graduate program for clinical mental health counseling, I began hearing, outside of the class setting, about an international human rights movement centered around the “voice hearing” experience — what would be called auditory-verbal hallucinations in clinical mental health settings. The movement includes people with unusual perceptions that often get labeled as psychosis.

I slowly came to learn about the movement through an introductory workshop, a three-day group facilitator training, attendance in online and in-person groups for a year, and the reading of the literature on the topic. Most recently, I traveled to Montreal for the 11th World Hearing Voices Congress, where I was able to shake hands with and hear one of the movement founders, Dutch psychiatrist Marius Romme, speak.

With this article, I hope to familiarize counselors with the Hearing Voices Movement and related international networks of recovery groups. I believe the Hearing Voices Movement is in alignment with the values and ethical principles of the American Counseling Association.

History and current development of the movement

The Hearing Voices Movement started in the 1980s in Europe when a patient confronted Romme about the limitations of the psychiatric care being provided. Why, the patient asked, was it OK for Romme to believe in a God whom he could not see or hear but not OK for her, the patient, to believe in voices that she really did hear? To learn more about the voice-hearing experience and to try to help his patient, Romme had the woman’s story told on TV and asked for other voice hearers to contact him. Approximately 550 reached out.

Remarkably, many of the people who heard voices did not need clinical help. Writing in the Journal of Mental Health in 2011 after conducting a literature review, Vanessa Beavan, John Read and Claire Cartwright asserted that it was safe to say that 1 in 10 people in the general population will hear voices. Romme eventually compared psychiatric treatment to eliminate voice hearing to conversion therapy for sexual orientation.

How did he come to that conclusion? By accepting the reality of the voices rather than just checking them off as a symptom to be treated, Romme said, he could learn much more about their origin and meaning and identify ways to help his patients. He discovered that voices were often a reaction to problems in life, such as bullying or abuse, with which the person could not cope. In other words, there was a relationship between the voices and the person’s life story.

The Hearing Voices Networks (HVN) are the network of community groups that emerged from the Hearing Voices Movement. As of early March, the Hearing Voices Network USA had 119 groups listed on its national website. At the World Hearing Voices Congress that I attended, it was reported that Brazil has quickly grown over the past few years to have 35 groups, whereas the province of Quebec in Canada started with one group in 2007 and now also has 35 groups. The majority of groups are in Europe, where the Hearing Voices Movement started.

The groups developed when people with experiences of voice hearing got tired of not being listened to and of being labeled as having mental disorders. They were also frustrated by the coercive nature of the often ineffective treatments. Individuals with experiences that might be labeled as psychosis in clinical settings can meet in these groups and explore their experiences in spaces that are free of clinical judgment. If a clinician brings a person to attend a Hearing Voices group, the clinician will often be asked to wait outside or in another room while the voice hearer attends. Members of these networks believe in the freedom of voice hearers to interpret their experiences in any way they see fit. The key to this approach is for individuals to be listened to in a curious, nonjudgmental way as they describe their experiences.

People are discovering that when listened to in this way, profound healing can occur. Eleanor Longden’s TED Talk, titled “The voices in my head,” is a great introduction to this approach. Longden describes how changing her perspective on hearing voices — from a disorder to be treated to experiences with meaning if one could just open up their metaphorical wrapping — led to a huge developmental shift that allowed her to make peace with her experience.

Treatment alternatives

I firmly believe the Hearing Voices Movement is in alignment with ACA values. ACA has a rich tradition of promoting social justice, honoring diversity, and supporting the worth, dignity, potential and uniqueness of people. In clinical practice, counselors work to promote the ethical principle of client autonomy, fostering the right of clients to control the direction of their treatment and lives. This aspiration is realized with all range of mental health concerns, but experiences that could be labeled psychosis are generally approached differently in the U.S. mental health system, potentially indicating a blind spot in the field of mental health.

In contrast to the ACA values I learned in my first semester of graduate school, I began to have a growing concern when learning about counselor roles that stood in opposition to those values. Specifically related to psychosis were the two roles of providing psychoeducation and monitoring adherence to medications. This involves instructing the client in the medical model, explaining that hearing voices and other unusual experiences are symptoms of a brain disease process, asserting that symptoms have no personal value or meaning to be explored, and teaching that treatment should consist of attempting to arrest that disease process. In taking that approach, psychoeducation essentially serves to impose a particular value or framework on the client’s experience of hearing voices.

The American Psychiatric Association established the medical model upon its founding in 1844, writing in its journal at the time that “we consider insanity a chronic disease of the brain …” That is the lens and approach that the organization has taken and buttressed with evidence. Of course, the medical model framework is useful for some people, and many useful treatments have been derived from it. However, there are other people who prefer alternative social or developmental models and lenses that are more in alignment with ACA values.

A 2017 United Nations Human Rights Council report concluded that one of the barriers to mental health and wellness was a lack of free and informed consent. Specifically, “In order for consent to be valid, it should be given voluntarily and on the basis of complete information on the nature, consequences, benefits and risks of the treatment, on any harm associated with it, and on the availability of alternatives.”

The availability and awareness of alternatives and complementary approaches may be a key piece that needs some work. It is important for counselors to identify innovative approaches in line with the ACA ethical principles of client autonomy and nonmaleficence, or avoiding actions that cause harm. I believe the Hearing Voices Movement is one such promising innovative approach, with evidence building in academic journals and books, including Living With Voices: 50 Stories of Recovery, by Romme and colleagues (2009).

A developmental model

In contrast to the medical model, counselors rely heavily on a developmental model of client concerns. The Hearing Voices Movement comes very much from a developmental perspective and fully acknowledges that voices are often a reaction to problems in life. Having learned that with 70% of adults the onset of voices was related to trauma or conflicts, Romme and colleagues studied 80 children who heard voices and published the results in 2004 in the International Journal of Social Welfare. They found that 75% of children had an onset of voices in relation to circumstances they felt powerless over.

Although the Hearing Voices Movement acknowledges a trauma connection to the onset of hearing voices for the majority of people, a blanket causal explanation for all voice hearing is not declared. All explanations are given space to be heard in the Hearing Voices Networks groups, including the medical model, psychological models such as voices being subpersonalities of the voice hearer, spiritual beliefs that the voices are spirits, and other possibilities.

As a side note to the developmental perspective of hearing voices, there is a new culture emerging of tulpamancers — people who intentionally work to develop voices they call “tulpas” to interact with as friends, based on an ancient Buddhist practice. A researcher at McGill University, Samuel Veissière, has done phenomenological research on tulpamancers, and Tanya Luhrmann of Stanford University is working on a neuroimaging study of these individuals.

The book Living With Voices outlines a three-phase developmental recovery framework identified from people who recovered from the distress of hearing voices:

1) Startled phase: Anxiety and a feeling of being overwhelmed dominate. Sigmund Freud wrote about his experience of being a voice hearer while living alone in a strange city in The Psychopathology of Everyday Life. His description of his experience was translated into English as the voice suddenly pronouncing his name.

2) Organization phase: Interest in the experience is developed, and the voice hearer looks for more information.

3) Stabilization phase: Person recovers their own potential and capacity to live the life they choose.

Although this may appear to be a linear process, in actuality the process may be repeated each time that a new voice makes itself know to the voice hearer.

To clarify, in the Hearing Voices Movement, to “recover” does not mean that symptoms have been eliminated but rather that the person has recovered from the distress of hearing voices. As was the case in the not-too-distant past when homosexuality was termed a mental disorder, the solution is not to force people to be different than they are but rather to change society to allow people to accept themselves as they experience life and love. 

A role for the counselor

In the U.S. mental health system, clients who hear voices are most commonly acculturated into the perspective that their voices reflect a disease process with no inherent meaning. Frequently, once a mental health professional identifies voice hearing as a symptom, the voice hearer’s underlying traumas are systematically ignored and invalidated. The only history then asked about is family history of mental illness to confirm the diagnosis, even though the person’s trauma history could be addressed in counseling.

The Hearing Voices Movement allows many voice hearers to discover relationships between their voices and their life experiences. Some voices have the tone or use the language of a childhood bully or an abuser. Often, voices express difficult emotions that the voice hearers are not able to express themselves.

The Maastricht interview, named for the Netherlands university city in which it was created, was originally a research tool designed in collaboration with voice hearers to learn more about their experiences, but it was found to have clinical value in the beginning process for clients to explore their experiences. The Maastricht interview can be considered a voice-mapping process in which the interviewer asks the voice hearer questions about the voices. Through this process, voices are discovered to serve different purposes, such as representing unfelt emotion, protecting the voice hearer, or attempting to solve loneliness or social isolation.

Among the questions the Maastricht interview uses to accomplish this are:

  • Have you noticed whether the voices are present when you feel certain emotions?
  • Are you able to carry on a dialogue with the voices or communicate with them in any way?
  • Does the manner or tone of the voices remind you of someone you know or used to know?
  • Can you describe the circumstances when you first heard them (each voice)?
  • Please describe your own interpretation of what causes your experience and what your theory is for why you have this experience.

The Maastricht interview can be found on Intervoice, the International Hearing Voices Network website.

The Maastricht interview features eight specific questions that explore potential trauma experienced in childhood at home, in school or in the neighborhood. In addition to the counselor facilitating the organization phase of recovery for the client, these questions provide validation of the client’s life experience and raise awareness of unprocessed trauma that may be worked through more effectively with counseling than in the Hearing Voices groups.

Similarities with internal family systems

In Richard Schwartz’s internal family systems (IFS) model, a person is conceived as being born with several distinct parts (like subpersonalities), each of which can pick up burdens or traumas in life, and a core self that is not affected by traumas. The parts interact within the person, much in the way that different members of a family interact as a system.

I asked Schwartz if the IFS model could work with people who hear voices. He told me that it could. The voices can be worked with as parts in the IFS model, and Schwartz has done work with people with schizophrenia diagnoses.

In the Hearing Voices Movement, voices are seen as being very interactive within the individual who hears them. Likewise, in the IFS model, voices can be looked at as parts that interact as a family system. Additionally, in the Hearing Voices Movement, the goal is not to eliminate the voices (although that sometimes happens). Similarly, in IFS, the goal is not to eliminate the person’s distinct parts but rather to help the person discover and release unprocessed trauma burdens so that the system can live in a harmonized way. Much like in the Hearing Voices Movement, in which voices are acknowledged as real, IFS is best carried out from the understanding that a person’s distinct parts are real and can act within the internal family system.

In one last similarity of note, at the World Hearing Voices Congress, Romme said that most voice hearers know the age of their voices. At his workshop, Schwartz had some participants check in with their parts and find out what their ages were. 

Conclusion

Romme has drawn comparisons between using treatment to try to eliminate a person’s voice hearing with using treatment to try to change a person’s sexual preference. I was struck when I first read this comparison because I at the same time kept reading about ACA’s push to support bans on conversion therapy for sexual preference. Romme repeated this comparison at the World Hearing Voices Congress.

Initially, I kept thinking about the level of distress people must feel who hear voices that tell them to harm themselves or others. But I have since met, talked with and listened to so many people who hear voices — and who have really taken control of their lives by changing their relationship to those voices — that I am beginning to think that Romme is right. In my lifetime, homosexuality was included as a diagnosable mental disorder in the Diagnostic and Statistical Manual of Mental Disorders. It took a rights movement to change that. The Hearing Voices Movement — a human rights and social justice movement — is now well underway, with networks in 37 countries and counting.

 

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Laren Corrin is a counseling graduate student at the University of Southern Maine. Laren is an advocate for alternative frameworks for psychosis and complementary approaches to wellness. Contact Laren at larencorrin.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.

Learning from highly effective counselors

By Sidney Shaw March 10, 2020

The term “supershrink” has been used to refer to counselors and other mental health professionals who are very good at what they do and who attain significantly better client outcomes than average. It is perhaps not surprising that such a witty and playful term would come from an adolescent.

In the early 1970s, David Ricks conducted an analysis of the long-term outcomes of “highly disturbed” adolescents treated in a metropolitan guidance center. In this center, some of the youth had labeled one provider “the Supershrink.” Upon subsequent data analysis, Ricks found that adolescents who received treatment from this provider had significantly better long-term outcomes than did those who saw another provider. Turns out that the teens were right; the provider was a supershrink.

The idea that some counselors are exceptional and have very high success rates with clients is not new. In fact, this phenomenon has been verified empirically. Research over the past several decades has demonstrated that some counselors consistently achieve higher client improvement rates than do other counselors. With that in mind, it is important to consider what we can learn as counselors from so-called supershrinks and how we can embody the characteristics and actions of highly effective counselors to improve our own effectiveness.

Counselor effects and outcome research

The term “therapist effects” or “counselor effects” refers to variation in counseling outcomes that are attributable to the counselor, in contrast to other factors such as techniques or theories that contribute to counseling outcomes. Findings of counselor effects appear in a variety of study settings such as naturalistic clinic settings and in randomized clinical trials (RCTs). Counselor effects in RCTs are particularly intriguing because these studies are tightly controlled. In RCTs, counselors commonly adhere closely to a treatment manual (i.e., following specific steps in adherence to a specific theory), and there is also control for client severity. RCTs are the gold standard for comparing efficacy of specific treatment approaches for specific disorders.

Although there have been important findings about the efficacy of different treatment approaches or theories from RCTs, another finding that has received less attention over the years is that counselor effects are the better predictor of counseling outcomes. In other words, who the counselor is makes more of a difference in terms of client improvement than does which theory the counselor professes to use. It is impossible to completely disentangle counselors’ characteristics and actions from the theories that they use, but meticulous research and meta-analyses by renowned researchers such as Bruce Wampold have indicated that counselor effects are up to eight times stronger at determining client outcomes.

As Wampold and others have pointed out, these findings about the relative strength of counselor effects in comparison with theoretical approach are not justification for tossing out counseling theories. Framework, structure, a road map for navigating clinical territory, and conceptualization are just some of the benefits of grounding our work in theories of counseling. That said, outcome researchers have for decades focused predominantly on comparing different theoretical approaches while giving relatively little attention to a more powerful factor — the characteristics, pan-theoretical practices/actions, and attributes of the counselor.

Five characteristics and actions of highly effective counselors

Although the existence of counselor effects in outcome research has been around for several decades, empirical attempts to discern pan-theoretical characteristics and actions of highly effective counselors are rather new. There are limits to developing a list of such characteristics because new research is frequently emerging. In fact, it is noteworthy that the five characteristics highlighted in this article are just some of the major characteristics and actions of highly effective counselors.

The list contained here is composed of qualities that counselors can actively cultivate in their current practice. In other words, there are some strategies for growth with each of these five qualities. There are other characteristics of highly effective counselors in the research literature for which it is not currently clear how to increase or enhance those characteristics (e.g., attachment history, facilitative interpersonal skills). Thus, this list focuses on characteristics and actions that can be enhanced to improve counselor effectiveness. Accompanying the descriptions of these characteristics are some tips for developing each of them in your own counseling practice.

1) Presence and
2) countertransference management

The counselor’s “way of being” serves as a vehicle through which therapeutic actions and interventions take place. Two related concepts from the counselor effects research that speak to the counselor’s “way of being” and “way of relating” are presence and countertransference management. Both concepts have theoretical roots.

For instance, in the existential-humanistic tradition, presence refers to counselors being “in the moment,” connected with clients’ experiences and their own, and fully engaged in the I-Thou relationship with a client. Presence can also be defined by identifying it as the opposite of absence (e.g., distraction, boredom, disconnectedness, remoteness).

Countertransference, of course, has theoretical roots in psychoanalysis. Sigmund Freud considered it to be when a client’s transference activated a counselor’s unresolved childhood conflicts. More broadly, a totalistic view of countertransference is that it encompasses all the counselor’s reactions to the client. Although countertransference reactions are commonplace, the impact of countertransference on counseling outcomes is largely due to how the countertransference is managed. Meta-analytic research by Jeffrey Hayes and colleagues has indicated that successful management of countertransference predicts better counseling outcomes. Similarly, presence has been described by Shari Geller and Leslie Greenberg as a “prerequisite for empathy,” and counselor empathy is a strong predictor of client improvement.

Multiple factors can lead counselors toward increased presence and better countertransference management, including self-insight (e.g., awareness of self in relationship, cognitive and emotional awareness), anxiety management, intentionality and mindfulness. Given all these factors, counselors can be left feeling a bit overwhelmed by methods to strengthen their presence and countertransference management. Fortunately, research evidence supports a few overlapping practices to enhance both of these qualities.

> Meditation/mindfulness practice: Sustained and consistent meditation practice has been shown to increase effective countertransference management, promote emotion regulation and nonreactivity, sharpen awareness and increase presence. Many different types of meditation and mindfulness practice exist. Counselors are advised to investigate these practices, to choose a practice aligned with their own preferences, and to maintain a consistent mindfulness practice.

> Self-insight and anxiety management: Counselors should work on their own psychological health and consistently practice self-observation and self-reflection. This can be done in supervision, in one’s own experience as a client, and through deliberate planning aimed at increased self-awareness.

Relatedly, anxiety management is an important component of countertransference management and presence. Although it is not unusual for counselors to experience anxiety within sessions, unmanaged anxiety can have untoward effects on a counselor’s presence, ability to manage countertransference reactions, and the therapeutic alliance. A first step is developing sensitivity to noticing anxiety when it appears. Second, counselors likely already have anxiety management skills (e.g., behavioral, cognitive, mindfulness-based) that they use with clients. Counselors can apply these skills to themselves.

> Pre-session centering: A study by Rose Dunn and colleagues revealed that counselors perceived themselves as having higher levels of presence when they engaged in a brief mindfulness centering exercise within five minutes of a counseling session. Additionally, clients perceived the sessions to be more effective when the counselor used the mindfulness exercise prior to the session. The basics of the centering exercise are consistent with acceptance and commitment therapy principles.

In this case, counselors would simply sit comfortably with a straight spine, take and notice gentle and full breaths, notice physical sensations, notice thoughts that emerged, acknowledge the existence of those thoughts and allow them to be present, imagine creating additional space for the thoughts with each breath, and then let go of focus on the thoughts to broaden attention to the environment around them. In this mindfulness approach, counselors aimed to accept the thoughts and experiences as an observer rather than clinging to or pushing away those thoughts. For more detailed information on mindfulness and acceptance centering, I recommend the work of John Forsyth and Georg Eifert.

> Self-care: This term is frequently discussed in our field, and self-care activities can vary greatly among individual counselors. It is important for presence, countertransference management and multiple other reasons that counselors engage in consistent self-care actions. One self-care behavior that seems relatively universal, and which has an impact on attention (i.e., presence) and emotion regulation, is sleep. Practicing healthy sleep hygiene (keeping room temperature at 62-68 degrees, sticking to a consistent sleep schedule, maintaining a dark environment, having technology limits at night, etc.) can provide conditions that are favorable for increased presence and greater countertransference management.

3) Professional self-doubt

The essence of this quality of highly effective counselors is captured in the title of an article by Helene Nissen-Lie and colleagues: “Love yourself as a person, doubt yourself as a therapist?” At first glance, the idea of professional self-doubt may seem like an unproductive place to be as a counselor. However, if we consider just a basic definition of “doubt” (i.e., to be uncertain), then the benefits for clients become clearer.

Counselors who possess certainty that they are helping a client are likely closing the door to self-critique and thoughtful consideration of ways to improve their work. Indeed, several studies by researchers such as Corinne Hannan and others have indicated that counselors consistently overestimate the effectiveness of their work with clients. Regarding self-doubt, two studies of experienced counselors by Nissen-Lie and colleagues revealed that counselors higher in professional self-doubt had stronger alliances with clients and higher levels of client improvement than did counselors lower in professional self-doubt.

Importantly, a third study by Patrizia Odyniec and colleagues showed that increased professional self-doubt among trainees/students resulted in poorer client outcomes than did lower professional self-doubt. One explanation for these findings is the difference in developmental stage of the counselors. Experienced counselors likely have higher confidence in their basic skills as counselors. Thus, professional self-doubt about their effectiveness can be beneficial as they strive for improvement due to their own uncertainty about client outcomes. In contrast, high professional self-doubt among trainees may be debilitating because of their earlier stage of counselor development and lower confidence in their basic counseling skills.

All that said, there appear to be clear benefits for clients when experienced counselors cultivate professional self-doubt. Here are some strategies for doing that.

> Prevent the “overconfidence effect.” This concept from social psychology is particularly relevant here due to numerous studies that have shown that counselors commonly overestimate whether and how much their clients are improving. Just being aware of this tendency to inflate their own client success rates can help counselors become increasingly humble and self-reflective about their effectiveness. Consciously questioning our own self-serving biases is an important step in maximizing client improvement rates.

> Monitor your effectiveness. Counselors should use some type of outcome measure (e.g., Outcome Rating Scale, Clinical Outcomes in Routine Evaluation-Outcome Measure, Outcome Questionnaire-45) to assess the degree to which their clients are improving or not. Routine outcome monitoring has repeatedly been found to improve client outcomes, and concrete client reports of their improvement level can help keep counselor overconfidence in check. Additionally, outcome monitoring can promote the beneficial stance of professional self-doubt because awareness of clients who are not improving or who are deteriorating
can lead counselors to act intentionally to improve.

> Love yourself as a person. An important caveat in the studies by Nissen-Lie and colleagues is that counselor self-doubt can improve client outcomes more when coupled with what is referred to as a “self-affiliative introject.” In general, this refers to higher levels of self-affirmation, self-love and self-acceptance. When a self-affiliative introject or self-affirmation is an area of struggle for counselors, it can affect their work with clients and their capacity to embrace professional self-doubt. Steps to build and strengthen a self-affiliative introject or stronger self-affirmation could include self-help, support groups or personal counseling.

4) Deliberate practice

Deliberate practice, a concept that originates in the expertise literature from researchers such as Anders Ericsson, refers to intentional and individualized exercises and actions aimed at strengthening specific areas of one’s performance. Early research on deliberate practice examined its effects in noncounseling domains such as chess, music and sports, to name a few.

In counseling, a promising study by Daryl Chow and colleagues of more than 1,600 clients working with 17 counselors found that the top quartile of counselors (i.e., those whose clients showed the most improvement) spent nearly triple the amount of time engaged in deliberate practice than did counselors in the lower quartiles of client improvement. Consistent with some previous research, Chow and colleagues found that the following factors were not significantly related to client outcomes: counselor age, professional discipline, gender, years of experience, highest qualification level and theoretical orientation. Below are some core components of deliberate practice combined with recommendations for integrating them into your counseling practice.

> Establish your baseline. To improve as a counselor and to determine if you are increasing effectiveness over time, you need to know how effective you already are with your clients. Routine outcome monitoring is a way to establish a baseline. Using an outcome measure and then tracking your client improvement rates over time is an initial step in deliberate practice.

> Record sessions with difficult or stalled cases. While not intrinsically motivating, we stand to learn a lot about areas for improvement with cases in which our weaknesses are most evident. Video recording is simple these days, and it is an indispensable tool that is not just for practicum students. Video recording can help counselors identify gaps in awareness and skills that simple self-reflection alone is unlikely to reveal. Relying only on our self-assumed clinical wisdom by mentally reflecting back on a session is unlikely to interrupt and change unhelpful patterns that may have emerged outside of our conscious awareness.

> Work with a consultant or consultation group. Stepping out of our own perspective and potential for self-serving biases is a critical ingredient of deliberate practice. By working with a competent consultant or consultation group, we can obtain diverse perspectives on our areas of weakness as counselors and thus develop specific goals and plans for growth while receiving ongoing support and feedback.

> Develop clear, targeted goals. Our goals need to be very clear and specific. It is not very effective to set a goal to “improve as a counselor.” Instead, a first step here would be to identify specific areas for potential growth as a counselor. This could be done in collaboration with your consultant/consultation group. With deliberate practice, the real growth takes place outside of actual client sessions. Outside of session, you have time, support and opportunity for reflection and practice as you engage in intentional efforts to develop new therapeutic skills or “ways of being” with challenging cases.

The specifics of deliberate practice are very detailed. Thus, counselors are encouraged to read the works of scholars such as Daryl Chow and Scott D. Miller on this topic for a more comprehensive review.

5) Multicultural orientation

Multicultural orientation is a rather new construct that differs  from multicultural competencies. As described by Jesse Owen and colleagues, multicultural competencies are considered a “way of doing,” whereas multicultural orientation is a “way of being.” Multicultural orientation is a way of being that communicates the counselor’s
attitudes and values about culture to the client. Specifically, multicultural orientation consists of three overlapping pillars. Each of the pillars is described below and accompanied by recommendations for strengthening it in your counseling practice.

> Cultural humility: This refers to an interpersonal stance that is “other oriented” and open to understanding the client’s cultural experience and background. In addition to this interpersonal dimension of cultural humility, there is also an intrapersonal dimension in which counselors have an openness and eagerness to reflect on their own limits and blind spots in understanding the cultural experience of another. Four studies with more than 3,000 clients have found a significant positive correlation between client ratings of their counselor’s cultural humility and counseling outcomes. An important consideration here is that the “client’s perception” of their counselor’s level of cultural humility was related to client outcomes.

There are some strategies and actions that counselors can take so that clients are more likely to experience them as being culturally humble. First, given the intrapersonal domain of cultural humility, counselors are encouraged to self-reflect upon and analyze their own areas of potential biases and cultural blind spots. Pamela Hays’ “ADDRESSING” model can be a useful framework for determining domains in which a counselor has a privileged status because these domains of privilege are likely sources of blind spots.

Second, counselors are encouraged to broach the topic of culture at the intake session with clients in an open-ended manner. This strategy also overlaps with the pillar of “cultural opportunities” (broaching strategies will be described in that section).

Third, counselors should check in with clients frequently to ensure that they accurately understand the client’s cultural perspective. This “cultural check-in” should be one part of a broader culture of feedback that is created by the counselor in the session. Specifically, counselors need to acknowledge with clients that they strive to understand clients’ perspectives and cultural experiences, but despite their best efforts, they may sometimes misunderstand. Openly and repeatedly inviting clients to provide candid feedback (especially negative feedback) is a way to express humility and to make repair attempts if and when a counselor misunderstands or unknowingly commits a microaggression.

> Cultural opportunities: This pillar refers to opportunities in sessions for the counselor to broach the topic of culture with a client. Importantly, research on this topic indicates that “missed cultural opportunities” (i.e., the client’s perception of the counselor missing and not acting on opportunities to discuss/broach culture) are negatively correlated with client outcomes. In other words, as the counselor misses more cultural opportunities, client improvement declines.

One way to enhance the positive effects of cultural humility and cultural opportunities is for counselors to broach the topic of culture at the intake session. For example, “How does culture influence the problem?” The purpose of such an open-ended question is to better understand the client’s perception of culture. If clients are unclear about what is meant by “culture,” alternative phrasing ideas can be gleaned from the “Cultural Formulation Interview” in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The interview offers numerous examples for asking open-ended questions about clients’ cultures.

Broaching or inquiring about the influence of culture should not be limited to the intake session. Counselors need to attentively engage with clients to understand how they
see the role of culture as sessions progress. This can lead counselors to sensitively seize upon cultural opportunities in sessions in a way that resonates with clients.

> Cultural comfort: The final pillar of multicultural orientation is counselors’ level of openness, ease and comfort in working with diverse clients and engaging with clients about the topic of culture. In a 2017 study, Owen and colleagues found that counselor cultural comfort level predicted client dropout rates. Higher levels of counselor cultural comfort were associated with lower client dropout rates. This is particularly important given that a high dropout rate is one of the more pernicious challenges for our field to address. Indeed, a 2012 meta-analysis by Joshua Swift and Roger Greenberg found that the average dropout rate in counseling is 20%.

In terms of counselors increasing their cultural comfort levels, some of the strategies mentioned for cultural humility and cultural opportunities (e.g., intentionally reflecting on/analyzing biases and blind spots, broaching the topic of culture in sessions) can apply. One additional strategy that can help in this regard is role-playing and rehearsal — specifically, role-playing with colleagues in which the counselor practices engaging with mock clients around the topic of culture. Counselors are advised to practice broaching the topic of culture in situations that represent a wide range of challenge. For example, if a counselor has had little or no contact with clients who are transgender, then role-playing a scenario in which the counselor broaches culture with a mock client who is transgender would be a way to expand the counselor’s cultural comfort. Inviting and receiving feedback from colleagues in such mock sessions is essential for counselors to expand and enhance their broaching skills and increase their level of cultural comfort.

Conclusion

The number of factors that contribute to effective counseling is vast and incalculable. As research continues to evolve on this topic, we develop a richer understanding of some of these factors. We now have abundant research support for counselor effects and the relative strength of these effects in comparison with theoretical techniques.

The lines between counselor characteristics, common factors (e.g., therapeutic alliance, placebo effect) and specific factors (e.g., treatment interventions, techniques) are not neat and discrete. Instead, each of these has some overlap with and multidirectional influence on the others. That said, recent research indicates that the characteristics, qualities and pan-theoretical actions of counselors are prominent in potentiating the therapeutic alliance and theoretical techniques to improve client outcomes.

 

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Sidney Shaw is a core faculty member in the clinical mental health counseling program at Walden University and a certified trainer for the International Center for Clinical Excellence. Contact him at sidneyleeshaw@gmail.com.

 

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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.

Creating successful home visits in community-based counseling

By Robin M. DuFresne and Allison K. Arnekrans March 9, 2020

Many newly minted counselors begin entry-level positions as home-based counselors, traveling to see their clients in homes, schools, community centers and elsewhere. Traveling to the client may seem foreign, particularly if the counselor’s internship experiences were all office-based. However, according to a 2005 study by D. Russell Crane, Harvey Hillin and Scott Jakubowski, home-based counseling has proved to be cost-effective and to reduce hospitalizations, so there is evidence for its usefulness.

Home-based counseling, which is sometimes referred to as community-based counseling, can be effective and beneficial with multiple client populations, including families, older adults, children, and individuals with developmental disabilities. Mood disorders, anxiety disorders, psychotic disorders, behavior problems and family disturbances are typical presenting problems that may benefit from home-based counseling. It is often helpful to have a counselor in the home environment to witness maladaptive behaviors, relational issues and other contextual considerations. Finally, home-based counseling can be particularly helpful for individuals who cannot or will not come to a counselor’s office for services.

Transferability of skills is one main benefit of home-based counseling, meaning that it can be helpful to those who struggle to transfer skills from one environment to another environment. For example, a child with intellectual disabilities and behavior problems may be able to successfully implement a calming technique in the counselor’s office but unable to do the same thing in the home. Learning and practicing the skill in the home environment with the counselor present to assist and support the child increases the likelihood of success. Additionally, the counselor can observe the parent or caregiver prompting the child to use the skill and work with them to increase consistent implementation. Another example is that of adults diagnosed with anxiety who struggle to use effective coping skills in triggering situations. In the home, the counselor can prompt the individual to recognize the triggers before anxiety begins and encourage the use of coping skills.

Home-based counseling offers the counselor a more enriched perspective of the client and the context of the presenting issues. Issues specific to the family or environment can be assessed through examples and observation in the here and now, which often leads to a more immediate feedback process. For example, family members may be on their “best behavior” while in the counselor’s office, or an individual family member may deny their part in a problem. Conducting counseling in the home allows the counselor to directly observe these behaviors and use immediacy to point them out, then work collaboratively to identify more appropriate behaviors.

In combination with behavioral indicators, the physical environment and the home’s level of cleanliness can provide the counselor with important information relative to the client’s situation. For example, a client who cannot pay her rent, has little food available for her family, and has broken floorboards in the kitchen may not have the same focus or motivation as a client in a more stable living situation.

Finally, clients may “no-show” or cancel office-based counseling sessions for a variety of reasons. Examples include the recent loss of transportation or employment, parental leave for a new baby, medical or health issues that warrant bed rest, severe and limiting psychiatric symptoms and so on. Home-based counseling provides the opportunity to meet clients where they are and with what they can contribute to the relationship.

For instance, clients diagnosed with a psychotic disorder may experience symptoms such as paranoia that prevent them from coming to the office and seeking treatment or engaging in other activities such as grocery shopping. A home-based counselor could work with such an individual in their home to help them identify their feeling of paranoia and learn to use reality-testing techniques to decrease the paranoia.

Although home-based counseling offers many benefits, ethical and safety concerns can dissuade professional counselors from providing this service. Additionally, the possibility of experiencing counselor burnout is a factor to consider when evaluating this type of format for sessions.

Ethical concerns

Counselors are required to act ethically when providing counseling services to their clients. Confidentiality, boundary issues and access to supervision are among the ethical concerns that counselors are likely to encounter when providing home-based counseling services.

Confidentiality

One of the primary ethical duties of counselors is to maintain their clients’ confidentiality. However, confidentiality is difficult to guarantee or provide in home-based settings, where the structure and consistency of the office-based setting are not in place. When entering a client’s home, the counselor cannot be certain who else might be residing in or visiting the home during the session. A roommate could walk through the front door, or a sibling might refuse to leave the common space — either of which could jeopardize the progress and process of counseling. Additionally, if multiple people are participating in the session, confidentiality cannot be guaranteed. Maintaining confidentiality can be particularly difficult if the home is small or if it lacks sufficient and safe space to conduct a private session.

When counseling children and families, confidentiality requirements change. Children do not own the right to their own confidentiality; this belongs to the parent or guardian. Counselors explain to both the parents and the child the limits of confidentiality. In the office, the counselor can suggest that the parent wait in the waiting room while the session is occurring, affording the child the feeling of privacy or confidentiality. In a home setting, it may be more difficult to persuade the parent that they should leave the room during the session. The parent may insist that because the counselor is in their home, the parent has the right to be wherever they want to be within the home. Communicating the importance of allowing the child to have some privacy can be more difficult in such situations.

Boundaries

Counselors are taught to respect the boundaries of the counseling relationship and to consider how bending those boundaries might affect the counseling relationship. Typically, counselors do not interact with their clients outside of counseling sessions. Establishing these boundaries is much easier when there is an office space dedicated specifically to counseling and when time constraints must be observed (e.g., staying on task with a session because the next client has already shown up for their appointment). Once in a client’s home, however, boundaries can become blurry. Both the client and the counselor might struggle with boundaries of time and space.

There are a few ways that clients may blur the boundaries in their homes that are different from what is typically experienced in an office setting. For example, the client may feel inclined to provide food and drink as if they were entertaining a guest. This puts the counselor in the position of deciding whether to accept and what messages this decision may send. Accepting can set a precedent that the client needs to “entertain” at each session. The client may also feel that they have to clean their home or otherwise change their environment to impress the counselor. If the client is putting on a show, this may interfere with the authenticity of the counseling relationship.

Counselors may blur the boundaries by becoming so comfortable in the client’s home that they begin treating the counseling relationship as a friendship or become distracted by the environment. It can be easy in a relaxed setting to spend too much time checking in and lapsing into chitchat rather than focusing on doing the needed work on client issues. This can be particularly true if the location of the counseling in the home changes from session to session.

Supervision

Most counselors are required to undergo weekly supervision while accruing hours toward their license to practice independently. Access to this supervisor can be difficult, however, when counselors are not down the hall from or in the same building as their supervisor. This circumstance may tempt counselors to make decisions without seeking supervision or consulting on important issues when they should.

For example, a counselor might assess a client for suicidal ideation but be unsure about the results. Rather than contacting the supervisor, the counselor may decide to trust their own judgment. This could lead to a wrong assessment and intervention plan. It can also be difficult for the supervisor to monitor the services being provided or to evaluate the supervisee when the supervisee is not based at the same location. The feedback process is altered merely by proximity and immediacy in the home-based environment. This can have ethical implications that are different from those in the office setting.

Safety concerns

In addition to ethical concerns, client and counselor safety should be considered. A client’s home can be an unpredictable environment with safety concerns for the counselor. These can include safety concerns related to pets, physical barriers, the client’s neighborhood, other people associated with the client, and so on. For example, the counselor may be allergic to the client’s pets, or a pet might not be happy about having a stranger in the home and become aggressive. Conversely, the pet may be overly friendly. If the counselor is not comfortable with the pet’s behavior, the pet could misread the counselor’s actions and become aggressive. These interactions with the pet might make it untenable for the counselor to continue providing home-based services to the client.

Counselors also need to be aware of people in the household who could pose a safety concern. One example is when a client’s significant other is unhappy about the client seeking help. The significant other may become intimidating or aggressive toward the counselor to prevent the client from receiving services.

Clients themselves could be a threat to the counselor. If the client has a history of aggressive behavior, the counselor may want to consider seeing the client in an office or referring the client to an office-based counselor.

Counselors may also struggle with concerns over client safety. For example, a client could be expressing homicidal or suicidal ideation. Even though the client is not threatening the counselor, intervention may be needed to protect the client or others. Under such circumstances, a newer counselor may need to seek immediate supervision or a more experienced counselor to help them access more intensive interventions. If the counselor does not have direct access to their supervisor, they may not be able to intervene appropriately. At the agencies where we worked, we were encouraged to have contact information for our supervisors and an experienced counselor easily accessible in our cell phones and computers.

Burnout

Being mindful of ethical concerns and safety concerns while trying to assist clients in making positive changes can lead to stress and burnout for home-based counselors. American psychologist Herbert Freudenberger first coined the term burnout in the 1970s as a way to describe the consequences of severe stress associated with the helping professions.

Burnout has three components: 1) loss of empathy, 2) a decreased sense of accomplishment and 3) feelings of emotional exhaustion. Common experiences of burnout can include sleep disturbances, blurred boundaries, feelings of relief when a client is late or cancels, and even realizations that one is not paying attention when the client is speaking. It is not uncommon for professional counselors to experience burnout at some point in their careers, but home-based counselors often experience these negative symptoms more frequently than do their office-based peers. Three possible reasons for this phenomenon are the physical demands of travel, the toll of consistently facing difficult client issues, and the realities of operating in professional isolation.

First, home-based counselors are moving around all day. The sense of being established and organized flies out the window when one’s trunk is filled with therapeutic toys and the filing system for client worksheets has toppled over in the back seat of the car. Home-based counselors bring their entire office on the road. This can present challenges in terms of the utilization of space, one’s level of organization, and how one’s work life impedes on one’s personal life — especially for counselors who must use their own cars on the job.

In addition to these challenges, home-based counselors must face off against weather conditions and the general wear and tear of travel. Traffic, construction, road hazards and car issues present ongoing and uncontrollable stressors for counselors working in the field. A colleague comes to mind who hated to travel on the weekends for her son’s soccer games because she was so frustrated by having to drive all week for work. She became exhausted by the physical demands of lugging her laptop and resources around and dispirited by having to repeatedly pay for car repairs. These external sources of stress piled up and finally led her to look for another position. Although the travel involved in a home-based position might provide counselors with variety, flexibility and stimulation, too much of any one of those things can lead to burnout.

Home-based counselors can also be affected by burnout as a result of encountering more intense client issues in the field. In general, home-based clients are seeking services due to a lack of resources, systemic issues, family/relational issues or co-occurring diagnoses. These cases tend to be more laborious, time consuming and complex than are cases for the average office-based client. This might be because of the amount of phone calls, interdisciplinary meetings, paperwork, crisis management and case management involved in the wraparound approach.

In addition, because home-based counselors travel from site to site throughout their workdays, they do not necessarily receive the downtime to process, reflect, or consult with other counselors and supervisors who could offer a supportive ear. As a result, compassion fatigue may set in and result in counselor burnout.

Additionally, home-based counselors often lack the structure of a set schedule. They may need to finish documentation at home or after hours depending on how the day went. The likelihood of burnout increases when boundaries are blurred, time “on” and time “off” are not distinct, and there is little to no time to process client issues.

Finally, the daily work of home-based counselors can be perceived as isolating or lonely. Although there is interaction and stimulation with many other people throughout the day, home-based counselors often lack professional support and the ability to vent and collaborate with colleagues after sessions. There is also less time for immediate supervision and consultation on client issues, mainly due to having to pack up and get to the next home. Details are lost, and there is less time for the home-based counselor to process and conceptualize, all of which invite burnout more quickly than normal.

Tips for success

At this point, we know that the work of home-based counselors can be physically and emotionally challenging, although it can also be very rewarding and client-centered. To mitigate against the effects of burnout, several tips and strategies can be implemented to more fully wrap around these counselors, increase employee satisfaction and improve client outcomes.

To address the physical demands of the position, home-based counselors should carefully consider their schedules and level of organization. Taking time each week to plan, pack, and create structure for themselves can be invaluable. For example, instead of driving from ZIP code to ZIP code, counselors should, if possible, map out their schedules based on mileage or on seeing all clients from one area on a specific day. Meetings and supervision can be planned for a day of the week that coincides with time for completing paperwork in the office, when the counselor will have access to a printer and other resources. “Work smarter, not harder” was a popular catchphrase in our agencies when we were providing home-based counseling services.

Additionally, supervisors should have access to and be mindful of home-based counselors’ caseloads and schedules. Travel time, weather conditions and the possibility of a session getting extended due to crisis should all be considered each day. On particularly hot days, Allison’s supervisor would have popsicles and cold bottled water available at the weekly team meetings. This was a small gesture, but it made the counselors feel cared for given the unique demands of their job.

In terms of addressing safety challenges, home-based counselors should remain prepared, observant and cautious of their surroundings. One way to prepare is to have the first meeting with the client in an office setting. The counselor can use this initial meeting to assess whether the client is an appropriate fit for home-based services. If the client shares that they have a significant other or a pet who has been aggressive in the past, for example, then the counselor might decide to refer to office-based counseling. If the client reveals having a pet that the counselor is allergic to, the counselor can refer to a different home-based counselor who is not allergic. Setting a starting and ending time for the home-based services is also advised.

Once in the community, safety precautions could include keeping a basic food and hygiene kit in the car in case of an emergency. Carrying proper identification, making sure one’s phone is charged, and wearing appropriate clothing and footwear are easy steps to take to retain some level of control. It is sometimes advisable to avoid certain roads or areas to reduce the risk of injury or crime. Counselors can position themselves near the door of the house or apartment if they fear that their client or someone else in the home could become aggressive. Counselors may also want to be aware of items that agitated clients or others in the home could use as weapons. Rather than meeting the client in a home environment that the counselor fears could be unsafe, the counselor might encourage the client to meet at a community center or somewhere else that is less isolated. In addition, there are benefits to learning about the resources available in the client’s community and networking with other local agencies concerning opportunities and supports.

The use of a team-based approach is one method for increasing support for home-based counselors while simultaneously decreasing the feelings of loneliness that they sometimes experience. Weekly team meetings at rotating locations, group text messaging, daily “counselor check-ins” by email or phone, quarterly retreats, and staff recognition/celebrations are other examples of intentional ways that supervisors can create a layer of protection and support for their home-based counselors. A team-based approach can also help to process any of the ethical concerns that may arise when counselors are in the field.

Finally, personal wellness and a SMART-based (specific, measurable, achievable, realistic/relevant, time-limited) self-care plan are essential to the success and sustainability of home-based counselors. Intentionally planning one’s schedule to include time for paperwork and continuing education is important to reduce the amount of work that flows over into time off the clock.

As much as possible, home-based counselors should provide distinction between their work selves and their nonwork selves — not only for themselves but for their colleagues and loved ones as well. For example, one of this article’s authors would use the ride home from her last session to mentally process the day so that she could “leave” her work in the car. Staying physically active and making room for rest are important too. Home-based counselors should also be sure to stay engaged with others through consultation, supervision and collaborative efforts. Engaging in personal counseling as a form of self-awareness and health maintenance can be helpful as well.

Home-based counseling can be a daunting experience for novice counselors, but it can also be a rewarding and enriching experience, both for them and their clients. Properly assessing clients and ensuring appropriateness for home-based visits is the first step toward a productive working relationship. Understanding the various aspects of the position, including ways to be strategic and maintain appropriate boundaries, is also essential for the home-based counselor. Likewise, it is important to implement regular ethical and safety checks, in addition to scheduling sufficient time for paperwork, supervision and collaboration each week. Each of these strategies can help counselors be successful out in the field, even with some of the most difficult client issues. Those who supervise home-based counselors should focus on using a team-based approach to help prevent isolation and burnout in these counselors.

At the end of the day, home-based counseling is challenging work, although it is also meaningful and often quite productive. We encourage you to think about it as a possibility when looking for your next job.

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Robin M. DuFresne is an assistant teaching professor and program coordinator for the clinical mental health and school counseling programs at Bowling Green State University in Ohio. She has worked in a variety of settings in community mental health. Contact her at rdufres@bgsu.edu.

Allison K. Arnekrans is an associate professor, faculty adviser for the Mu Kappa chapter of Chi Sigma Iota, and practicum and internship coordinator at Central Michigan University. She is a child and adolescent counselor by trade, with experience in community mental health, partial hospitalization and employee assistance program settings. Contact her at arnek1ak@cmich.edu.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Letters to the editor: ct@counseling.org

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

Bouncing back from ‘failure’ as a counselor

By Lindsey Phillips March 3, 2020

Jude Austin, an assistant professor and clinical coordinator in the professional counseling program at the University of Mary Hardin-Baylor in Texas, started his counseling practicum like many clinicians do — with the lofty goal of saving lives and empowering clients. So, when he saw a client who was in an abusive relationship, he tried to do just that, reassuring her that she was a strong, independent woman who could stand up to her husband. The client took his advice. She went home and told her husband that she didn’t have to take his abuse. He responded by hitting her.

The client returned to her next counseling session with a black eye, and Austin was stunned. After recovering, he handled the crisis by informing the client he would have to report the abuse even if she couldn’t do it herself. In that moment, he realized the power he had over clients’ lives and that his words and savior mentality could get someone killed if he wasn’t careful. After the incident, Austin sought his own therapy to better understand his identity and role as a counselor.

Counselors aren’t immune from making mistakes, so they often have to deal with “failure” in their line of work. However, Jennie Vila, a licensed professional counselor (LPC) in Edison, New Jersey, would consider Austin’s interaction with his client to be a learning experience, not a failure. In fact, she doesn’t believe in failure. If a counselor learns something after making a mistake, then it was a success after all, she asserts.

“You can still be hurt by some of these struggles, but you can use that to move forward,” says Vila, an American Counseling Association member who likes to speak about the importance of mindset. “You don’t have to stay in [the pain] if you’re willing to learn from it.”

Fortunately, counselors can also learn from the mistakes of others. Here are a few lessons that fellow counselors and ACA members say they have learned the hard way.

Lesson 1: Set realistic expectations

Jude Austin, an LPC and a licensed marriage and family therapist associate in private practice in Temple, Texas, and his twin brother, Julius Austin, a clinical therapist and coordinator of the Office of Substance Abuse and Recovery at Tulane University, agree that a common mistake many counselors make early in their careers is trying to be an “ideal” counselor rather than being themselves.

Julius, an LPC in Louisiana, admits that he personally experienced this. From the day he started his counseling program, he began forming an idealized version of the future “Dr. Austin” — a professional counselor who never made mistakes, instantly identified a client’s emotions, and knew exactly what to say in session. “As a beginning clinician, one of my biggest issues was getting over the fact that [this ideal] Dr. Austin didn’t exist,” he says.

When Vila, a certified integrative wellness and life coach and owner of the business Growth Mindset, was working at a hospital, she also held assumptions about what she should be doing in session. She had one client who during active episodes of mania would barge into Vila’s office and ask for help paying her bills. Vila would call the credit card, rental and utility companies while the client waited with her in the office. When the client didn’t have the patience to wait on hold any longer, she would abruptly stand up and try to leave the room. Vila would remind her that they would just have to start the waiting process all over again if they hung up now and called back at some later point.

Vila, who is now the assistant executive director of the New Jersey Counseling Association, had imagined counseling to be more than assisting a client with paying his or her bills. Feeling frustrated and discouraged, she eventually said to her supervisor, “What am I doing for this client? We are just calling and paying her bills in session. I’m not helping her.”

But the supervisor corrected Vila: “No, you are modeling what it means to have social skills in the world. That is what she needs right now. She doesn’t need to go into deeper issues.”

This experience helped Vila realize that “not every session or client you work with [requires] deep psychotherapy. Sometimes, it is life skills or soft skills. That’s its own kind of therapy.”

Lesson 2: Embrace that therapy is an active process

Counselors frequently wrestle with a sense of failure when they feel like they have messed up or could have done better. But sometimes, clients will tell a counselor directly that the counselor has failed them.

Sam Gladding, a professor of counseling at Wake Forest University and an LPC in North Carolina, recalls a time when he was too Rogerian and reflective with a client. At the end of the session, the client told him, “You haven’t done a good job. I expected you to be more active in working with me.”

Those words stung, but they also taught Gladding a valuable lesson — that counseling isn’t only about listening to the client or offering minimal encouragers such as “Uh-huh,” “I hear you” and “Tell me more.” Instead, counseling is an active process. Now he makes sure to ask clients more engaging questions such as “What would you like to do?” “What do you think would be a good response to this?” and “What are some choices you have in this matter?”

Also, instead of starting sessions by asking what clients want to talk about, Gladding asks, “What do you want to work on?” This phrasing sets a tone and expectation that counseling involves work and action.

At the end of the day, “it’s our interaction [with the client] that is going to make or break the session,” says Gladding, a past president of ACA. “We can’t control everything, so [we] control what we can, and we have to let the other happen as it will.”

Lesson 3: Be mindful of what you bring into the therapeutic relationship

Counseling is a professional relationship, and because of that, counselors’ personal lives can affect sessions. When Julius Austin was working as a clinician at a university during the final year of his doctoral program, his dissertation chair called him to say that his committee had requested some final revisions. This meant he would no longer graduate that spring. He was devastated and embarrassed. His family had already bought tickets and were excited to see him and his twin brother, Jude, graduate together. As soon as Julius hung up the phone, he received another call informing him that his next client had arrived.

In retrospect, Austin says he should have explained the situation to the client and rescheduled the session so he could have taken time to process the news he had just received. Instead, the client came in and started talking about her decision to drop out of school and travel the world to gain real-life experience.

Austin recalls opening his mouth and unleashing his frustration on the client by saying, “You know, traveling doesn’t work like that.” He proceeded to paint a grim picture of traveling — one filled with misplaced luggage, missed connections and lost photos.

The client was quiet for a few seconds before responding, “I’m sorry that you haven’t had a good experience traveling, but I don’t think that is the case for everyone. I think I’m going to leave now.”

Austin, co-author with his brother Jude of the recently published ACA book Surviving and Thriving in Your Counseling Program, says that he had a great relationship with the client up until that moment. But after that encounter, he never saw her again. He instantly regretted what he had said, but counselors don’t always get a second chance to fix their mistakes in session.

Austin still laments that his personal struggles made him lose a client that day, but the lesson he learned from the experience has positively influenced his handling of subsequent therapeutic relationships. He says he has grown more aware of how he feels in the moment and is more intentional about what he says to clients in session.

Similarly, Suzan Thompson, an LPC in private practice in Virginia Beach, Virginia, acknowledges allowing her own feelings to affect her relationship with a supervisee. In their final session together, the supervisee said, “I’ll contact you for supervision in the future.” Previous supervisees had made similar claims without following through, so Thompson was skeptical. Without explaining that fact, she replied, “I doubt you will.”

Thompson, the author of an ACA member blog on failure (“Toolkit for Transformation: Allow Yourself to Fail”), instantly regretted her response. She tried to process her mistake through supervision, journaling and emotional freedom techniques (EFT) tapping. The misstep still lingers in her mind, but she hasn’t made a similar mistake again. In fact, recently, when another supervisee said she would like to continue supervision, Thompson laughed and replied, “I would love to have you come back.”

Sometimes a simple regionalism or phrase can lead to a misstep. Because Jude Austin is from southern Louisiana, he says he often uses “man” in his greetings (for example, “Hey, man” or “How’s it going, man?”). Once, a new client who was in gender transition was waiting in the office. Austin walked out and casually said, “Hi, man. Ready to come back?”

Instantly, the client’s face changed. Austin didn’t yet realize what he had done, but he decided to address the tension the second they started their session: “It feels awkward right now. Did I do something to make you feel uncomfortable?”

After discovering his mistake — and that the client preferred they/their pronouns — Austin apologized and explained that “man” was a common phrase where he came from. Even so, he promised not to use the phrase again.

Lesson 4: Be forgiving of your mistakes

Jude Austin had just finished eight hours at a supervision site when he met with a client. It was a beautiful fall day, and the windows in the room were open. The client spoke in a low, soft voice, and before Austin knew it, he had nodded off for a few seconds. When he woke up, the client was crying and saying, “You’re right.”

The client hadn’t noticed that Austin had gone to sleep, so he asked what had most affected her during the past few seconds of the session. The client said, “You sat there listening so quietly.”

Austin was mortified. Even though he hadn’t been caught dozing, he knew he had failed the client because his job was to be present — and he hadn’t been. He sought supervision and realized that he wasn’t taking proper care of himself, including getting enough sleep.

Gladding, who is president of the International Association of Marriage and Family Counselors, also fell asleep once during a session with a client, but his client noticed and was not happy. Gladding apologized and tried to turn the focus back to the client by asking how people in the client’s own life might not be listening to him. (Gladding wrote about this experience in his book Becoming a Counselor: The Light, the Bright and the Serious, published by the American Counseling Association Foundation.)

Those experiences taught Austin and Gladding the importance not only of self-care but also of self-compassion.

Counselors have to be “forgiving of [their] mistakes, forgiving of [their] own thoughts and forgiving of [themselves],” Julius Austin adds.

From Vila’s perspective, self-compassion is the biggest component in whether someone views an event as a success or a failure. Counselors are great at reminding clients to practice self-compassion, but counselors need to apply that same courtesy to themselves, she says. Of course, that is often easier said than done. Vila finds it helpful to externalize her problems or frustrations, asking herself, “If I had a client who came to me with this problem, what would I tell them?”

Lesson 5: Don’t be afraid to be vulnerable

It’s common for beginning counselors to feel like impostors whose mistakes will mark them as unfit for the profession. For this reason, Gladding and Julius Austin both say that counselor educators and supervisors should be vulnerable and share their own missteps.

“As educators, it’s important to share times where we felt uncomfortable, where we failed, where we had a setback or where things didn’t really go that well for us in session,” Austin says. “Being that vulnerable with students can really help [them] understand that it is possible to fail and still create meaningful, powerful relationships with clients.”

Austin also strives for vulnerability with clients by using the inside-out technique, which means sharing whatever he is feeling on the inside with the client. So, if he makes a mistake in session, such as missing a feeling word or not being as attentive as he should be, he directly addresses that as soon as he realizes it. For example, he may say, “I’m feeling like I missed something in your experience, and I feel like we should retrace our steps.”

Jude Austin agrees that the inside-out technique is an effective way for counselors to handle missteps. For instance, he sometimes finds that couple sessions can quickly escalate into an arguing match and leave him feeling overwhelmed. When that happens, he verbalizes his own needs out loud: “I need you to stop talking for a few seconds. I feel lost, and I need 30 seconds to collect myself. And if I feel lost, I can’t imagine how lost you must feel.” This technique can give counselors the break they need to find a productive way to move forward.

“It takes a lot of courage to be vulnerable,” Vila says. Like lots of other counselors, she has had sessions where she later wished she had said or done something differently. When this happens, she is open with clients and says, “I’ve been thinking about what I said in the last session. It’s been bothering me. Has it been bothering you?”

Vila will also be upfront with clients if she is having an off day. For example, if her dog isn’t feeling well or if she is recovering from a head cold, she will apologize in advance if she isn’t 100 percent in session.

Lesson 6: Approach sessions with curiosity

One of the biggest mistakes clinicians can make related to multiculturalism is not approaching differences or even sameness with curiosity, Julius Austin says. He acknowledges that it would be easy for him to assume that an African American male client who is also a former student-athlete would share the exact same experiences as him, but the reality is that everyone’s experiences are unique, regardless of whether two people share certain similarities. “It’s really important to approach each person, each identity, with curiosity and childlike unknowingness and humility,” he says. “To understand somebody’s experience is giving yourself permission as a clinician to learn and be wrong.”

Jude Austin says he wishes he asked two simple questions more often to avoid potential awkward moments or miscommunications in session: “What’s your experience with me right now when you sit down and look at me?” and “Think about who you are as a person — your background, sexual orientation, race/ethnicity, etc. What’s something you want me to know about you so that I can build a better relationship with you?”

Lesson 7: Adopt positive habits

It’s easy for counselors to beat themselves up mentally for making mistakes, but they can adopt healthy habits to counter these missteps. Gladding often uses thought-stopping techniques such as focusing on the negative thought for a few minutes and then saying “Stop” quietly in his mind. Sometimes he will change the scenery (e.g., go outside) or exercise (e.g., go swimming) to help clear his mind. Gladding jokes that he should have gone for a walk with his client the day he fell asleep in session.

Ultimately, failure is about how a person internalizes an event, Thompson notes. If the person considers themselves (rather than the activity or technique) to be a failure, then they have to address their negative self-talk, she says. To help her monitor and manage her negative self-talk, Thompson started a morning routine in which she texts a friend about something she is grateful for — such as a beautiful day or the fact that her dog didn’t bark and wake her up that morning.

Vila also focuses on the positives by keeping a “one good thing about today” message board (a practice she adopted from a psychiatric hospital where she once worked). This involves writing down one positive thing that has happened to her that day. Sometimes it’s as simple as “a client thanked me” or “there wasn’t any traffic on my way to work,” and other times it’s something more notable, such as “I got a promotion.”

Vila says it may be difficult at first for counselors to find something positive to say about a bad day. In fact, she admits that on certain days, the only good thing may be that the day is over. “But as you start to look for more positives, you’re eventually going to have a hard time picking one thing to put on the board. You’re retraining [and] rewiring your brain to look more for the positive and to filter out and not focus on the negative as much,” she explains.

If counselors find things are not going well in session, Gladding advises them to take a few minutes to collect themselves before proceeding. They could excuse themselves from the session and quickly talk to a supervisor or colleague, or they could simply take a deep breath and look at their notes to gain fresh perspective and identify new insights, he says.

Lesson 8: Take risks

Counselors may avoid taking risks out of a fear of making mistakes or failing, and often for good reason. In 2001, Thompson, who offers training in supervision as well as complementary and integrative therapies to professional counselors, left a good job to start her own private practice. Shortly after taking this career risk, she went through a separation and divorce. She admits that during this time, she could have felt like a failure (and in some ways she did), but she decided to focus on how she could use the experience to learn and grow. So, while slowly building up her practice, she devoted an hour a day to learning a new counseling technique — EFT tapping — which is now the main counseling approach that she uses in her practice.

A few years later, Thompson suffered another loss when a miscommunication caused her to lose a close friend. But again, she ultimately turned the situation into an opportunity. While using counseling tools to cope with her loss, she realized she had collected and learned a stockpile of such tools throughout her career. She decided to write them all down. Within a few days, she had compiled a list of 75-80 tools and descriptions. The list eventually evolved into a deck of cards, dubbed the Toolkit for Transformation, that provides other counselors with practical tools and strategies for helping clients and themselves when they experience setbacks.

Missteps in session can also become information that assists counselors in better understanding how to help their clients. Thompson once forgot she had reduced a fee for one of her clients, so she accidentally overcharged the client for a month. The client caught the error and mentioned it awkwardly in her next session with Thompson. The client’s worried face instantly changed to relief when Thompson apologized and said she would deduct the overpaid amount from that session. This information prompted Thompson to ask about money in the client’s life, and she discovered that the client had money issues that had not been brought up before in session.

“Our biggest struggles are also our greatest opportunities for learning and growth. Those biggest struggles — especially when they’re bringing us to our knees — also bring our life lessons,” Thompson says. “We really don’t learn when we are in our comfort zone.”

Lesson 9: Become friends with failure

Making mistakes over the course of a counseling career is — in one word — inevitable. “You fail almost every five minutes as a therapist in session. There’s always some small failure,” Jude Austin says.

Counselors will not always say the right thing or be “perfect” in every session. As Gladding notes, perfection is not a human quality, so counselors will most assuredly make mistakes. The important part, he says, is that they learn from these mistakes. In fact, Gladding points out that self-doubt can be a strength in counseling because it helps counselors reflect more deeply on their role and be more attuned with clients who are vulnerable and having a difficult time.

Austin’s misstep with the client in an abusive relationship stuck with him and ultimately forced him to contemplate his identity and purpose as a counselor. “One way to handle failure is to figure out what you’re doing,” he says. The experience taught him that he wasn’t there to “save” clients but rather to help guide them through difficult situations and give them tools to help them help themselves.

The experience (and other missteps that have followed since) also taught him that he can’t avoid failure. “Failure is a part of our experience,” he says. “You have to build a relationship with failure. Make it your best friend [as a supervisor once told him]. Get to know what it feels like. Get to know how it affects your family and relationships … because the more awareness you have of your failures and who you are when you fail and how you react when you fail, the more freedom it gives you” to be more genuine with your clients about those failures.

Like any relationship, therapy will feature its fair share of missteps and miscommunications, and that can leave counselors feeling like failures. But, remember, you are not alone in this feeling. By adopting a growth mindset, you can learn from your mistakes and continue growing as a counselor.

So, go ahead and fail. You never know what you’ll learn from it.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.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.