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Counselors Audience

Tapping into the benefits of EMDR

By Lindsey Phillips September 27, 2021

Andie Bernard, a licensed professional clinical counselor at Rootworks Wellness in Cincinnati, was working with children and families in marginalized communities who had experienced complex trauma, but she didn’t get the sense she was truly helping them get better through the use of play and talk therapies.

“As I was treating these children and their families, I just couldn’t get to the root of what was really needed to make lasting gains. Their bodies were calm with me in session when they could be, but they were activated everywhere else,” she recalls. “I needed something more powerful beyond talk and play. I needed something that could help to reshape their worldview [and] their belief about themselves.”

This led Bernard to eye movement desensitization and reprocessing (EMDR) therapy. After using the therapy, she finally started seeing improvements with these clients. 

EMDR was developed in the late 1980s when Francine Shapiro discovered a connection between eye movement and a decrease in the negative emotions associated with her own upsetting memories. More than 30 years after EMDR was first introduced, it has not only proved to be effective but has also been recognized by the World Health Organization, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense as a primary treatment for posttraumatic stress disorder (PTSD). 

EMDR pulls directly from many evidence-based therapeutic approaches such as psychoanalysis, cognitive behavior therapy and somatic therapy, notes Bernard, a member of the American Counseling Association. Like psychoanalysis, EMDR therapy explores clients’ past, present and future, but its aim is to help clients realize that what happened to them in the past is not happening now. The cornerstone of EMDR, Bernard explains, is the adaptive information processing model, which asserts that humans will move themselves toward healing once they have all necessary information and can see it adaptively. 

Our body’s ability to naturally heal itself from a cut is similar to how we heal emotionally, Bernard points out. “But if we are unconsciously locked in unsafe experiences that still feel true, the body cannot get to that natural healing,” she says. “EMDR moves the past into the now in partnership with the therapist so the client can see what’s in front of them and assess threat from today.” 

Bernard, an EMDR-certified therapist and a consultant-in-training with the EMDR International Association (EMDRIA), finds that clients often come to counseling with a myopic view of their problems. EMDR therapy helps them widen that lens and move toward healing.

How EMDR differs from other approaches

The first three phases of EMDR (history and treatment planning, preparation and assessment) are similar to other counseling approaches because they focus on understanding the client’s full history, building a strong therapeutic relationship, creating safety, and cultivating coping skills that are centered on the mind and body. Phase 4, desensitization, is where EMDR shifts toward a neurobiological approach by helping the client change the way the brain and body associate the trauma with its trigger, Bernard explains. Rather than directing the client to simply share their narrative verbally (as might be done with trauma-focused cognitive behavior therapy), an EMDR therapist will have the client focus on a targeted traumatic memory while they undergo bilateral stimulation such as eye movements. This process speeds up the client’s ability to integrate the material into an adaptive neural pathway, she says, and removes the emotional charge and associated behaviors in everyday life. 

This hints at one major way that EMDR differs from many traditional counseling approaches: It doesn’t require much talking, at least during the desensitization phase. (See sidebar below for an overview of the eight phases of EMDR therapy.) Addie Brown, a licensed professional counselor (LPC) in Virginia and a licensed marriage and family therapist in California, acknowledges that at first it was challenging for her to resist the urge to reflect and validate her clients’ thoughts and feelings. She had to retrain herself to follow the EMDR protocol and respond only with simple phrases such as “go with that” when a client mentioned a new feeling or memory.  

Brown says this aspect of EMDR can be freeing for clients who prefer not to share details about their traumatic experience. “Some clients like the fact that they don’t have to talk a lot, they don’t have to give a lot of details, because there are things that are so shameful for them that they don’t want to talk about. [Talking about those things] can be more traumatizing. They’re still doing the work [with EMDR] … but they’re not having to tell that story over and over again,” notes Brown, an EMDR-certified therapist with a private practice, Harbor Site Counseling, in Woodbridge, Virginia.

Carla Parola, an LPC in private practice at Seven Centers Counseling in Phoenix, once worked with a client who was hesitant to share his history of being sexually abused as a child. She explained to the client that he didn’t need to disclose many details of his abuse while doing EMDR therapy and that he didn’t have to talk about the abuse until he was ready. If he decided to work on a trauma memory, he had to share only the image that represented the worst part of the traumatic experience as well as the emotions, negative cognition and body sensation associated with the image. For example, the client could select the image of “being alone in the closet,” without having to disclose what happened in the closet or the events leading up to it, says Parola, an EMDRIA-approved consultant and humanitarian assistance program facilitator. This explanation eased the client’s concerns, and he agreed to continue with treatment. 

EMDR’s use of bilateral stimulation can be powerful, but some clients are naturally verbal and are accustomed to sharing more details than are required when using EMDR therapy. Clinicians in EMDR training often tell Bernard that they struggle to help some clients effectively target and reprocess certain traumatic memories because these clients seem to want only to talk about their feelings and feel supported by the clinician. 

But there is room for clients to talk and process when doing EMDR therapy, Bernard says. In her sessions, she stays relationally attuned and listens to the client for the first 10-15 minutes. While connecting with her clients, she looks for themes that relate to their already-targeted negative memories and associated self-beliefs. For example, if a client comes in talking about how she was arguing with her husband because he was busy with work and was distant at home, Bernard may say, “I’m wondering if your feelings with your husband this week relate to not feeling important to your mom when you were growing up. Does that feel like it fits?” If the client agrees, Bernard steers the content back to reprocessing the client’s past targeted memories and belief that she is not important. This allows the client to begin seeing how the self-belief she developed in childhood is shaping her thoughts, feelings and reactions in her current relationships. “This is the power of EMDR. We are not asking clients to cope with their symptoms; we are helping them know how they developed them,” Bernard says. 

Unlike other counseling approaches that help clients make a state change (moving from an anxious state to a calm state, for example), EMDR therapy helps clients make trait changes, Bernard says. As she explains, a state change approaches the problem through the brain’s frontal cortex and helps clients learn coping strategies to deal with their symptoms, whereas a trait change involves looking at what is underneath the state by using historical memories, the nervous system and the limbic part of the brain. Integrating new insights and beliefs through bilateral stimulation creates a trait change that helps clients form more adaptive viewpoints and appropriate responses to difficult triggers. 

Bernard uses an analogy to highlight the difference between state changes and trait changes. Whereas a state change requires clients to change lanes (moving from an anxious road to a calm road), a trait change requires building a new highway in the brain that reshapes how clients view their world and themselves in it. 

“If [clients are] interested only in state change and just want to talk through their symptoms to learn ways to cope … that can be accomplished with phase 2 of EMDR. But if [they] want to clearly believe, see and know that the threat has changed regarding that trigger and make a true trait change,” then that involves the latter phases of the EMDR protocol, she says.

When to use (and not use) EMDR 

G. Michael Russo, a visiting assistant professor of counselor education and addiction program coordinator at Boise State University, specializes in integrating neuroscience into counseling practice. He took part in a meta-analysis led by Richard Balkin and A. Stephen Lenz, consisting of research studies from 1987 to 2018, to determine the overall efficacy of EMDR for reducing symptoms of overarousal. They found that EMDR can be an effective treatment for anxiety and trauma, but the results showed varying levels of efficacy — with some reporting high levels of efficacy and others indicating that it may be better to go with a different intervention. 

“None of the articles that were included in the study utilized neuroscience measures. Sowe are unable to explore claims regarding neurological changes resulting from EMDR,” says Russo, an LPC in Idaho. “Some might even say that neurological changes resulting from the EMDR processes are unfounded. However, what we can say is that there very well could be an alternative explanation for client growth in EMDR sessions that does not relate to the eye movement, tactile or auditory stimulation. It is possible that the relationship itself is the agent of change.” Russo presented the findings from the meta-analysis, which has been accepted for publication in the Journal of Counseling & Development, during ACA’s Virtual Conference Experience this past spring.

The bottom line, Russo says, is that despite the potential effectiveness of EMDR, counselors should remain critical consumers when using it with clients. They should ask themselves: When does EMDR work? When doesn’t it work? Who is represented in the research? Is this the best approach for this client? 

According to the VA, other recent meta-analyses suggest that EMDR produces moderate to strong treatment effects for PTSD symptom reduction, depression symptom reduction and loss of PTSD diagnosis. 

“EMDR is not exclusive to trauma or PTSD. It can be applied across the board,” Brown asserts. “There’s so many experiences we have that leave an emotional impact on us, and that really is why EMDR can be helpful, because it’s addressing the emotional impacts we’ve experienced.” Those impacts might include trauma as well as grief, job loss, eating disorders or relationship issues. If a client is having a strong emotional response to an event, or if a negative feeling or memory lingers and the clients wonders why they still feel this way, then EMDR can be a good approach to use, she says. 

Still, Brown acknowledges that EMDR may not be for everyone, so she assesses when and if she wants to use the therapy with her clients. She also explains the process to clients to determine if they are ready to begin the treatment.

Brown finds three main barriers that might prevent EMDR therapy from working with some clients. First, a client may be too emotionally detached. This often happens when family members or friends encourage a person to seek counseling, but the person doesn’t really believe that they need to be there, she says. 

Second, clients may not be ready to completely release their emotions related to an event. Brown advises counselors to use phase 2 of EMDR therapy to explore any potential barriers that would prevent the client from fully processing their feelings. 

Third, an internal conflict could hinder the client’s progress. If a client is working on an issue that conflicts with their value system, they may have to work on that conflict in a different way before attempting to use EMDR, Brown says. For example, a client may not want to completely reprocess and heal from their grief because they would feel guilty about “letting go” of their pain. 

Brown once worked with a client who sought counseling because she was struggling after the death of her son. When Brown asked about her son, the client started sobbing as if he had died the day before and the loss was still very raw; in fact, it had been 10 years since her son had passed away. After a few sessions of EMDR with Brown, the client had lowered her distress level only modestly, from a 10 (high level of distress) to a 6 (moderate level of distress). Despite still being in a great deal of pain, the client was satisfied with that progress, Brown recalls, because she didn’t want to feel better than that. 

Because EMDR therapists are excited about the potential impact this therapy can have, they may be tempted to use it with every client they encounter, Brown says, but that isn’t an ethical practice. She reminds counselors to stay within their scope of competency. Someone recently came to see Brown because they wanted to use EMDR therapy to help them with obsessive-compulsive disorder (OCD). Even though Brown is trained in EMDR and EMDR is a good intervention for treating OCD, she referred the person to another clinician because Brown did not feel competent working with that particular disorder. 

“Just because you’re trained in a really great intervention that can be used for so many different issues doesn’t mean that you, as a clinician, have to use it for all of those issues if you don’t have the clinical competency to address those issues,” she says.

Case example with complex trauma

Larisa Lomaeva/Shutterstock.com

Bernard offered to provide a case example (based on a composite of her clients) to illustrate how to apply the EMDR protocol with a client experiencing complex trauma. The client is a woman in her 30s who experienced significant abuse and relational neglect in her family beginning at birth. The client is functional in her everyday life, but she struggles to let go of the shame and feelings of responsibility for what happened to her. “Kids are hardwired to believe that traumatic things that happen to them are their fault, and she was no exception,” Bernard notes. For many years, the client coped with the trauma by dissociating her mind and body from her past experiences. She had gone to counseling on and off throughout her life, but this was largely unsuccessful because she was stuck in the childhood belief loop that her past traumas were her fault.

During phase 1 of EMDR, Bernard gets to know the client and her history. EMDR allows counselors to be creative when taking a full history, she notes. Bernard asks the client to mark on a chronological timeline (from ages 1 to 38) any significant events that have affected her or contributed to her symptoms and how she sees herself today. This includes both positive and negative experiences. Bernard sets a three-minute timer, and the client marks these events in grounded silence. 

When the client finishes, Bernard looks for any marks that are more pronounced than the rest — those with a thicker line or a circle around them, for example. She notices one mark is larger, and she asks the client to tell her about that event. The client says, “This is when I met my one and only true friend.” Bernard writes this down at the top of the timeline. 

Bernard continues to discuss these experiences with the client, marking positive events on the top and negative events on the bottom of the timeline. Clients are often stuck in seeing only the negative, Bernard explains, so marking the timeline in this way helps show clients the duality of their experiences (i.e., some are hard, while others are good or OK). 

Highlighting these positive experiences is also the first step toward building the client’s resources, which occurs during phase 2 of EMDR. This phase is crucial for this client because initial sessions reveal that she has limited resources for assessing her own relational and physical safety, which often leaves her hypervigilant, anxious and overwhelmed in everyday life. 

Bernard asks the client how she feels about the memory of making that one true friend. The client replies that she doesn’t have any feelings about it, which becomes a theme indicating to Bernard that the client is experiencing some levels of disassociation. 

After three months of working on creating a sense of safety, developing a strong therapeutic alliance and cultivating coping skills, Bernard determines that the client still does not have sufficient resources to target distressing memories in the latter phases of EMDR, so she decides to use EMDR to increase access to stabilizing resources with the client. This allows them to tackle the issue through a strengths-based approach by targeting positive (rather than negative) memories and beliefs.

“EMDR is an artful, flexible and powerful approach to meet any client where they are in their healing journey,” Bernard says. “We can use the bilateral stimulation to reprocess past traumas or to help them see their strengths and resilience in the present, in spite of the trauma. So many clinical choices are possible for EMDR clinicians who understand the robustness of the protocol and can apply it creatively to the therapy.”

Next, Bernard writes down a list of positive things the client is responsible for, such as surviving her past abuse, graduating from college, and being a good teacher and parent. She asks the client, “Are you responsible for all this?” Then she uses bilateral stimulation to grow these positive neural pathways in the client’s brain. This allows the client to focus on the present positive experiences instead of the negative feedback loop that stems from her past abuse. 

“While I’m building resources, I’m also teaching past versus present orientation to this client,” Bernard explains, “so, later, when we’re doing the hard traumatic reprocessing, I can say, ‘See those experiences back there? That is over; you made it through.’” This is a powerful aspect of EMDR therapy, she asserts, because it allows the client’s mind and body to begin to know that the past traumas are over and they are safe.

A few months later, the client is ready to target the traumatic memories, including the thoughts, sensations and self-beliefs developed from those experiences. The self-beliefs formed by her early trauma are such foundational elements of her present self-concept that she and Bernard must target them one at a time. After working on reprocessing the memory to understand it (using bilateral stimulation), they integrate the new insight into the body to create new meaning. This process is repeated for every traumatic memory target, which ultimately allows the client to revise the thought that she is responsible for what happened to her as a child. 

After reprocessing the traumatic memories for several months, the client no longer feels responsible for the past abuse that happened to her. The client now sees her abusers as a row of dominoes and realizes that she no longer belongs in the same line with them.  

“This shift could not have been achieved without the use of EMDR’s full protocol of using bilateral stimulation in conjunction with holding the traumatic memories, images and bodily sensations; processing the emotions; and redefining what the experience has come to mean to [the client] from a vantage point of safety and recognition that it is in the past,” Bernard notes.

Now, the client possesses a healthier sense of self and stronger boundaries, works in a career she loves, and feels safe in her own mind and body again. 

Be fluid, not rigid

As an EMDR coach, Bernard has seen several competent therapists doubt themselves when undergoing EMDR training, which involves five intense days of learning new terms and concepts. She recently wrote a blog post, “Five things every newly trained EMDR therapist wished they knew,” to address these issues. In it, she reminds practitioners that they don’t have to be competent when starting out. Instead, she recommends that they remain curious and practice with other EMDR-trained therapists in consultation to grow their confidence. 

“EMDR is a protocol and a process to learn, but it’s an art when delivered,” Bernard says. If counselors are too rigid or more cognitive-oriented, then they may struggle with EMDR, she notes, and they may not be able to create a sense of coregulation with the client. 

“The protocol feels linear, but it’s not always the case,” Bernard emphasizes. Counselors should move through the EMDR phases as needed in attunement with their clients. If they try to stay too on script or are overly focused on what phase they are in, then the approach will feel rigid and affect the energy in the room, she points out. In addition, they may not be attuned to what the client just said or what the client needs. 

Most counselors are well-intentioned and want to get it “right,” Bernard acknowledges, which is why having colleagues and consultants to support them while learning and remind them to trust their clinical instinct is so important. She always advises her trainees to practice EMDR with fluidity rather than rigidity. 

Counselors can be faithful “and have efficacy to the treatment model while also being creative and flexible,” she says. “In the beginning as a new EMDR therapist, is it going to go slower? Yes. Is it going to be more impactful and profound and life-changing for you and the client than many other clinical approaches? Yes.”

Don’t rush the process 

People often assume that phase 4 — the desensitization or bilateral stimulation component — is EMDR, but that is wrong, Bernard says. If counselors jump too quickly to desensitization, then clients can get overactivated. “When we take people to intense feeling states without paying close attention to their window of tolerance, they can’t stay present in their body, and if they can’t stay in their body, we’re not healing them. We’re retriggering them,” she explains. 

She advises counselors to slow down and not to overlook or rush phase 2. This phase helps prepare clients to handle the intense emotions that may come up during latter phases of EMDR by using containment skills such as a mind-body shift, deep breathing, safety cueing, mindfulness and grounding. 

“When working with clients with complex trauma or highly activated ones with anxiety, depression or dissociation, you’re going to spend important time creating safety, strengthening the therapeutic alliance and building regulation skills to use to bring them affectively down when in later reprocessing phases of EMDR,” Bernard says. 

She assesses a client’s sense of safety the moment they walk into her office, asking them what makes them feel safe about the room. If a client responds by saying, “I know where the front door is,” then she knows their sense of safety is low and that she will need to strengthen it to prepare them for EMDR. If, on the other hand, the client responds, “I like the colors in your office and your plants,” then she knows the client possesses a higher degree of safety to leverage during the reprocessing phases.  

Parola has found some clients are hesitant to proceed with EMDR therapy because they worry the dual-attention stimuli (or bilateral stimulation) involves hypnosis or that they will not be in control of their emotions or body. So, she introduces them to the concept of dual-attention stimuli by doing a slower and shorter version of it when they are establishing the client’s safe place in phase 2. The client picks a place that makes them feel safe. Then she tells them to think about an image that represents this place and asks, “What emotions are you feeling? What sensations are you having?” If the client is having a positive reaction, she incorporates short, slow dual-attention stimuli to reinforce this resource. This helps the client prepare to use a faster and longer version of dual-attention stimuli later when they are reprocessing memories that are more traumatic, she says. 

Brown notes that some clients say they are ready to begin processing their traumatic memories but then hit an emotional wall during the latter phases. For example, someone who was constantly told by their parents as a child not to cry may protect themselves by learning how to stop themselves from crying. If they don’t address this barrier before moving to the desensitization phase, then this protective strategy may prevent them from fully feeling that emotion during treatment, Brown explains. For that reason, she started incorporating the internal family systems model (which views the mind as made up of subpersonalities or “parts,” each with its own unique viewpoint) during phase 2 of EMDR to ensure that, together, they explore all parts of the client and address any barriers that could interfere with healing. 

“Phase 2 is life-changing but is often overlooked by many EMDR therapists,” Bernard stresses. “If we have limited time with a client for reasons outside of our control and are only able to help them develop accessible feelings of safety and much-needed cognitive and somatic regulation resources, we have still changed their lives in powerful ways, even without the trauma reprocessing.” 

Adapting to the client’s needs  

EMDR therapy continues to evolve and now has specialized approaches that address the needs of certain populations or mental health issues. For example, the desensitizing triggers and urge reprocessing (DeTUR) protocol was developed by AJ Popky to treat addiction; this approach helps clients target their desire to use drugs or alcohol while also addressing underlying traumas. 

Parola, who is EMDR sand tray certified, sometimes incorporates sand tray techniques throughout the eight phases of EMDR therapy. For example, she may have a child use the figurines in the sand tray to represent a safe place while she engages the child in bilateral stimulation by slowly moving a paintbrush back and forth across the child’s hand. 

Counselors can also make modifications to the eight-phase protocol. Bernard’s case example illustrates one adaption of tailoring the protocol toward installing resourcing and adaptive self-beliefs, rather than processing trauma, because the client’s internal resources were so low initially. 

Bilateral stimulation is another way counselors can adjust the protocol to fit clients’ individual needs. Eye movements are the most commonly used and well-researched form of bilateral stimulation, but clinicians can also use tapping, tactile stimulation or auditory tones. Bernard finds using tappers for bilateral stimulation helpful for people with attention-deficit/hyperactivity disorder or who are highly distractable because it allows them to close their eyes and tune in to their body. For clients who dissociate or those who have difficulty managing their emotions, she often uses a light bar (a bar containing LED lights that move back and forth) or finger movements because the proximity allows her to notice changes in clients’ eyes as they track the movement. 

Brown discovered that several of her clients didn’t want to use the light bar for bilateral stimulation and didn’t want her sitting in front of them during the reprocessing phases. So, she adjusted to better meet their needs. She often sits off to the side where she can still observe them from a safe distance, and she allows clients to use different types of bilateral stimulation. Most of her clients prefer holding pulsers that vibrate, but she has one client who chooses to simply tap on the side of their leg. 

Research continues to shed new light on ways EMDR can be used to help clients who are struggling with trauma and other mental health issues. Two recent articles in EMDRIA’s Go With That magazine discuss how EMDR can be used to address racialized trauma and addiction.

Bernard notes there is promising research highlighting that just taxing working memory (and not necessarily with bilateral stimulation) shows signs of decreasing the emotional charge around traumatic memories. 

Bernard appreciates that Shapiro’s theory has given her an eight-phase protocol that allows her to be with her clients in extraordinarily profound ways: “Any therapy that sees the person as a whole — brain, body and mind — that asserts it’s not about what’s wrong with you but what happened to you, that teaches what happened to you then is over and we’re here now, and that says the information your body is sending to you is an important part of your own healing … is a gift to the therapeutic community at large.”

 

1) History and treatment planning (discuss the client’s history, develop a treatment plan, assess the client’s internal and external resources)

2) Preparation (build a therapeutic alliance, explain EMDR, set expectations, build the client’s coping strategies)

3) Assessment (identify the event to reprocess, establish a baseline with the Subjective Units of Distress (SUD) and Validity of Cognition measures)

4) Desensitization (use bilateral stimulation while the client thinks about the traumatic event with the goal of reducing the client’s SUD to zero)

5) Installation (strengthen a positive belief that the client wants to associate with the target experience until it feels completely true)

6) Body scan (ask the client to think about the target event and positive belief while scanning the body from head to toe, process any lingering disturbances with bilateral stimulation)

7) Closure (help the client return to a calm state)

8) Reevaluation (discuss recently processed memories at the beginning of a new session to ensure the client’s distress is still low and positive cognition is strong, determine future targets and directions for continued treatment)

(Information adapted from EMDRIA)

 

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@counseling.org.

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

Assessment, diagnosis and treatment planning: A map for the journey ahead

By Bethany Bray September 22, 2021

Clients impart so much about themselves, verbally and nonverbally, in counseling sessions that it will overwhelm clinicians who don’t organize the information and use it to create a structured plan for their work together, contends Nathaniel N. Ivers, associate professor and chair of the Department of Counseling at Wake Forest University.

Fully understanding a client’s situation, symptoms and needs and then matching them with a diagnosis (when appropriate) and a treatment plan that will help them heal, grow and thrive are core aspects of professional counseling. Counselors learn these skills, at least conceptually, in graduate school but gain true understanding of them through their direct work with clients. 

Practically applying that knowledge is “where the rubber hits the road,” says Ivers, a member of the American Counseling Association. Examining a client’s concerns in depth — moving beyond surface-level questions such as “How did this week go?” or “What do you want to talk about?” — is the most integrative and effective way to devise a rich treatment plan and pinpoint a destination that the client and practitioner will work toward together in therapy.

Ivers acknowledges that counselors who are busy with full caseloads may be resistant to the idea of dedicating time to create a comprehensive, integrative plan for each client. But as he tells his students: The more you do it, the easier it will get.

“Eventually, you won’t have to write out a full, multipoint case conceptualization plan for every client,” says Ivers, a licensed professional counselor in Texas and a licensed clinical mental health counselor in North Carolina. “But when you eventually have … trouble figuring out [a case], that’s when you need to fall back on it — put pen to paper and conceptualize a full plan.”

When teaching these concepts to students, Ivers often shares a quote from psychologist Donald Meichenbaum, professor emeritus at the University of Waterloo in Canada and one of the founders of cognitive behavior therapy: “A clinician without a case conceptional model is like a captain of a ship without a rudder, aimlessly floating about with little or no direction.”

An important responsibility

The three components of assessment, diagnosis and treatment planning are intrinsically linked and provide a “map” for counselors to offer evidence-based treatment that best fits the client, says Shannon Karl, an ACA member who is a professor and field-based clinical coordinator in the Department of Counseling at Nova Southeastern University in Florida. Not only is the process vital to establishing a foundation for counseling work with a client, but it also creates a pathway for the individual to access appropriate treatment services from counselors and interdisciplinary professionals.

Assessment, diagnosis and treatment planning are important responsibilities, and mastery of these skills is often closely tied to clinician confidence, Karl says, so it’s understandable that new professionals may worry if they are getting things right. She urges counselors who feel this way to remember that their mentors are there to advise and support them. Similarly, counselor education and supervision programs are meant to help trainees through this learning curve, she says.

Even so, both novice and experienced counselors should seek continuing education, peer consultation and mentorship in these areas throughout their careers, stresses Karl, co-author of the ACA-published book DSM-5 Learning Companion for Counselors. It is imperative for counselors to keep these skills sharp and up to date, not only because they are integral parts of the counseling process but also because diagnoses and related criteria are constantly changing and evolving.

Karl was on an ACA task force formed to study the updates and changes introduced in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) in 2013. She was dismayed, she says, to see how long it took many counseling practices to update their procedures to reflect the changes made between the fourth and fifth editions of the DSM.

Karl urges clinicians to stay informed and up to date by attending workshops, conferences and other continuing education events; consulting regularly with professional peers; seeking mentorship or supervision; joining professional Listservs; and reading counseling journals and other publications. Remaining active with state and local counseling organizations will also help practitioners stay abreast of criteria and processes that vary state to state, she notes. Leadership within the counseling profession must ensure that funding for continuing education on assessment, diagnosis and treatment planning is prioritized, especially for counselors in economically disadvantaged or rural areas and settings where practices or clinics are short-staffed, Karl adds.

“One thing we can do at all levels is make sure that clinicians have access to free or reduced-cost continuing education, workshops and seminars. Accessibility is important,” says Karl, a licensed mental health counselor whose area of focus is childhood trauma and DSM-5 disorders. “It’s important for professional counselors, regardless of work setting, to be able to best serve their clients, and one way to do that is to be active in learning regarding assessment, diagnosis and best treatment planning. We can’t help others heal in isolation.”

Danica Hays, author of the ACA-published book Assessment in Counseling: Procedures and Practices, notes that counseling graduate students often take only one class each on assessment and diagnosis. Continuing education, in addition to competency gained through experience, is needed to round out counselors’ knowledge, she says.

“With the amount of material to cover, [counselor graduate education] lessons are often distilled to case conceptualization and treatment planning as simply following a recipe,” says Hays, a professor and dean of the College of Education at the University of Nevada, Las Vegas. Gaining comprehensive knowledge that includes “other ways of knowing — often from scholars and practitioners of color — can be incredibly helpful to ensure clients are not harmed by an incomplete and/or distorted story told on their behalf,” she adds.

Client driven

Tracie Keller, a licensed professional clinical counselor and supervisor in Ohio, has found that teaming directly with the client to identify goals and build a treatment plan strengthens the level of trust and rapport between clinician and client, which in turn improves treatment outcomes. She chooses to highlight this collaborative approach on the website for her group practice in Columbus, Ohio, by including the following statement: “We believe that treatment planning is a process that both the therapist and the client determine together.” 

Keller tries to think about the process from the client’s perspective. She notes that if she went to a medical doctor and the doctor prescribed a treatment plan and medication without bothering to tell her that she had the flu, she’d question what was going on and whether the doctor valued her input.

Keller, who specializes in treating clients with eating disorders and trauma-related concerns, says a prescriptive approach has never really worked for her. “[Clients know] themselves the best,” she says. “For me, it [collaborative treatment planning] is something that helps build a lot of trust. It’s not just prescribing ‘this is what I want you to do,’ but instead walking alongside [clients] to execute the goals they want. … If the client doesn’t buy in, [counseling] won’t be successful.”

Hays notes that involving clients in case conceptualization and treatment planning also allows for better cultural understanding and responsiveness. Counselors have a significant responsibility to get a client’s story right, she says, and “getting the story right involves co-constructing it with the client in a way that honors their cultural experiences as well as points of trauma and resilience.”

“Really good assessment is committing to gather a client’s story with that client, engaging in basic helping skills to affirm what the client is sharing as they share it, incorporating multiple qualitative and quantitative tools in the process, and proposing and evaluating treatment approaches with the client,” Hays asserts. “Thus, assessment may not involve many questions but [rather] more space within sessions for the client to share their stories, with the power and voice to confirm or disconfirm an evolving conceptualization of those stories.”

When Keller begins working with a new client, she listens carefully as they talk through their history and symptoms. Possible diagnoses and issues to work on in counseling often become apparent to Keller as she listens, but she stores those ideas away for the time being. Instead, she prompts the client to think of treatment goals, asking questions such as “If you could change anything in your life through our work together, what would that be?” or “What would you want to be different in your life after our relationship concludes?”

Clients presenting with symptoms of an eating disorder might respond with statements such as “I don’t want to fight my body anymore” or “I’m sick of hating my body,” Keller says. In this example, Keller and the client might work together to create a goal of improving the client’s body image in counseling. Later, once the client has made some progress on that goal and established a stronger therapeutic relationship with Keller, she will circle back to some of the issues that revealed themselves in the initial assessment session and try to tie those issues into the client’s treatment goals. If the client mentioned purging behavior or restrictive eating in the initial session, for example, Keller might gently raise the idea that this behavior could be something to work on as part of reaching the client’s goal of obtaining a healthy body image.

Because Keller accepts insurance at her practice, she diagnoses all of her clients to submit for reimbursement. Keller lets each client know that she will share their diagnosis with their insurance company, and she dedicates time to explaining the diagnosis to the client and how she arrived at that decision. Depending on the client, she sometimes takes out her copy of the DSM-5 in session and looks through the diagnosis criteria with them.

“I talk about it from the start because they’re in a very vulnerable space [at intake], and it’s important to be really transparent about what their diagnosis is and what it means,” Keller says. She never moves forward with a treatment plan or diagnosis unless a client agrees to it.

After talking through the diagnosis with the client, she explains the methods and tools she uses (such as cognitive behavior therapy or eye movement desensitization and reprocessing) to treat that particular diagnosis and how she will tailor her approach to help the client meet the treatment goals they have identified.

A large portion of the initial goal-setting and therapeutic work with clients is frequently focused on reducing symptoms, Keller notes. As treatment progresses, she works with clients to shift or change treatment goals to move beyond symptom management and to focus on the issues that lie beneath their original presenting concern.

For example, a client with chronic depression might first identify goals that involve improving their mood and alleviating their symptoms. Later, as their symptoms lessen and the client is feeling better, they could be ready to focus on past trauma or relationship issues that they didn’t have the bandwidth to tackle earlier, Keller says. 

She finds this process often happens organically; the “win” of seeing symptoms lessen often motivates clients to identify additional goals. “It’s cool because you have a lot of trust and past success in therapy [at that point] to go off of, and the client often wants to dig deeper and make greater changes,” Keller says.

Client treatment plans need to evolve and stay flexible because clients’ needs will change throughout therapy. Keller notes that it is common for individuals with eating disorders to experience periods when their symptoms worsen, sometimes to the point of needing hospitalization or inpatient care. Whenever this happens, Keller works with the client to shift their treatment plan and identify different goals for the near future, and then they repeat the process after the client has been discharged or their situation has otherwise improved.

Assessment shouldn’t be limited to the initial and concluding sessions with a client. As Keller points out, an important part of this process is being attuned to a client’s needs and blending assessment work into each session. She says that she continually listens for short- and long-term treatment goals.

“As you go on through treatment, you’re getting information [from the client] with each session,” Keller says. “As you walk with them, you’re learning more and more: how they relate to you, how they relate to other people. You can’t ignore that information. It will guide you. I’m constantly assessing and holding that information.”

Keller acknowledges that her understanding of the treatment planning process has expanded over time. “Now it’s a process that is pulled up in my mind during every single session — not just at intake and conclusion,” she says. “Even if I don’t verbalize it with the client, I’m thinking of every conversation through the lens of their goals. It becomes an unspoken but ever-so-present aspect of the work, and it moves it along.”

Diagnosis: A love-hate relationship

Many professional counselors have mixed feelings about diagnosis. On one hand, it can be a tool that connects clients with the mental health care they need. On the other hand, it can be viewed (both by clinicians and clients) as a “label” that follows clients throughout treatment and, in some cases, life.

Keller says she understands both sides; however, she values diagnosis and finds it useful. Diagnosis is a tool that allows her to understand how she can initially help her clients, and it guides her interventions and therapeutic approach as treatment progresses. It can also remove financial barriers to mental health care. Counseling can be expensive, and insurance companies typically require a diagnosis for reimbursement. So, Keller views diagnosis as a way of providing treatment access for clients who wouldn’t be able to afford counseling without insurance coverage. 

The key, Keller says, is to be fully transparent with clients and include them in the diagnostic process, especially for diagnoses that can carry a stigma, such as personality disorders, substance use disorders and eating disorders. In some cases, counselors may need to offer psychoeducation to dispel inaccuracies or stereotypes about a diagnosis.

“I can have a love-hate relationship with it [diagnosis] at times,” Keller admits. “It can have a stigma and the burden of sharing it with insurance. … Oftentimes in therapy, we end up having to process and unpack a lot, [including] what they [clients] have heard and experienced in carrying that diagnosis. If I can be involved in that process with them and acknowledge the stigma, I can help them.”

Ivers says there can be limits to diagnosis, including when clients develop a sense of dependency on their diagnosis or use it as a “crutch.” But as a whole, he finds that the process of diagnosis generally encourages counselors to seek out best practices, research and resources to help and support their clients.

“We have to be cautious that we don’t reduce people to their diagnosis,” Ivers warns. “But for others, finally receiving a name for the cluster of symptoms they’re experiencing can be a relief. It also can open them up to treatment and connect them with you [their counselor] or other practitioners who can help for their specific concern, [including] prescribing medication.”

Karl agrees that one benefit of diagnosis is that it often helps connect clients to interdisciplinary treatment. Even if a counselor is not required to assign diagnoses to clients, they need to have a “comfortable awareness” and foundational knowledge of the diagnosis process and be able to triage clients to connect them to further treatment if needed, Karl says. Screening skills and competency regarding diagnosis are also a requirement for counselor licensure in many states and therefore something to keep oneself updated on through continuing education, she adds.

Diagnosis also requires counselors to know how to use the DSM. Karl advises clinicians to become comfortable with looking things up in the manual and knowing where to turn when they have questions or need more information, rather than trying to memorize its contents.

Additionally, there are certain conditions mentioned in the DSM that counselors would not be involved in diagnosing, such as neurodevelopmental disorders. Because counselors will often be included in treatment plans for clients with those types of diagnoses, however, they still need to be proficient enough to have an understanding of any DSM diagnosis and its best treatment practices, even if they do not diagnose the client themselves, Karl notes.

Trying to remember all the nuances of the diagnoses in the DSM is “setting yourself up for failure,” Karl says. The DSM-5 contains more than 1,000 pages and hundreds of diagnoses. Even if clinicians were able to remember everything the manual contains, revisions and updates are made to the information regularly. For that reason, Karl urges counselors to focus on having a core knowledge of the manual, being comfortable enough to use it as a resource and adapting with it as it changes.  

Potential bias

Counselors are human beings with individual personalities and worldviews, so there is always a chance of potential bias creeping into assessment, diagnosis and treatment planning. To avoid this, clinicians must diligently reflect on their biases and really think about their assessment questions and diagnosis processes, says Ivers, who presented the session “Using Case Conceptualization to Navigate the Turbulent Waters of the Human Condition” at ACA’s 2018 Conference & Expo.

Ivers stresses that counselors need to critically examine why they are asking what they are asking — and what they are not asking. “If a client is acknowledging some of the cultural struggles they’re facing and we skirt those issues and do not focus on them,” he says, “what we’re telling them is that it’s not therapeutically important.”

“Case conceptualization is a tool, and when used effectively, it can be extremely helpful,” Ivers notes. “But when used ineffectively, it can be hurtful and damaging. In the case of culture, it can actively discriminate and misalign. It can [cause a clinician to] try and fit a client into a mold.”

Clinicians must also keep in mind that assessment and diagnostic tools can have an innate bias. Models often have a “cultural flavor” and are based on what is traditional (or Westernized) rather than on what is deviant or nondominant, Ivers says. He teaches Jon and Len Sperry’s case conceptualization method to his students at Wake Forest. One of the benefits of the model, Ivers says, is that it allows for flexibility and modification based on a client’s cultural factors. (For more information, read Jon and Len Sperry’s Counseling Today article “Case conceptualization: Key to highly effective counseling.”)

“There are evidenced differences in how symptoms are expressed culture to culture and, thus, individuals do not neatly fit in diagnostic or treatment ‘boxes.’ Fostering one’s competency is embracing these tensions,” says Hays, who is an ACA fellow.

She points out that research shows there are disproportionate rates of mental health issues among people of marginalized statuses. “The question has been whether differences in diagnostic rates — based in case conceptualization — are actual differences among cultural groups or whether they are a result of faulty assessment and diagnostic processes on the part of the counselor,” Hays says. “The answer is likely a little of both. Counselor cultural bias does substantially shape assessment and treatment, and experiences of privilege, oppression, trauma and resilience shape what symptoms are presented.”

Keller acknowledges that the potential for practitioner bias in assessment, diagnosis and treatment planning is one of the messiest aspects of professional counseling. What she finds invaluable in this realm is seeking feedback through regular consultation with professional peers as well as attending counseling herself. 

Personal counseling and professional consultation allow Keller to process things, identify her “blind spots” and work through her own biases, “so they don’t come out in the counseling room,” she says. “The last thing I want is for my stuff to affect [my client’s] stuff.”

Ivers admits it is “inherently reductionistic” to take all the information that a counselor gleans from a client through the therapeutic relationship and organize it into a treatment model and plan. There is no way to keep from losing data as the counselor processes all the information, he says.

“Therefore, it’s important to remain flexible and be aware that there can be blind spots,” Ivers advises. “You’re never going to get it 100 percent right, and that’s why we [counselors] are always reassessing and modifying a treatment plan. But you’re hopefully on the right path.”

A career-long learning curve

It’s not easy to competently assess what a client needs and then match those needs with an accurate and responsive treatment plan that will help the person to heal. Therefore, counselors find themselves continually developing and strengthening these skills over the entire course of their careers. 

Keller says it remains her goal to grow her skills in assessment, diagnosis and treatment planning over the decades to come with the mission of better serving her clients. “To be an effective counselor is to trust and to be OK with always learning and pushing ourselves to grow,” Keller says. “If I stop doing that, I probably shouldn’t be practicing anymore. Counseling is a process that I have to be willing to grow and change and evolve with — just as clients do. [Counselors should] trust that wherever you’re at in your professional journey, it’s OK — and it’s good even — to be learning.”

fizkes/Shutterstock.com

 

Wrestling with a client’s previous diagnosis

It’s not uncommon for counselors to see clients who have received a prior diagnosis from another clinician. If the client comes via referral, the counselor may have case notes that include the diagnosis in writing. In other situations, a client might report to the counselor that they were told they have a certain diagnosis. This introduces the possibility that the client might have misunderstood or misremembered clinical terms that they heard from the other practitioner or found on the internet.

So, what happens if the counselor, after getting to know the client, disagrees with the previous diagnosis? It’s a common scenario, says Shannon Karl, a licensed mental health counselor and professor at Nova Southeastern University. She urges counselors to remember that individuals grow and change, so a diagnosis shouldn’t stay static. A previous diagnosis may no longer be relevant or applicable for a client, especially if it’s more than a few years old.

Counselors need to come to their own conclusions about a client without allowing a previous diagnosis to color their assessment, Karl says.

Danica Hays, a professor and dean of the College of Education at the University of Nevada, Las Vegas, suggests that practitioners ask the client questions to get additional information about a past diagnosis, including how (and by whom) it was made, how the client feels about the diagnosis, the extent to which the client still identifies with the diagnosis, and how or if they feel that the diagnosis led to finding support to address their symptoms.

“Given the inevitable role of bias in clinical decision-making, counselors should always be cautious when a client presents a treatment history in which they were diagnosed a particular way,” Hays says. “It is important that counselors not quickly jump to a diagnosis based on what has been diagnosed before. This is a clear example of the improper ways that cognitive tools are used to yield misdiagnosis and client maltreatment.”

A counselor’s role also includes ensuring that a client feels heard and trusted when they talk about previous diagnoses or conditions that they think they have but that have yet to be diagnosed, adds Tracie Keller, a licensed professional clinical counselor.

“I try and hold that [information] with respect and honor, but at the same time, I do my own assessment and treatment plan based on what I’m hearing,” says Keller, who owns a counseling practice in Columbus, Ohio. “I use that as a jumping-off point to garner further questions, [as] a starting point to dig deeper.”

Karl once worked as a mental health counselor in a pain clinic where she had the freedom to have an initial session with clients before she opened and reviewed the individual’s records. “Clients really valued that I wanted to take a few minutes to hear it [their mental health history] from them,” Karl says. “They knew they had the chance to share their story with me without any filters.”

Karl acknowledges that this will not be possible for most counselors. However, she urges clinicians to find ways to hear a client’s backstory in their own words, even if they know the client’s diagnosis and case history before the person walks in the door.

“We need to preserve the ability to hear clients’ stories from them,” Karl says. “Keep in mind that we are not defined by our diagnoses; we grow and evolve in positive directions. What was happening previously doesn’t mean it’s happening now. Be aware that assessment is a continual, ongoing process, and a diagnosis is never set in stone. If we come from that lens, it helps us see clients for who they are as opposed to what they’re tagged with.”

 

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

A survivor’s lens on counseling and intimate partner violence

By Leontyne Evans August 12, 2021

Speaking as a survivor of domestic violence, I have found that society is not often kind or understanding about matters related to this particular form of abuse. Frequently, society seems to perceive it as something someone has chosen for their life instead of something someone was forced into. Grace and empathy are generally given when we talk about other forms of abuse, but mention domestic violence, and that same grace isn’t always extended. 

For years I wondered why — why is one type of abuse viewed differently in comparison with another? Just like any other victim, I never planned to be a victim, so why was I looked at differently? Why is it that victims of domestic violence have their pain invalidated by questions such as “Why didn’t you just leave?” 

That question alone — Why didn’t I just leave? — is what led me to the counseling profession. Given that I was a strong, independent woman who came from a good family, it was a question that plagued me. To transition from victim to survivor, I needed answers — answers that I just didn’t have. 

No easy answers

When I was an uneducated victim of domestic violence, the question of why didn’t I just leave felt complex. But after majoring in behavioral science/psychology and completing specialized courses in domestic violence intervention, trauma-informed care and, eventually, clinical counseling, I found that answering the question still wasn’t simple. In fact, as an educated grad student removed from her past situation, it became inherently clear to me that no amount of education would provide a clear-cut answer. 

I was in my last semester of graduate school and preparing to enter into the practicum portion of the degree when I enrolled in a class on family violence. Each week, we would watch videos and discuss our views and how we would help the client. In week four of the class,
that difficult question came up again. I was reading through the discussion post when I saw it: “Why don’t people just leave? If you want it to end, just leave.”

Being this far into my degree program, I was surprised to see other soon-to-be counselors asking this question and making that comment. I assumed other professionals had taken classes outside of this one to better understand a problem so prevalent in our society. If that wasn’t the case, were counselors really prepared to serve this population? 

In my own experience seeking counseling, I was asked, “Why do you think you chose not to leave?” I immediately felt like the counselor didn’t understand my position, and I decided to never see her again. I was hurt and angry, but I realized I still needed help. Luckily, I found another counselor and continued to educate myself on the cycle of abuse. 

Unfortunately, that is not the story for the majority of survivors with whom I have worked. If they feel misunderstood or invalidated, they don’t go back to counseling. In other words, asking the wrong question as counselors doesn’t just keep us from building a trusting relationship with these clients; it may actually deter them from ever seeking help again. 

It’s not that asking “Why do you think you chose not to leave?” is a horrible question. In relationships that do not involve abuse, it’s a perfectly acceptable question. When domestic violence is present, however, it crosses the line into victim blaming. Society constantly asks those who were victimized why they stayed instead of asking those who perpetrated abuse why they abused or why they created environments where leaving was not an option. According to Cynthia Hill, director of the 2014 documentary Private Violence (in an interview published in The Guardian), between 50% and 75% of homicides related to domestic violence happen at the point of separation or after the victim has left their abuser. We must be sensitive to the real danger involved in trying to escape intimate partner violence.

Natalia Lebedinskaia/Shutterstock.com

Tips for building relationships with survivors

I understand that as counseling professionals, we can ask questions only of the individual we are working with, and we always want to make sure the client is focusing on their behavior and not that of a partner or anyone else. Accountability is important and key in the healing process. However, it is not the best idea for this to be the primary focus when working with this specific population. 

When working with individuals who are currently experiencing intimate partner violence or have recently left an emotionally, mentally or physically abusive situation, counselors can use the following six tips to build relationships with these clients. 

1) Start by understanding that if leaving were an option, domestic violence would not be a thing. Remember, up to 75% of deaths related to domestic violence occur while the victim is attempting to leave or afterward. Because domestic violence is rooted in power and control, perpetrators of abuse often lash out at the idea of losing the person they feel they control. 

In the movie What’s Love Got to Do With It, based on the life of singer Tina Turner, her husband, Ike, says at one point, “Tina, if you die on me, I swear I’ll kill you.” To most people, that sounds crazy, but in Ike’s mind, he wanted to maintain control over Tina, even in her death. For those who are not movie people, the Duluth model of domestic violence intervention also explains this concept. Leaving is dangerous and maybe even impossible for most victims. So, stop asking clients why they didn’t or don’t leave. If they could, they would.  

2) Always be on time and end on time. This might seem trivial to most, but if you are working with clients you suspect are actively experiencing intimate partner violence, being on time and ending on time is a must. You never know what the client had to tell their abuser so that they could meet with you. You don’t know if this is the time when the abuser is out of the house and the only time the client can meet. If the counselor is late, the session still needs to end on time. The client should always know they will be home when they are supposed to be home. Messing with the schedule could potentially mess with someone’s life. 

3) Talk about every other relationship rather than focusing on the abuse. Individuals involved in intimate partner violence are fully aware of the nature of their relationship. Trust me, they do not need a reminder of how dangerous or unhealthy the relationship is, even if they are not ready to leave. The cycle of grooming, gaslighting and manipulation can lead to victims feeling that they have to prove everyone wrong and show the world that their partner can still be the person they fell in love with. Most of the time, victims truly believe if they work very hard to adjust their behavior, their partner will treat them like they used to before the abuse started. Speaking directly about this relationship can cause the client to become defensive. It hurts the chances of building a trusting client-counselor relationship.

I have found that discussing other relationships in the client’s life can be helpful in shining a light on the behaviors of their current partner without making the client feel judged or attacked. You might say something along the lines of: “Oh, it sounds like you didn’t like your father when he drank because he became violent. How do you feel about XYZ’s behavior when they drink?” This allows the client to make the comparison on their own.

4) Realize that “Christ” and “counselor” are two different titles. Counselors are not saviors, nor should we try to be. In all situations and with all clients, the objective should be to meet them where they are. As with addiction, a client experiencing intimate partner violence may not understand the severity of the problem and may not want to leave. Perhaps instead of leaving the relationship, the client wants to learn to cope with certain behaviors. If that is what the client wants, it is also what the counselor should want. 

Go home resting in the fact that you are doing your job. Even though the client may be in an unhealthy situation, they are working with you, trusting you and listening to you. They hear you. When the time is right, they will make the best decision for their life. Your job is not to save anyone; it is to give clients the tools to save themselves. 

5) Accept that you are not the expert. Counselors work hard to become licensed professionals. That hard work is so appreciated. However, we are not the experts in this situation. No matter how many studies we have read, statistics we have memorized or theories we can apply, survivors are the experts when it comes to their experiences and their stories. 

Every survivor’s journey is different. There isn’t a one-size-fits-all approach when it comes to counseling survivors of intimate partner violence. Even if you’ve seen 10 clients in one day and they all have experienced intimate partner violence, ask questions of the next client rather than assuming that you know how the story will end. Because I promise you that you don’t.

6) Check your biases. We all have biases, but not everyone is aware of what theirs are and how they affect the lives of the individuals they work with. If you have certain views about intimate partner violence, if you believe it is a “choice” to stay, if you believe someone is able to “just leave,” please stay away from this population. It takes a lot for survivors to ask for help and to expose themselves enough to discuss the abuse. If this situation is handled incorrectly, they may never seek help again. Let’s be a part of the solution as professional counselors, not the reason that a survivor returns to the problem. 

As a survivor myself, these tips helped me build a long-lasting relationship with my counselor. Now, as I sit on the other side of the table, these tips have worked for me in counseling and coaching individuals who have experienced intimate partner violence. I hope you find these tips useful and join me on a journey to end the cycle of unhealthy relationships.

A Survivor’s story

During an internship, I worked with a young woman who had experienced physical abuse throughout her entire life. Every man from her father to the father of her children had abused her. At this point in her life, abuse was the expectation. The interesting part is that she wasn’t seeking help because of the abuse; she wanted help learning how to be better for her future husband. What I heard was: “What can I do to be who he wants me to be so he doesn’t hurt me?” I couldn’t immediately confirm my suspicions, so I continued to listen, ask questions and build trust.  

In about our fifth session, she opened up and revealed that she had been in the hospital the night before, put there at the hands of her fiancé. After I asked if she was OK and in the mental space to continue the session, she said, “This is probably the safest place for me to be today.”

As we continued talking, I asked if she still felt like marrying this man was the best option. To my surprise, she said, “Yes, he isn’t nearly as bad as what I’ve dealt with before, and I knew better. I shouldn’t have made him that upset.” I could continue with the story, but just this portion of it serves to paint a vivid picture of the mind of someone who is a victim of intimate partner violence. 

This is an extreme example of a person who had a long history of being abused, but many victims find themselves in the same predicament — asking themselves how they can change to “be better,” what they can do to be abused less, instead of asking what the abuser needs to change to stop abusing. Because survivors blame themselves enough, they do not need anyone else to do it for them. They don’t need someone to reinforce what they already believe. Imagine if I would have asked this client, “Why don’t you leave?” In that moment, I would have become the problem instead of the solution. She didn’t want to leave; she didn’t feel as if she needed to. 

My internship ended shortly after this session. I offered for this client to continue having sessions with the therapist on staff, but she was not interested. She never went back. I later found out that she did in fact get married to her abuser, and they lived happily ever after — until he killed her a little over a year later. 

This story sticks with me because it reminds me to be intentional about my time with clients and how I end things. It’s so much more than ending an agreement with a client; it’s the end of a relationship. I wish I had known then what I know now. I would have been more intentional about including a long-term therapist in our sessions. I wouldn’t have ended things the way I did. My only hope is that someone else can learn from me and we can all be better when it comes to dealing with clients who have been or are currently experiencing intimate partner violence. 

 

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Leontyne Evans works as the survivor engagement specialist for Survivors Rising, where she helps to empower and uplift survivors by providing education and resources that encourage survivor voice and self-sufficiency. She is a published author of two books, Princeton Pike Road and Relationships, Friendships and Situationships: 90 Days of Inspiration to Keep Your Ships From Sinking, both of which support her mission of ending the cycle of unhealthy relationships. Contact her at leontynesurvivorsrising@gmail.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.

Pride in practice: The journey towards LGBTQ+ counseling competence

By Jonah Friedman and Megan Brophy June 30, 2021

Lesbian, gay, bisexual, transgender and queer+ (LGBTQ+) people are marginalized, often at risk of discrimination due to sexual, gender and affectional minority orientations. While queer people experience heightened prejudice, research from the American Psychiatric Association has indicated a lack of suitable counseling for LGBTQ+ groups that would greatly benefit from increased services.

This need for appropriate queer counseling is amplified by the growing percentage of self-identifying LGBT people. The Washington Post recently published findings from a Gallup Poll revealing a 1.1% increase in LGBT adults from 2017 to 2020 and that 1 in 6 individuals ages 18-23 identify as LGBT. Given a growing queer population and the increased need for counseling, there is a clearly identifiable gap for qualified services.

Queer-competent counselors can help. Unfortunately, there is a lack of queer competence among many practitioners, perhaps because of the small number of available LGBTQ+ courses and training opportunities for counseling graduate students. Even when proactive and eager graduate students seek out dedicated coursework, internships and training experiences in queer settings, viable options are limited. The cycle of limited to nonexistent queer-accessible counseling resources is perpetuated without available training experiences. How can we become LGBTQ-competent counselors when so few opportunities exist for education and practice in this area?

The queer experience

We live in a society that gives preference to white, Christian, male, cisgender, and heterosexual people. To retain power, both intentionally and not, these dominant identities often oppress any divergence. Youth are commonly indoctrinated to believe that departure from societally deemed normative standards, such as same-sex attraction or nonbinary gender, is deviant or wrong. This belief system often intensifies with age and can lead to the discrimination and oppression of queer people throughout the life span. To remain safe in today’s heteronormative and cisnormative society, many queer individuals hide their identities. Doing so is often the only way for them to be treated equally to their straight, cisgender counterparts.

Researchers Laura S. Brown and David Pantalone showed that the nature of constant secrecy, dissonance and struggle to conform adversely affects mental health. The Substance Abuse and Mental Health Services Administration has found that sexual minorities who experience exclusions from society have higher rates of mental health disorders, major depressive episodes and substance abuse. The Trevor Project’s data even indicate that queer youth experience higher rates of suicidal ideation.

Additionally, Darrel Higa et al. from the University of Washington found that when LGBTQ+ people choose to share their identities with parents, guardians, schools and workplaces, they are often met with rejection and discrimination. This is seen through higher rates of homelessness and increased unemployment in comparison with heterosexual individuals. Despite LGBTQ+ people experiencing heightened mental health disparities, queer clients often find unsupportive counseling services. 

Counselor competence 

LGBTQ+ clients benefit from counselors and mental health agencies that provide acceptance and validation through queer counseling competence. The Society for Sexual, Affectional, Intersex and Gender Expansive Identities (formerly known as the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling), established a task force in 2012 that outlined queer-competent counseling behaviors. The competencies touch on queer human growth and development, social and cultural foundations, helping relationships and more. The same group released competencies for counseling transgender clients in 2009. These resources, while important for agencies to utilize, have not been updated in a decade and would benefit from the inclusion of newer relevant queer research.

Having queer-competent counselors in all mental health settings is crucial to fostering open discussion and disclosure of LGBTQ+ client identities. A survey by the Center for American Progress shows that a lack of trust exists within the LGBTQ+ community for health care systems. It is likely that counselors will need to continually gain the trust of queer clients due to their historically negative health care experiences and traumas. To achieve such trust, counselors should provide appropriate services to LGBTQ+ clients as directed by the queer counseling competencies and the American Counseling Association’s ethical obligations of beneficence and nonmaleficence.

Paper guidance on LGBTQ+ competence exists, but the field is obligated by these same values to provide more than the prevailing “self-teach” approach. When queer competence is effectively implemented, the resulting safe spaces, open dialogue and unconditional positive regard will encourage more LGBTQ+ clients to show up authentically. Findings from Edward Alessi et al. revealed that a queer affirmative approach to counseling resulted in a stronger therapeutic alliance and increased well-being for LGBTQ clients. There is a great need for graduate students and current practitioners to better learn queer counseling competencies.

Missing coursework

To gain LGBTQ+ competence, graduate students and practitioners must engage in coursework and continuing education on queer theory. Furthermore, they must partake in related training experiences. Many students and practitioners face obstacles to finding such offerings. The following details our experiences (Jonah Friedman and Megan Brophy) as we struggled to find appropriate training in this area.

Jonah entered a master’s in counselor education graduate program in August 2020. In an early academic advising session with faculty, he expressed interest in LGBTQ+ counseling. When seeking out classes in gay affirmative therapy and related theories, Jonah was informed there were no related course offerings at the college he attends. An institution that so strongly emphasizes its core tenet of multicultural competency had no classes specifically on LGBTQ+ counseling. While regretful, this is the case at a majority of universities offering master’s in counseling and related degrees. The resulting options were to forgo such classes or to transfer in pertinent elective credits from one of the few programs with queer counseling coursework. Eager to obtain such training, Jonah began the search to find other CACREP-accredited graduate programs offering courses in LGBTQ+ theoretical approaches.

In New Jersey, there are 12 CACREP-accredited universities offering graduate counseling degrees on a variety of tracks. A review of these programs and their course directories revealed only four clinical mental health programs regularly offering electives on sexual issues in counseling or gender issues. None of these courses was explicitly dedicated to the study of working with LGBTQ+ clients. The remaining programs did not list relevant electives or did not offer any form of an LGBTQ+ counseling course. This absence may be attributed to CACREP not requiring the integration of LGBTQ+ counseling education to earn accreditation for clinical mental health programs.

To take appropriate courses, Jonah applied to Southern Methodist University (SMU) in Dallas. The school has a counseling program that boasts an affirmative therapy with LGBT clients track. Jonah has since enrolled as a nonmatriculated student in two electives: “Affirmative Therapy with LGBTQ+ Individuals: Advocacy Across the Lifespan” and “Affirmative Therapy with Transgender and Gender Non-Conforming Clients.” Although the experiences have been enlightening, allowing for exploration of sexuality and gender through a deeper and more critical lens, it was a difficult and arduous process to obtain this theoretical training. The time, costs and effort of taking these classes at a second institution only adds to the hardships created by the lack of initial course offerings.

Additionally, Jonah was able to take courses online and remotely at SMU only because of COVID-19 guidelines. During regularly structured semesters, such courses are in person and unavailable to out-of-state students. Furthermore, Jonah enrolled in these courses proactively; students not seeking out queer counseling coursework will be minimally exposed to these crucial theories. When such courses are not offered or required, there is an inherent implication that queer theory is not important to CACREP or our practice as counselors.

Lacking clinical experiences

Even if LGBTQ+ courses are secured, counseling students must then engage in queer-relevant training experiences to build practice competency. This approach follows the logic of formative development within the counseling field: first learning the theories through coursework, followed by application during clinical experiences.

Megan Brophy’s experience finding an LGBTQ+ based internship as a graduate student proved challenging. Throughout the states of New Jersey, New York and Pennsylvania, Megan found only four sites offering exclusively LGBTQ+ oriented counseling. To secure competitive internships at such sites, students often begin applications and interviews up to six months prior to the start of a program. At one site in Philadelphia, the application window was open only for a single month. Many other sites accept only one to three interns annually. This highly selective approach for interns greatly increases the already difficult endeavor of finding a relevant training position. The limited funding and logistical roadblocks for hiring interns and licensed practitioners at these sites hinder counseling students from gaining the clinical experiences necessary to become queer-competent counselors. Students struggle to structure their degrees around obtaining these queer-focused internships while working to stay on track to graduate.

In her search for internships, Megan called a variety of LGBTQ+ community centers in New Jersey to assess the availability of internship opportunities. She discovered that among those offering services, most were limited to support groups facilitated by nonlicensed professionals. In part due to a lack of funding and resources, services were more related to social gatherings, legal referrals and Pride celebrations. Resultantly, queer youth have severely limited access to appropriate counseling services. Relatedly, graduate students attending CACREP-accredited programs cannot obtain internships that meet accreditation requirements for supervision without licensed clinicians at such sites.

Even when qualified services are available, they are often niche and unrepresentative of the greater queer community. One such counseling opportunity is offered through a residential living program available to queer, homeless adolescents in Ewing, New Jersey. While homelessness is critical to address, it is an extreme situation for LGBTQ+ youth to find themselves in. We must also consider queer youth not displaced who are still looking for mental health services.

Finally, we must consider how the lack of availability and accessibility to LGBTQ+ sites directly affect our clients. Traveling great distances to the nearest LGBTQ+ counseling center is a privilege that many do not have. We cannot expect or require our queer clients to travel so far to attain mental health services. Queer-identifying youth almost never have this option without the help of a supportive friend or family member. Beyond that, given school and homework obligations and involvement in extracurricular activities, they may not have the time to travel long distances for services.

While the recent influx of online mental health services stemming from the COVID-19 pandemic has made counseling more widely available, online counseling within an unsupportive home environment may be harmful for LGBTQ+ clients. In such situations, queer clients may not be able to safely disclose information regarding their sexual or gender identity. This emphasizes the work that still needs to be done within the counseling field to create more queer-inclusive spaces with queer-competent counselors.

Understanding queer identity

As counselors, we have a duty to be multiculturally competent. The Multicultural and Social Justice Counseling Competencies, developed by the Association for Multicultural Counseling and Development, detail the layers leading to more inclusive counseling: counselor self-awareness, client worldview, the counseling relationship, and advocacy interventions.

While our field has made strides in the integration of diversity, there is more to be done in helping queer clients. To train and sustain queer-competent counselors, we must make a commitment to better understand the multifaceted aspects of queer culture, identity and relevant terminology. Beyond this, counselors can engage in continued research and relevant literature with the community, including resources provided by leading queer organizations (e.g., The Trevor Project, GLSEN). The understanding of queer identity and worldview is foundational in effectively working with LGBTQ+ clients and empathizing with their unique experiences.

Active advocacy

Rainbow Black/Shutterstock.com

ACA has established a nondiscrimination policy banning all forms of harassment, including protections for transgender, gender nonconforming and LGBTQ+ individuals. We as a profession must move past this passive protection and evolve as active advocates. Practitioners can act with and on behalf of their queer clients on the micro-, meso- and macrolevels of advocacy.

On the microlevel, counselors may work with queer clients to continually affirm their identities. On the mesolevel, advocacy might take the form of working alongside local school systems to organize LGBTQ+ support groups or arranging professional development for staff. On the macrolevel, practitioners can become involved with legislation that is supportive of LGBTQ+ individuals and communities. All three levels of advocacy are required to make a difference in our current climate.

Graduate course offerings

Gov. Phil Murphy of New Jersey recently signed into law LGBTQ+ inclusive curriculum legislation, following the states of California, Colorado, Illinois and Oregon. Out of 50 states, only five have recognized the importance of a queer-inclusive approach to education. Across New Jersey, boards of education have begun to integrate the accurate representation of queer individuals and history into curricula.

So many of the accredited institutions of higher education in the same state have yet to adopt similar coursework. These schools, which are training the counselors of the future, need to offer more classes on queer theory. In doing so, all graduate counseling students will be exposed to basic LGBTQ+ terminology and culture. This integration of queer curriculum will take queer counseling skills past the point of specialization.

LGBTQ+ oriented sites

While it would be ideal to open queer-focused counseling sites across every state, a more realistic plan would be for existing agencies to introduce LGBTQ+ services. For example, High Focus Centers in New Jersey, known for their outpatient substance abuse programs, recently added an LGBTQ+ track addressing substance abuse, queer wellness, self-esteem, empowerment and relational skills. Other sites can commit to adding queer tracks within their programs to allow for more internship opportunities and training in queer-competent counseling. In turn, sites will become more welcoming to queer clients.

A better future

By gaining basic queer counseling competence, advocating for all LGBTQ+ people, enhancing counseling curriculum to be queer-inclusive, and integrating queer support services at all agencies, our field can significantly improve the counseling provided to LGBTQ+ people. We must all become queer-competent counselors and the agents of change in our increasingly progressive field.

 

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Related reading: See Counseling Today‘s June cover story, “Listening to voices of color in the LGBTQ+ community

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Jonah Friedman is a Master of Arts in clinical mental health counseling candidate at the College of New Jersey. He completed his undergraduate studies at Tulane University, where he first discovered his passion for helping others and the value of counseling. Inspired by his current work with the Trevor Project, Jonah hopes to eventually work as a practitioner utilizing an LGBTQ+ affirmative approach. Contact him at friedj11@tcnj.edu.

Megan Brophy (she/her/hers) is a recent graduate from the College of New Jersey. Her work is guided by a passion for social justice and advocacy for marginalized communities. Contact her at brophym1@tcnj.edu.

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

White House: Counselors have role to play in fostering trust of COVID-19 vaccine

By Bethany Bray June 24, 2021

At an online event for mental health practitioners earlier this week, U.S. Surgeon General Vivek Murthy emphasized that professional counselors’ role as “trusted healers” in their communities affords them an important opportunity to support clients — and clear up misinformation — as they’re making decisions regarding the COVID-19 vaccine.

“The name of the game right now is trust. This vaccine campaign will move at the speed of trust,” Murthy said. “And it will depend on what people who are trusted in their communities do.”

Roughly two-thirds of eligible Americans who have not yet elected to receive the COVID-19 vaccine believe common myths regarding the vaccine, Murthy said. These myths, including those that claim getting the vaccine alters your DNA, causes infertility or will give you the COVID-19 virus, are false, Murthy stressed.

The vaccines, the first of which the Centers for Disease Control and Prevention (CDC) greenlighted for adults in December 2020, reflect the culmination of years of research on the mRNA vaccine platform, he said. As with any vaccine, there are risks of side effects with the COVID-19 vaccine, but they are rare — and the risk of getting the COVID-19 virus “far exceeds” the risks of side effects from the vaccine, Murthy said.

The June 21 event, organized by the White House, was part of a larger push by federal health officials in recent weeks and months to close the gap between the number of vaccinated and unvaccinated people in the United States. The forum, held over Zoom, was meant to equip mental health practitioners with information to answer clients’ questions surrounding the COVID-19 vaccine.

The American Counseling Association was a partner in Monday’s event, along with the American Association for Marriage and Family Therapy and the American Psychological Association. ACA members Suzzette Garcia, a licensed professional clinical counselor in California, and Rufus Spann, a licensed professional counselor in Maryland, were included on the event’s panel of mental health practitioners.

Garcia and Spann noted that some of the most important tools counselors can wield to support clients are empathic listening and validation of their uncertainties regarding the COVID-19 pandemic, including vaccine-related concerns. They also acknowledged that clients’ mistrust of the vaccine can dovetail with deeper and long held cultural mistrust of the medical system of a whole.

Garcia said she has role-played with clients during sessions to focus on distress tolerance and challenge their cognitive distortions regarding the vaccine. It’s also important for mental health practitioners to familiarize themselves with accurate information about the vaccine and local resources with which they can connect clients, Garcia said.

Navigating COVID-related uncertainties “is a question that a lot of ACA members have had to deal with,” said Spann, a past president of the Maryland Counseling Association. “We are part of the front-line experience. When these conversations come up, we allow [the client to talk through] life pressures, stress and anxiety. … It has been an opportunity [for clients] to talk to counselors who are able to listen to their stresses, fears and hopes, allowing space for clients to talk about what they’ve experienced and what they hope for the future.”

(Left to right, top to bottom) Bechara Choucair, White House vaccinations coordinator; Suzzette Garcia, a licensed professional clinical counselor in California; Robin McLeod, a licensed psychologist in Minnesota; Kelly Roberts, a licensed marriage and family therapist in Oklahoma; Rufus Spann, a licensed professional counselor in Maryland; Neetu Abad, a behavioral scientist at the CDC; and U.S. Surgeon General Vivek Murthy speak at at June 21 event titled “White House Virtual Conversation: Mental Health Professionals and the COVID-19 Vaccinations Effort.”

Murthy noted that the COVID-19 death rate in the United States is now the lowest it has been in a year. However, thousands of cases are still diagnosed each day, and variants have emerged that pose particular danger to the unvaccinated.

“We have a lot more work to do, and this is where we need your help,” Murthy told the mental health professionals participating in and watching the online event (dubbed “White House Virtual Conversation: Mental Health Professionals and the COVID-19 Vaccinations Effort”).

The key to increasing vaccination rates is for people who are uncertain about the COVID-19 vaccine to hear from people they trust, including professional counselors. No amount of advertising can match that power, Murthy said.

Bechara Choucair, the White House vaccinations coordinator, acknowledged that it is not within mental health professionals’ scope of practice to encourage their clients to get vaccinated. However, the White House wants to ensure that practitioners are well-equipped to answer clients’ questions surrounding the vaccine and talk through any potential fears they may have, Choucair said.

Those fears and hesitancies might include a phobia of needles or medical offices, a lack of trust in the vaccine and its development (or in the medical establishment as a whole), and resistance to government influence.

Murthy noted that mental health is a priority of President Joe Biden’s administration and that mental health-related topics come up often in Murthy’s regular COVID-19 briefings with the president.

The COVID-19 vaccine is “our most reliable pathway out” of the pandemic, Murthy asserted. It’s “one giant step toward getting back to normal” so that people can once again gather in person and find social connection — “which we know [is] so important to mental health,” Murthy said.

 

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Watch the full video of the event on the White House YouTube channel: youtu.be/tzFS63G5sP8

 

Visit the CDC’s COVID-19 page at cdc.gov/coronavirus and ACA’s page of COVID-19 resources for counselors at counseling.org

 

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