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Counselors Audience

Why the body matters

By Katie Bascuas June 27, 2022

Somatic therapy, or therapy that incorporates the body into the therapeutic process, continues to grow in popularity. This is likely due to the evolving nature of our understanding of trauma and the need for various approaches to treat the impact of traumatic experiences, which often have a significant physiological impact on the body, especially the nervous system. But as a relatively new therapeutic approach, which lacks the equivalent evidence-based research to support its efficacy compared to other modalities, somatic therapy is not without skeptics. Many clinicians who use it, however, advocate for its ability to help clients, especially those who may have tried other modalities with mixed results and those who are processing traumatic experiences. 

Incorporating somatic techniques into psychotherapy work came almost second nature to Kimberly Hanson, a licensed professional counselor (LPC) in Charleston, South Carolina, and a trained dancer. 

“I understand a lot about the body, and how our emotions can be reflected through our body and vice versa,” says Hanson, who uses movement exercises and breathwork as part of her work with both adults and children. 

“I’ve done exercises where [clients] stand up, and they’ll stretch their arms up to the ceiling and then drop down and swing them on the floor and bring them back up, all while focusing on their breath,” Hanson says. She also incorporates modern dance techniques such as expanding and contracting the body into her clinical work. For example, she once worked with a client to process a fear of taking up space and using his voice by asking him to stand up, spread his arms and move in a circle to establish his own personal zone. “We did some expansion work with that and coupled it with some breathwork, and I’d ask him what he noticed when he took up territory and established his own personal boundaries,” Hanson recalls. “That was very impactful for him.”

Hanson has found that pairing body-based techniques with other more talk-based therapies to be incredibly effective when working with clients. “It can give [counselors] a lot of information,” she explains. “We are a three-part being. We are body, mind and spirit, and all of those things integrate together, so why don’t we incorporate that into our therapeutic process? 

Using a somatic approach may look different depending on the counselor’s training and preferences. Some clinicians may be fully certified somatic experiencing practitioners (SEPs) trained in the somatic experiencing (SE) program based on the work of Peter Levine, whereas others, such as Hanson, may be trained in other modalities but incorporate somatic-based techniques such as mindfulness, movement and breathwork into their therapeutic work. Even the pathways to incorporating somatic techniques can look different to most counselors. However, one thing that many of these clinicians have in common is their belief that the results of body-based techniques often speak for themselves.

Brain-body connection

Mike Wendt, an LPC at Sherman Counseling in Appleton, Wisconsin, has been doing SE work since 2019 and says that it has transformed his therapeutic orientation. “It’s gotten to the point where this is my main modality,” he notes. “It’s really that powerful. It just floors me with what I’ve seen in practice.” 

Wendt, who has a background in neuroscience and is certified by the Biofeedback Certification International Alliance in the use of electroencephalographic (EEG) biofeedback, says that neurofeedback was his gateway into therapy. “I was very interested in the mechanics of how the brain works and the neurological patterns associated with things like anxiety, depression and trauma,” he says. While fine-tuning his neurofeedback skills, however, he kept encountering clients with a lot of trauma markers in the brain. For example, alpha brain waves, which can be detected with an EEG, show up differently in traumatized and nontraumatized clients, he explains. When a client who has not experienced trauma closes their eyes, the EEG shows a healthy increase of alpha waves in different parts of the brain, he says, but for a traumatized client, the rise in these waves may be blunted or absent. And for some severely traumatized clients, it may even decrease, he adds. 

After noticing these neurological markers among several clients presenting with trauma, Wendt says that he began looking for other modalities to help treat traumatic experiences. “There haven’t, historically, been a lot of effective ways to work with trauma, so I thought if I’m just going to keep encountering these neurological markers, I better come up with an effective way to work with it outside of neurofeedback,” he recalls.

Wendt later stumbled on some writing about SE while researching neurofeedback and decided to attend a training session in 2019. “It was incredibly eye-opening how everything with SE just tied together with neuroscience and changes in brain pathways — so using the body to train the brain and not the other way around, which is where I was coming from with the neurofeedback,” he says. “This tied things all together for me when we brought the body on board.”

When he first began incorporating SE into his practice, Wendt would start a session with neurofeedback until he noticed a client’s physical reactions, and then he would shift into more somatic work. “There’s always a somatic reaction when trauma is brought to the surface,” Wendt explains. “Later on, I would just skip the neurofeedback entirely and just go into what is a person’s body language saying to me.”

He once worked with a 16-year-old female client who was experiencing chronic physical pain and was referred to Wendt for his expertise in neurofeedback. In working with the client, Wendt also incorporated SE and was able to help the client to reduce the pain to a level where she could focus on other issues, such as an eating disorder. 

Wendt says that he brought in body work to help treat the eating disorder by reflecting the client’s posture and how it changed when she discussed her journey dealing with disordered eating. He would notice how her hands would fold over stomach, for example, as she discussed different parts of her experience, especially the time she was hospitalized and when discussing her body image compared to her friends, whom she thought had a more “normal” body weight and physical condition. After reflecting what he noticed, Wendt says that he then asked the client to try moving her hands out away from her stomach as she talked. “What I had her do is experience what it was like in her body when she would put her hands out a little further, so she would be more open physically and less threatened emotionally, and then she would bring them back again and feel her anxiety rise and fall,” Wendt explains. “And she’d also feel the comfort of having her hands folded around her stomach as security.” 

He also helped this client work on developing positive coping strategies using SE, and over time as the client continued to experience and process the anxiety, she was able to move her hands away from her stomach completely without fear or hesitation. When this happened, Wendt recalls that the client looked at him and said, “Did you trick me?” He asked her what she meant, and she explained that “the feelings of how she looks and how others see her weren’t there anymore.” And eventually, the client felt comfortable enough to engage in activities she might have previously passed up such as wearing a bathing suit at the beach. 

Improving self-regulation 

For Nancy Skocy, an LPC and SEP in Tucson, Arizona, SE became part of her clinical work after she experienced its effects via her own personal therapy. 

“I worked with other kinds of therapy and personally have been in therapy myself, and what I had discovered in my own work is that I could understand a concept — for example, the concept of setting a boundary — yet when it came to doing it, I would have the words [to verbalize the boundary], but it seemed that something was missing in that I didn’t know how to be effective around setting [or enforcing] the boundary.”

Skocy also has a background in equine therapy, and she says that working with horses, combined with her personal experience with somatic therapy, helped her to see the possibility for helping clients work on emotional regulation.

“If you are emotionally dysregulated when you’re trying to work with a horse, the horse reads that emotional dysregulation in your body,” she explains. “Taking those types of nuances into the SE world is when I started realizing that many times when I was communicating with family members or loved ones and I was upset emotionally, I would communicate in a dysregulated way and it would not be effective.”

She says that she noticed a similar theme among some of her clients who struggled with emotional dysregulation, which affected their communication styles as well as their relationships. “What I noticed was that a lot of my clients had a hard time shifting to taking responsibility for self-regulation,” Skocy recalls. There’s often a belief that other people will regulate us, she adds, especially in clients who have experienced trauma. 

She finds that having clients track their bodily sensations, in addition to their emotions, helps them improve their ability to self-regulate. “Tracking emotions isn’t the same thing” as noticing physiological responses, she says, “because if I’m tracking my emotions — I’m angry, I’m hurt, etc. — I will then justify my reasons for attacking someone else.” Taking this extra step of noticing bodily sensations and then regulating the nervous system response allows clients to come from a more empowered and controlled place when responding to emotionally triggering people or situations, she adds. 

One way Skocy shows clients how to regulate their emotions is by helping them shift negative bodily sensations into more positive ones. For example, if a client reports feeling tense or constricted, Skocy may prompt them to remember a time when they were happy or to think about a loved one and to notice how their body feels. She may also ask clients to explain how they know they feel happy, which may be because their cheeks feel warm or they notice that they’re smiling. 

“Finding the positive is where you restore the balance,” she says. “When I think about someone that loves me or a happy time that I had, I can learn how to shift things myself, and I can settle into a more regulated state and think about how I want to approach communicating with someone.”

In that sense, clients then have more autonomy around how they show up in the world, including the boundaries they set. “A boundary is no longer telling somebody, ‘When you do this, I’m going to confront you,’” Skocy says. “It now becomes, ‘It’s important for me to take care of myself and to protect myself in my relationships as well as to consider the other.’” 

Filling a gap 

Whitney Norris, an LPC and SEP in Little Rock, Arkansas, and co-owner of Little Rock Counseling & Wellness, was also drawn to SE work after experiencing the benefits firsthand through her own personal therapy. She later completed the three-year SEP training, which had an effect not only on her therapy worldview but also on how she presented herself as a clinician.

“The first thing that I noticed with SE training was the way that I showed up in the room, noticing my own reactions to what was going on in the room and noticing and differentiating what was going on with the client even if I didn’t speak any of it,” Norris says. “I felt like I was more present.” She adds that SE training and learning more about her own nervous system helped her to expand her capacity to sit with different things that may come up in a session or that might happen in her own life. 

Norris, who specializes in trauma work, says SE also helped her fill a therapeutic gap that she felt was missing in her work. She had some clients from whom talking about their experience was not that helpful and others who found eye movement desensitization and reprocessing (EMDR) to be too intense. She says using SE is especially helpful for these clients — ones she admits “might have otherwise been falling through the cracks treatment-wise” — because it incorporates the client’s bodily response in a way the other therapies do not.

Although she occasionally runs into a client who is initially hesitant to try somatic techniques — largely due to the fact that they may differ from anything the client has tried before — she finds that most clients are willing to engage in SE and are typically surprised at the results. In fact, clients often tell her, “I have no idea how that worked, but I feel like it did” or “I don’t understand what we just did, but that felt helpful.”

Skepticism

That sense of mystery behind somatic therapy and how it works, coupled with a lack of research compared to other modalities, can contribute to a feeling of skepticism. Some critics argue that there is not enough research to prove the effectiveness of somatic-based techniques. 

In a 2021 literature review of the effectiveness of SE published in the European Journal of Psychotraumatology, for example, Marie Kuhfuß and colleagues found preliminary evidence suggesting positive effects of SE for the treatment of symptoms related to posttraumatic stress disorder (PTSD) as well as affective and somatic symptoms, yet they also noted that the quality of research surveyed was mixed due to risk of bias. The authors recommended further research through randomized controlled trials. 

Meanwhile, a 2017 randomized controlled study of SE — billed as the first of its kind — found evidence to suggest that it is an effective treatment modality for PTSD. The study, published in the Journal of Traumatic Stress by Danny Brom and colleagues, randomly assigned 63 participants living in Israel, all of whom had reported traumatic experiences within the previous four years, to two groups: one that underwent 15 sessions of SE and another that was assigned to a waitlist. In the post-session analysis, researchers found significant effects of SE on posttraumatic and depression symptom severity among participants assigned to the treatment group.

Danny Brom and colleagues also noted, however, that the small sample size as well as the difficulty in measuring the effectiveness of a treatment that does not adhere to a strict protocol were both limitations to the research. 

Unlike a modality such as EMDR, which is protocol-driven and more black-and-white in its approach, Norris says, SE is less linear and looks different to various practitioners who may incorporate a variety of techniques based on their own preferences or the needs of a client, making it harder to research. But “it doesn’t necessarily mean that it’s ineffective because there isn’t that type of research out there,” she says. “It may mean that it doesn’t lend itself to be able to be researched in that way.” 

Challenges

Skepticism and the need for more research aren’t the only challenges counselors may face with somatic-based work. “I frequently run into people not wanting to have a relationship with their body,” Skocy says. In fact, she points out that some clients may have a dislike or even hatred of their own bodies and feel shut down physically. 

Hanson agrees and notes that she sometimes encounters clients who are resistant to trying a somatic technique or who don’t experience any immediate benefit. When this happens, she says that she often tries to use the resistance or the lack of effect as a catalyst for further exploration. “As a trauma professional, I’m trained to understand those blocks, so we’ll do something else to try and access why they’re not getting anything or why they feel numb,” she explains.

Eugene Titov/Shutterstock.com

Both Norris and Wendt agree that the learning curve associated with somatic therapy provides another challenge. “There’s a reason the [SE] training is spread out over three years — you need to have time to integrate each piece,” Norris says. Because she didn’t learn about the nervous system or the body in her graduate program, she had to catch up on those pieces, all while learning the specific SE techniques.

Not only is there sometimes a knowledge gap, but the work also takes practice. “It is very much an art form,” Wendt says. “If you push someone too quickly, they might shut down and go into that freeze or collapse state, and you’re most likely not going to get them back in that session.”

The possibility of triggering someone while doing SE emphasizes the importance of creating safety for clients. Wendt says that he uses mindfulness skills such as body scans to help clients safely connect to their bodies, and he encourages clients to think of a pleasant experience or a safe person that they can focus on when they want to feel safe and relaxed during a session. 

“That way we have something that they’re able to tether to because the goal of SE is not to approach trauma to the point of being overwhelmed, but to approach the outer orbits where can we feel the first whiff of that signal in our body that tells us that something isn’t right,” Wendt says. “Oftentimes we don’t need to go any further than that, but we want to have a tether because if we go too far, the person can shut down very quickly and then you have to start over again.”

Try it for yourself

Some clinicians are hesitant to try somatic approaches because they fear retraumatizing or triggering a client. Yet many who support the work have been able to move through that fear, and they say that the results they see among clients are worth it. 

The counselors interviewed for this article all recommend that clinicians who are interested in delving into somatic therapy should try it for themselves as part of their own personal therapy. They suggest that practitioners read, research, and take training and continuing education courses about the practice of somatic approaches and body-based interventions to gain a deeper understanding of this approach and how it can be helpful to clients. Counselors can also find a therapist who specializes in somatic work and try a session or a series of sessions. 

“That really tipped me over the edge of being convinced,” Norris says. “I had done a lot of therapy up to that point, and it was all helpful, but once I started doing my own SE therapy, it was just beneficial in ways that other stuff I was doing wasn’t.”

She and Hanson also make the point that without doing the work yourself, it can be hard to fully comprehend how the techniques work and why they can be effective. 

“You can’t do these techniques without understanding it from a personal level,” Hanson says. “There’s just no way. You can try, and it will either feel forced or feel too rigid, and the client will pick up on that and know that this isn’t what you do.” 

She adds that the essence of this type of work is experiencing — being present with the feelings and sensations of the body as they arise — and that needs to feel genuine. “Part of the goal of these processes is that they’re organic and that it feels natural, so the therapist must be very comfortable with these types of interventions in order for the client to feel comfortable with it,” Hanson says. And “you have to do it yourself to get that understanding.”

 

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Contact the counselors interviewed in this article:

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Katie Bascuas is a licensed graduate professional counselor and a writer in Washington, D.C. She has written for news outlets, universities and associations.

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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.

Counseling after brain injury: Do’s and don’ts

By Bethany Bray May 20, 2022

Traumatic brain injury (TBI) is complicated.

Counseling practitioners may work with brain injury survivors who struggle with impulsivity, anger, despair, personality changes, memory loss, language or cognitive difficulties and a range of other symptoms. Not only do post-injury symptoms and recovery differ from person to person but the way these challenges dovetail with their mental health, relationships and overall wellness also varies.

Here are 12 important do’s and don’ts for mental health practitioners to keep in mind when counseling clients who have experienced a brain injury:

 

1) Do devote a lot of time to listening. One of the most important and beneficial things a counselor can offer a brain injury survivor is empathic and nonjudgmental listening. Having a space to talk about what they’re going through and struggling with and what they need without feeling like a burden can make a world of difference for these clients, says Herman Lukow, a licensed professional counselor (LPC) and licensed marriage and family therapist who spent three years as a postdoctoral fellow researching TBI at Virginia Commonwealth University’s Traumatic Brain Injury Model System program.

 

2) Don’t equate struggle with resistance. What might seem to be resistant behavior in this client population is often not intentional. They may miss sessions or be hard to contact, but it’s more likely to be caused by the memory and cognitive challenges they live with (e.g., confusing what day it is) rather than resistance, Lukow says.

 

3) Do be comfortable with silence in counseling sessions. Brain injury survivors may struggle with speaking or finding the right words to express themselves. Practitioners need to resist the urge to fill periods of silence, and they may also need to get creative to find other nonverbal methods or adaptive tools to communicate with these clients, notes Hillel Goldstein, an LPC with a private counseling practice embedded within the Brain Injury Foundation of St. Louis.

 

4) Don’t go it alone. Counselors can best treat these clients by collaborating, co-treating and consulting with professionals from a range of other disciplines who have expertise in helping brain injury survivors, including speech and language pathologists, occupational therapists, rehabilitation specialists and others, says Goldstein.

 

5) Do adjust your pace and expectations of progress. The therapeutic expectations, outcomes and what can be counted as a “success” will vary with clients who are TBI survivors, notes Michelle Bradham-Cousar, a licensed mental health counselor and certified rehabilitation counselor who recently completed a doctoral dissertation on counseling clients with TBI. The benchmarks or signs that counselors may associate with improvement or growth in clients may not be apparent — or appropriate — with clients who have experienced brain injury.

 

6) Don’t be a cheerleader. Life after a brain injury is hard, and survivors may feel that conversations in counseling only emphasize what they’ve lost, says Lukow. A constant stream of positivity or messages such as “you’ll get through this” from a counselor may turn these clients off; instead, they need honesty from a practitioner and validation that what they’re going through is rough.

 

7) Do ask clients if they’ve ever had a brain injury or related issues such as falls, sports injuries or loss of consciousness. Clients may not disclose past brain injury or realize that it can be connected to their mental health or presenting concern, so it’s important to ask at intake. It’s equally important for counselors to realize that a past brain injury — even if a client doesn’t think it was serious — can lead to or exacerbate mental health symptoms, Lukow adds.

 

8) Don’t forget these clients’ loved ones and caretakers. The mental and emotional burden that comes with caring for a brain injury survivor is heavy, yet caretakers often put themselves last, Goldstein notes. The loved ones of TBI survivors can also benefit from therapy, particularly the supporting environment that group counseling can provide.

 

9) Do dig deep into your counseling toolbox. The crux of what brain injury survivors need in counseling is help dealing with loss and change, says Lukow. And counselors already have an arsenal of tools and methods to help in this realm, from cognitive behavior therapy to the therapeutic relationship itself.

 

10) Don’t think of life after brain injury only in terms of loss. Post-injury recovery is also an opportunity to gain new skills and find new ways of doing things. A client may not be able to work in a job or field they used to, for example, but a counselor can help them reframe this loss as a chance to look for a new occupation that fits with the skills they do have, notes Bradham-Cousar.

 

11) Do consider this as a specialty. There are not many professional counselors who specialize in psychotherapy for brain injury, but it’s an important and much-needed expertise, says Goldstein. It could be a good fit for counselors who are interested in this client population or who thrive working in multidisciplinary teams.

 

12) Don’t assume that recovery ceases within a few years of a brain injury. Survivors can still make gains with emotional, social and psychological challenges long after — even decades after — brain injury, says Lukow, especially when supported by helping professionals who provide patient, empathic care.

 

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Read more on counseling clients who have experienced a brain injury in an in-depth feature article in Counseling Today’s June magazine.

arloo/Shutterstock.com

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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.

The impact of legalized marijuana on professional counseling

By Bethany Bray March 30, 2022

In 1996, California voters passed Proposition 215, making the Golden State the first in the U.S. to legalize the use of medical marijuana.

Two decades later, the medical use of cannabis is legal in 37 states, Washington, D.C., and the territories of Guam, Puerto Rico and the U.S. Virgin Islands. Additionally, 18 states, Washington, D.C., and two territories have enacted legislation to regulate cannabis for nonmedical (i.e., recreational) uses, according to the National Conference of State Legislatures. Just three states — Kansas, Nebraska and Idaho — do not allow public access to cannabis in any form, medical or otherwise.

In states where cannabis use has been legalized, many medical and mental health practitioners have found it necessary to shift their mindset — from viewing marijuana as an illegal substance to something that medical doctors can condone or even recommend and that potentially has benefits for a range of conditions, including chronic pain and posttraumatic stress disorder (PTSD).

“When it was first becoming legalized, it was a bit of a panic for the [addictions] treatment community around ‘How are we going to deal with this?’ What has evolved is that now, it’s viewed in a similar way as alcohol is: There is a continuum of users, [and] it can be abused but also used socially or occasionally,” says Adrianne Trogden, a licensed professional counselor and supervisor (LPC-S) and licensed addiction counselor (LAC) with a private practice in New Orleans. “It’s a hard transition for treatment providers to go from thinking of it as an illegal street drug to being dispensed as a medicinal medication. … In treatment facilities, you see the worst of the worst — those whose lives have been ruined by substance. It’s easy to see the ugly side of addiction and naturally be leery of [marijuana] being used for medicinal use. That mindset is hard to shift.”

Legalization has also meant that professional counselors cannot keep their heads in the sand about this issue, regardless of how they feel personally about the use of marijuana, says Paula Britton, a licensed professional clinical counselor and supervisor with a private practice in Cleveland. Practitioners need to be comfortable broaching the subject of how and why a client uses marijuana, and they should be familiar with the pros and cons of the substance as it relates to adult mental health and wellness. In addition, they should understand the nuances of cannabis regulation in their state.

At the same time, counselors must know how to assess clients for cannabis use disorder and listen for indicators that an individual may be drug seeking, Britton says.

Talking about clients’ marijuana use “gets tricky,” admits Britton, who is licensed as both a counselor and a psychologist. “Because of that, many counselors don’t want to get involved or learn about it. But I don’t know if we’re going to have that option in the years to come” as it becomes increasingly legalized. “We have to be aware that this is going on and that [marijuana use] is helpful for some people,” she continues. “We have to acknowledge that our clients are using it, or wanting to use it, for medical or recreational purposes and [consider] what … that mean[s] for us in counseling.”

Mixed messages

Cannabis is classified as a Schedule 1 substance under the Controlled Substances Act, which makes its distribution a federal offense. This puts marijuana alongside heroin, ecstasy, LSD and other substances that are “defined as drugs with no currently accepted medical use and a high potential for abuse,” according to the U.S. Drug Enforcement Administration.

This sends a confusing and mixed message, both to the public and to health professionals, given that marijuana may be legal and OK to use at the state level yet illegal federally, Britton says. In addition, the complicated regulatory scheme has impeded much-needed research on the effects marijuana can have on a range of conditions when used in a controlled, medically sanctioned way.

In the meantime, counselors must rely on the limited research that has been done by other disciplines or by researchers outside of the country. The few studies that have been done have yielded mixed results on marijuana’s efficacy for mental health diagnoses, particularly anxiety and depression, Britton notes.

“There’s just so much we don’t know,” says Britton, a professor of clinical mental health counseling at John Carroll University. “If we [counselors] are going to be evidence based, it’s hard to have an informed decision about what you think without that [research] behind you.”

One example of the mixed messaging surrounding cannabis use involves the U.S. Department of Veterans Affairs (VA). The VA has done studies that show medical marijuana can help individuals with PTSD, yet it will not endorse its use for VA patients because of the federal law, Britton notes.

The American Psychiatric Association issued a position statement in 2019 saying that it would not endorse the use of medical cannabis for the treatment of PTSD “because of the lack of any credible studies demonstrating [its] clinical effectiveness.”

Aaron Norton, a licensed mental health counselor, licensed marriage and family therapist and certified rehabilitation counselor with a private practice in Largo, Florida, suggests that the mixed data regarding marijuana use allows people who argue either for or against its legalization to cherry-pick studies that support their view. Some people, for example, have cited reports linking the legalization of medicinal cannabis with lower opioid overdose mortality rates as evidence that medical marijuana is the answer to ending America’s opioid epidemic.

“What I am concerned about is the touting of medical cannabis as the cure-all magical wonder drug,” says Norton, who has written and presented on legalized marijuana’s impact on the counseling profession. “There is contradictory evidence out there … [and] overall there’s very little evidence that medical marijuana helps many of the things that we think it does. I’m concerned about the claims that are made and [the] use of it in mental health treatment.”

It is well-known, however, that marijuana use can have a negative impact on child and adolescent brain development and has also been tied to lung problems (when used in inhaled forms) and other challenges later in life, Britton says. She advises counselors to also be mindful that marijuana use can affect the efficacy of psychotropic medications such as antidepressants that are commonly used by clients. 

Even when used legally, marijuana can still have adverse effects on clients’ employment, particularly if they work for the federal government or in fields that require regular drug testing. Marijuana stays in the human body and can show up on drug tests weeks after a person uses it, notes Britton, who co-authored a recent Journal of Counselor Practice article on Ohio mental health professionals’ attitudes, knowledge and experience regarding medical marijuana.

This aspect of marijuana use also has implications for counselors who work in the field of substance use because it can be difficult to determine an individual’s length of abstinence, says Trogden, an assistant professor in the counseling department at the University of the Cumberlands.

Dosing concerns

Dosing is another potential area of confusion related to legalized marijuana for individual users and health professionals.

Norton says that in Florida, it is mostly left up to the individual to purchase and use whatever dose they believe is best — a situation he labels a “free-for-all.” Physicians in Florida do not prescribe specific doses to patients who are granted a medical marijuana card because it remains illegal federally, he explains.

Similarly, Britton points out that employees at marijuana dispensaries in Ohio are not doctors and will often sell customers whatever dosing amount they request. Determining the correct cannabis dosing is complicated because the “optimal dose” will be different for every person, she says. The same amount of substance will affect people differently depending on whether it is inhaled or eaten, such as in gummy candy or baked goods. 

Matthew McClain, a school counselor in Fort Morgan, a small town in northeast Colorado, notes that dosing is a concern for youth because they often won’t read or adhere to the instructions or labeling for items that have come from a cannabis dispensary. For example, a teenager may open a marijuana brownie or piece of cake and eat the entire thing without pausing to read or acknowledge that it may be equal to two or three servings. “That can be pretty significant for the [body] systems of a teen,” says McClain, the executive director of the Colorado School Counselor Association (CSCA).

School counselors in Colorado are finding that youth (mostly in middle or high school settings) have adopted more casual attitudes about marijuana since its legalization in the state, McClain notes. In recent years, he says, school counselors’ awareness and concerns have shifted from students smoking marijuana to their consumption of it via vaping or edibles, both of which feature a high concentration of tetrahydrocannabinol (THC), the component in marijuana that produces a high. These methods allow students to consume the substance in a more clandestine way than smoking does, including during the school day. Edibles such as candy or gummy bears also make exposure and consumption of marijuana more familiar and less foreboding to youth.

One way to counteract this issue is to train teachers and noncounseling school staff in mental health first aid, McClain says. This can better prepare school staff members to notice behavior changes and other indicators that a student might benefit from talking with a school counselor — about marijuana use or anything else, McClain says. CSCA also offers regular trainings and continuing education programming to its members on marijuana use and its effects in school settings, he adds.

“This just adds another layer of complexity to the job, one other thing that can be going on” with students, McClain says. “We [at CSCA] have made sure that we’ve provided [educational] opportunities by seeking out experts and people who are well-versed to provide information and training, and other states are in a similar situation. We may want to stick our heads in the sand, but at the same time, if we’re dealing with the day-to-day lives of our kids, we want to make sure we can provide help and support.”

Use as instructed?

Norton says that in his experience, only a small fraction of his clients who have medical marijuana cards use the substance for medical reasons. He believes the majority obtained a medical marijuana card so they could use it recreationally, which remains illegal in Florida, or because they have cannabis use disorder.

When asked, many of these clients are unable to tell Norton why they have a medical marijuana card, or they name conditions — such as headaches, attention-deficit/hyperactivity disorder and trouble sleeping — that aren’t listed on the state statute that allows for the use of medical marijuana. The only mental health diagnosis mentioned in Florida’s statute is PTSD, Norton says. However, there is language in the law that allows medical marijuana to be prescribed for “similar” conditions to those listed in the statute, which gives physicians flexibility. Norton says he has never heard of a client who has been turned down for a medical marijuana card.

“Even clients who perceive they are using it medically … judge its efficacy by [not only] if they feel better but also [if they] feel high or euphoric — and that’s not the point of medicine,” says Norton, the executive director of the National Board of Forensic Evaluators and an adjunct instructor at the University of South Florida’s rehabilitation and mental health counseling program. “People are using cannabis to feel better in the moment — sleep better, lessen anxiety, etc. — but at the expense of addressing their core problems, which are thoughts and behaviors. They’re missing the opportunity for recovery from their behaviors.”

Trogden agrees, saying, “The challenge, just as with any other medication, is that you really need therapy and counseling services to gain insights and awareness [about a presenting issue] along with taking the medication.” She adds that in her experience, medical marijuana has benefited clients who have depression or other mood disorders, trouble sleeping, anxiety, racing thoughts or a history of trauma. But Trogden also notes that in addition to its potential benefits, marijuana use can cause paranoia or lead individuals to use it as a “crutch” to cope with pain and other difficult feelings.

Britton has done research on medical marijuana and counseled clients who use it. She says the substance can be tied to symptom relief or otherwise benefit individuals who have chronic pain, sleeping difficulties, autism spectrum disorders, anxiety and hyperarousal, nausea (such as in those undergoing chemotherapy treatment for cancer) and a range of other issues. At the same time, she says that more research is needed.

In Britton’s experience, medical marijuana has helped some of her clients, while others did not reap any benefit — or even had negative outcomes — from its use. “And that’s consistent with the literature,” she notes. “Not everyone benefits. It’s not a miracle cure. But just like with antidepressants [and other psychotropic medications], it can soften a client’s symptoms … [so they can] do the therapeutic work. But they still need behavioral intervention.”

Now that marijuana is legal in most states, the counselors interviewed for this article agree that clinicians should include specific, detailed questions about its use during the client intake process. Asking clients how often and why they use marijuana can help practitioners better understand the context of their use and assess for dependence or cannabis use disorder.

Cannabis use disorder is characterized by behaviors that indicate that a person cannot stop using the substance even though it is causing the person social or health problems, such as overusing or craving marijuana or driving while impaired. According to the Centers for Disease Control and Prevention, individuals who use cannabis frequently or began using it in adolescence are at greater risk of developing this disorder.

Practitioners should embed questions into assessment about how much and how often clients use marijuana, similar to the way they would ask about clients’ consumption of alcohol, suggests Trogden, who teaches in an addiction counseling training program for the state of Louisiana and is the chief operating officer of a behavioral health organization in New Orleans.

“We should be assessing for a variety of things. It’s helpful to understand the whole person and get a holistic understanding of what’s going on. Substances would be a part of asking about medication, whether it’s blood pressure [medication], mental health medication or marijuana,” Trogden says. “It’s important to call it out specifically, [asking] ‘Do you use marijuana?’ If you just ask, ‘Do you use drugs?’ they’ll probably say ‘no.’”

Trogden says multiple clients have mentioned to her in later counseling sessions that they smoke marijuana after initially answering “no” to generalized substance use questions at assessment. As a result, she’s learned to ask specifically about marijuana in assessment because some clients do not consider it to be a drug or on the same level as illegal substances.

Britton suggests that counselors take a nonjudgmental, curious and respectful approach to marijuana assessment with clients. “If a client senses that you are going to judge them — on any topic — they’re probably not going to tell you,” she says. “Start thinking differently about how you ask [and] how you put it on intake forms. Get outside of judgment.”

When clients ask

Clinicians in states where marijuana is legalized may have clients ask whether it could help them with symptoms related to their presenting concern or mental illness. Counselors cannot prescribe medication, however, and making a recommendation or giving guidance on marijuana use — or any other kind of health regimen — goes beyond a counselor’s scope of practice, says Emily St. Amant, counseling resources and continuing education specialist for the American Counseling Association. She recommends that counselors refer to the 2014 ACA Code of Ethics, particularly Standard C.2.a.

St. Amant, a licensed professional counselor with a mental health services provider designation in Tennessee, urges counselors to respond to client questions about legalized marijuana use with a nonjudgmental attitude and a recommendation to speak with a licensed psychiatric medical provider about the topic.

“I would also provide education about why I’m making that recommendation: my own scope of practice [and how a prescriber is qualified] to discuss risks and benefits, side effects, drug interactions, etc.,” says St. Amant, whose background is in substance use counseling. “As a counselor, I need to ensure I’m staying within my scope of practice or what I’m personally licensed to do. We open ourselves up for liability and ethical violations when we drift out of our lane and into the lane of other areas of expertise. We also open ourselves up for potentially harming our clients if we impose our own values or ideas on them. That takes away their autonomy, can damage the therapeutic relationship and creates a power imbalance.”

Rather than offering advice to clients regarding legal marijuana use, counselors should focus on strengthening clients’ personal autonomy and decision-making skills, St. Amant emphasizes. Ultimately, it is the client, not the counselor, who must make and live with the decision to use (or not use) marijuana, medicinally or recreationally. 

“That doesn’t mean we leave them hanging and avoid helping in some way. That would be risking invalidating the client’s concern and a missed opportunity to be supportive,” St. Amant says. “We can help our clients by providing education, teaching problem-solving skills, eliciting their decision-making process, validating their concerns and promoting their empowerment and autonomy. … Even for us experienced counselors, it’s vital to ensure we are staying true to the fundamentals of client-centered principles. Those that are particularly relevant here include the fact that clients are the experts in their own lives and that we genuinely trust that they can decide what’s best for them.”

Decision-making

Talking about a client’s marijuana use in counseling sessions will have a very different dynamic depending on whether the individual is voluntarily pursuing treatment or has been mandated to complete therapy, often as the outcome of a court case.

In the second scenario, practitioners must remember — and explain to the client — that their work goes beyond the needs of the individual client, Norton says. The client may want to get their driver’s license returned after a DUI violation, for example, and this is contingent on completing a regimen of counseling sessions. 

“The counselor is responsible not only for the safety of their client but [also for] the safety of the public,” Norton says. “You have to address the issue [of their marijuana use]. You can’t ethically clear them if they’re just as unsafe now [at the conclusion of therapy] as when they first came to you. Counselors now have more than one stakeholder in what you do.”

Norton is a counselor supervisor, and his interns often work with clients who are mandated to complete counseling after a DUI or whose children have been removed from their care by child protective services because of their marijuana use and related behaviors. Norton also sees similar scenarios in the work he does as a substance use and DUI evaluator for the court system in Florida.

It is common for clients to try to skirt the sobriety requirements in mandated treatment situations by obtaining a medical marijuana card, according to Norton. This scenario puts the counselor in a no-win situation because the client has a way to legally obtain marijuana and continue their behaviors, he says. Addressing the root of the problem that brought the client into counseling becomes exponentially harder because the counselor is not a medical professional and cannot advise the client to stop a medically prescribed treatment, Norton points out.

Norton’s experience — and frustration — with this scenario led him to create a decision-making matrix (see below) for counselors to use when discussing marijuana use with clients who have been prescribed legal cannabis for medical use.

When addressing marijuana use in counseling sessions, Norton suggests that practitioners focus on clients’ motivation to change and their attitudes toward stopping their use of marijuana. His model offers different treatment scenarios for clients who have and have not been diagnosed with a substance use disorder and for situations in which the counselor has leverage (i.e., resources or outcomes the client wants, such as the return of a driver’s license or child custody, that are conditional to successful treatment completion).

In the case of clients who want to stop using cannabis, the counselor can collaborate with and refer them to a physician to find an alternative treatment. For those who do not want to stop using cannabis, the counselor can take a harm reduction approach to make gains toward behavior change in other ways, Norton explains. This includes strategies such as using motivational interviewing to explore the client’s thoughts on continuing their marijuana use or co-creating a “preventative strategy plan” with the client to identify benchmarks such as avoiding driving while using cannabis.

A harm reduction approach can prompt growth and behavior change in clients even while they continue to use cannabis — and much more so than simply leaving it unaddressed, Norton emphasizes.

Taking a nonconfrontational and supportive approach

Many of the harm reduction techniques Norton includes in his decision-making matrix involve collaboration between the counselor and the client. This ensures the counselor meets the client where they are, he says, and increases the likelihood of positive behavior change.

Katharine Sperandio, Daniel Gutierrez, Alex Hiller and Shuhui Fan, co-authors of the April 2021 Journal of Addictions & Offender Counseling article “The lived experiences of addiction counselors after marijuana legalization,” interviewed six professional counselors in Washington and Colorado (the first states to legalize marijuana for recreational use) who work with clients experiencing substance use disorders. They found that using a nonconfrontational, “motivational enhancement” approach with clients regarding marijuana use was more beneficial than addressing it head-on.

One participant in the study provided an example of a nonconfrontational approach. They broached clients’ marijuana use by framing it as a question: “Why do you think it’s a problem for you?” 

The co-authors also learned that with the legalization of marijuana, practitioners are seeing an increase in client justification and rationalization of marijuana use and less acceptance that it can be harmful or problematic, particularly among adolescents. Many clients were found to be using legal marijuana to numb negative thoughts and emotions, ease chronic pain, cope with trauma and “as a substitute for alcohol or other drugs rather than seeking [counseling] treatment because it was so readily available.”

The study participants also reported that clients were “more likely to walk out of treatment” and less likely to communicate about marijuana use (even if it was a source of other problems) if they felt there was a policy or recommendation to decrease marijuana use.

When school students are facing discipline for marijuana use, addressing it in a supportive way is the best approach to discourage those students from returning to risky behaviors, McClain says. When possible, it is helpful to involve the student and their parent(s) or guardian(s) as well as the school counselor and administrator to ensure that the student has a support system and reentry plan that doesn’t involve marijuana use and related behaviors, he says. Such a plan might include regular check-in conversations with a school counselor.

Taking a holistic approach, rather than only punishing, avoids setting the student up for failure and ensures that all of the student’s stakeholders are on the same page, McClain adds.

“We want to make sure they have a support system, including a counselor, to turn to for help. As much as we can surround them with support, hopefully the outcome will be better,” says McClain, who has worked as a school counselor for 17 years.

Case example

An adult woman came to see Britton for PTSD after experiencing sexual trauma. The client was experiencing intense flashbacks, having trouble sleeping and struggling with chronic pain. Britton surmised that the pain was related to her trauma because the client held her trauma in her body.

Britton used dialectical behavior therapy with the client, who made a small amount of progress in the first year but eventually stalled despite staying engaged in sessions and showing a willingness to try exercise and other actions that Britton suggested. The client continued to be plagued with sleep difficulties and night terrors, even while using a prescription sleep aid. Britton continued to co-treat the client while referring her to a practitioner who specialized in eye movement desensitization and reprocessing (EMDR) therapy.

“It took her a long time to forge trust; it took her several months to even tell me what happened. Once we got to that part, we started making some progress, but then she hit a wall,” Britton recalls. “Not only was the EMDR not helpful, but she [also] found it upsetting and she started going downhill, discouraged that she’d ‘never get better.’ … She felt really stuck and scared, and we weren’t making a whole lot of progress. The more she couldn’t sleep, the worse her symptoms got.”

Avgust Avgustus/Shutterstock.com

Eventually, the client brought up the possibility of trying medical marijuana. Britton responded by saying that she couldn’t advise her on whether it would be effective, but she could write a letter confirming that the client had PTSD in case she wanted to pursue obtaining a medical marijuana card.

Ultimately, the client did receive a medical marijuana card and began using cannabis to alleviate her pain and trauma symptoms. 

“It wasn’t a miracle cure. … She still presented with some trauma symptoms [while using medical marijuana], but it helped her sleep, and that was huge,” Britton says. “It didn’t ‘cure’ her, but it took the edge off so she could look at things a little clearer, and she started feeling some hope [after] feeling so deflated, so defeated. It gave her the energy to work toward some other behavioral treatments. 

“She wasn’t drug seeking; she was seeking symptom relief. It helped enable her to do the work that was in front of us [and] gave her the braveness to face it. It was just part of [her treatment]. It wasn’t the full answer, but I was glad we tried it.”

Bias management

The counselors interviewed for this article agree that clinicians have a responsibility to seek training, consult with colleagues and stay up to date on the regulations regarding marijuana in their area as well as the ways that its use — and misuse — can affect mental health.

At the same time, counselors are ethically bound to keep their personal views about marijuana (and all substance use) out of their counseling work, St. Amant notes.

“Substance use exists on a spectrum, and just because someone uses legal or illegal substances does not mean they have a substance use disorder,” she says. “Counselors must be careful not to impose their own values about substances use on their clients or project their own beliefs onto others. When the use of substances is conceptualized as a moral concern or a personal failing, we add to the stigma of substance use. Our attitudes must remain nonjudgmental and nonmoralistic when it comes to substances.”

 

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Can counselors use legalized marijuana?

In states where marijuana use is legal for medicinal or recreational purposes, counselors have the right to use it on their own time, but they also have the ethical obligation to ensure that it does not cause an impairment to their clinical performance and their relationship with their clients. They can do this by approaching it the same way they do with alcohol use.

Counselors can ethically use legal substances as long as they do not perform clinical duties under the influence, the use does not impair their ability to function (e.g., seeing clients while experiencing a hangover or the prolonged impacts of the substance) and they are able to use the substances responsibly (e.g., not driving under the influence). If counselors choose to use legalized marijuana, one should be aware of how long the effects last (which can linger into the next day for marijuana) and ensure that no pictures are posted of them using the substance on social media.

If counselors have difficulty controlling their use or if it affects their health or clinical abilities, they should seek out an evaluation to see if they could benefit from treatment, and they should refrain from providing clinical care until it’s determined that they can do so safely and ethically.

Our ethics are founded upon ensuring client safety and preventing harm to those we serve, so our clients’ right to be protected from potential harm by their counselor using substances supersedes our personal freedom during the time in which we are working with them. Yes, we counselors are adults who are allowed to live our lives how we personally see fit, but, no, our personal choices cannot come at the cost of our clients’ safety.

See Standards C.2.g. and A.1.a. of the 2014 ACA Code of Ethics at counseling.org/ethics.

— Emily St. Amant, counseling resources and continuing education specialist for ACA

 

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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.

The rise of counselors on social media

By Lindsey Phillips March 25, 2022

Micheline Maalouf, a licensed mental health counselor and owner of Serein Counseling in Orlando, Florida, started making YouTube videos with inspirational and educational messages in 2018, but they weren’t reaching many followers, and making them often consumed a lot of her time. In 2020, her friend suggested she use TikTok, a video-sharing app well-known for its dance challenges, to educate people about mental health. These videos are short, ranging from a few seconds to three minutes, and she worried she wouldn’t be able to provide helpful information in this bite-sized form. But she decided to try it.

Florian Schmetz/Unsplash.com

At first, she created a few fun videos, including one that featured her dancing around her office by herself celebrating a client’s breakthrough. Then she decided to make a short video that introduced herself as a counselor and listed her specialties. That video gained her 120,000 followers overnight.

“From that video, I started getting a lot of questions” about mental health, such as how to manage anxiety or what to do if you have a panic attack, Maalouf recalls. “So, I started generating content based on the questions I was being asked.” That’s when she realized the potential this social media platform offered.

Navigating the unknown

Tristan Collazo, a licensed resident in counseling at Wholehearted Counseling in Virginia Beach and Carrollton, Virginia, was taught in school not to add clients on social media, but newer platforms such as TikTok are changing the rules because counselors don’t have any control over who “follows” them.

To further complicate the matter, some counselors are now getting clients based on their social media posts. Collazo says social media has functioned as a referral source for him because a few of his clients found him through his Instagram or TikTok posts.

This is unfamiliar territory, Collazo notes. Counseling programs “taught us all about boundaries,” he says, “but this is so new that it wasn’t even brought up.”

He constantly talks with his supervisor about how to set boundaries around social media, especially for clients who follow him. From these discussions, he has established some guidelines: He makes social media posts, but that’s where his engagement with his followers (and any possible clients) ends. He doesn’t respond to direct messages. He also includes social media in his disclosure statements and discusses it verbally with clients.

Shani Tran, a licensed professional clinical counselor, suggests counselors add disclaimer statements on the social media content they create. She became overwhelmed with the high volume of comments and questions on her TikTok videos, so she joined a group for therapists on TikTok. Together this group decided to create disclaimers stating their online content is educational and not a replacement for therapy.

Lindsay Fleming, a licensed professional counselor (LPC) with a private practice, Main Street Counseling Solutions, in Park Ridge, Illinois, also creates a clear boundary between her social media presence and her therapeutic one. She gives her clients the option to block her on social media, and she tells them that she will not respond if they do comment on her content and that she will not follow them.

She encourages counselors to make social media a part of the conversation in session. She often asks if clients have seen any of her posts online. If they have, she asks how they feel about the videos they have seen and if any made them feel uncomfortable. This gives them the space to talk and process if needed.

Tran receives daily follower requests based on her social media posts, but many are unaware that they must find a counselor licensed in their state. It’s hard, she says, because she doesn’t like having to turn down someone who needs help. For that reason, she added a link under her profile name that provides her followers with more mental health resources, including ways to find a mental health provider.

She also cautions clinicians against responding to comments or direct messages from people asking for clinical advice about their situation or potential mental health diagnosis. If counselors answer them, they could technically be entering into a therapeutic contract without paperwork, she warns, which is unethical.

Self-disclosing

Social media allows people “to see therapists before they are in the room with them,” says Tran, owner and founder of The Shani Project, a group counseling practice in Minneapolis. “They get to see what content therapists put out, what their voice sounds like when they talk, [and] how they talk about the different specialties. … They get an inside look into the therapists’ own personal lives.”

Allowing others to see the human behind the professional has benefits and potential challenges, so Ilyse Kennedy, an LPC and licensed marriage and family therapist, recommends counselors still maintain healthy boundaries when self-disclosing. But what these boundaries look like can vary from clinician to clinician.

Kennedy, founder of the group practice Moving Parts Psychotherapy in Austin, Texas, shares her own healing journey to normalize therapy, but she’s careful not to overshare to the point clients may worry she’s unable to do her job. For her, posting about having a glass of wine to calm down after a stressful day would cross a professional boundary because it is an unhealthy coping behavior for some. There’s nothing wrong with counselors drinking a glass of wine, she says, but she feels more comfortable sharing other coping strategies such as watching reality television.

Maalouf also discusses her mental health on social media to remind others that “mental health doesn’t discriminate” and to start a conversation on various resources and support systems that can help. Some of her clients have told her that it’s validating to see she’s also working on her own mental health concerns like they are.

But counselors have to be careful with the information they share and how they discuss this with clients, says Maalouf. A client who once saw a video she posted about struggling with depression asked her at the start of the session whether she was OK and able to see her in session that day. Maalouf reassured the client that she is fully present when she comes into work and that she takes mental health days if needed.

Is social media right for me?

Social media allows counselors to humanize the profession, educate others about mental health and even connect people with the resources and services they need. With all these benefits, counselors may find themselves contemplating if they too should create social media accounts.

“Social media is not for everyone,” Maalouf cautions. “There are people that would love it because they enjoy educating and helping people, but then when they get on it, their levels of anxiety go up because they don’t feel safe enough doing it [or] don’t know how to do it appropriately.” She recommends counselors carefully consider the reason and purpose behind why they are joining social media.

“If the purpose is because you love making this type of content or love educating on a large scale, then go for it,” Maalouf says, “and remind yourself why you’re doing it.”

Here are a few tips for counselors who decide they do want to use social media for marketing their business or as a tool to promote or advocate for mental health:

  • Grab people’s attention. If your content doesn’t capture the audience’s attention quickly, you could lose them, Collazo says. He often uses slogans such as “You are not alone” or “Bet you’ve never heard about this before” within the first few seconds of his videos to engage his followers.
  • Don’t compare yourself to others. Avoid modeling yourself and your content after others, Maalouf says, and don’t focus on how many followers you have. Instead, focus on your purpose and the goals you want to achieve. She says she’s seen therapists who begin to doubt their own clinical skills because their videos aren’t getting as much attention or doing as well as another clinician’s. “A lot of social media has to do with timing and has nothing to do if you are better than another person,” she notes.
  • Develop a thick skin. Prepare for negative, hateful comments, Maalouf advises, because you will get them. “You cannot read into those comments and take them personally,” she says. “Remember you’re not going to please everybody.”
  • Find support. Fleming and Maalouf both recommend counselors find support systems. Maalouf has a group chat with other therapists who are on TikTok and Instagram, and they check in with each other regularly. Fleming consults with other mental health professionals on potential social media content she’s creating to make sure she’s getting her message across in a healthy, educational way. These colleagues can also serve as a source of support if counselors receive hurtful comments or their posts are taken out of context. Fleming once had a video she made about suicide awareness altered by another person so that the audio said, “Go kill yourself.” This was a triggering moment for Fleming, but her online counseling friends reached out and offered support.
  • Remember, it’s hard work. Creating content and gaining a large following isn’t easy, Trans says. It’s a job that comes with its own stress.

Expanding the reach

Social media, of course, is no replacement for therapy, but more people, especially youth, are turning to these platforms for mental health advice and to share their own mental health struggles. As of March 2022, TikTok videos with the hashtag #mentalhealth had been viewed more than 29 billion times, which shows the popularity of this content.

Many worry this app could be making mental health concerns worse, not better. Recently, several states have begun investigating the potential effect TikTok may be having on young people’s mental and physical health.

Counselors, however, have an opportunity to use these platforms to offset misinformation and educate others on mental health. “Every therapist has their specialties, they have a unique personality, [and] they have something they can offer,” Collazo says. They “can add value to TikTok among all the misinformation.”

Social media can also normalize the process of going to counseling. Collazo’s first TikTok video explained why counselors don’t hug you or hand you tissues in session, and it got more than 200,000 views. That motivated him to keep going. If this information was new to people, he wondered what else could be interesting and educational for them. So, he made videos explaining why counselors have a clock in the room and why the chairs are a certain distance apart.

Many people have an inaccurate understanding of what happens in session, Fleming says. They sometimes assume that they have to talk about anxiety or their feelings the entire time. She’s created TikTok videos that demystify what therapy looks like.

TikTok videos on mental health are “having a big impact on people,” Fleming says, “and helping people recognize it’s OK if they don’t want to feel like this and [that] they can feel better.”

Social media has the added benefit of potentially decreasing the stigma around certain mental health issues. Kennedy has noticed an increase in posts about trauma, neurodivergence and mental health concerns that often have been highly stigmatized, such as autism and obsessive-compulsive disorder. “There wasn’t a lot of information about how it really feels to experience them [these stigmatized diagnoses],” she notes. “And now that we have social media where people are sharing their … experiences of living with these diagnoses, people are resonating with that and noticing the stereotypes of it versus how it actually feels to live with it.”

Social media can also allow more access to mental health care for people who might not be able to go to counseling because of the expense or time constraints, Kennedy says. “Not everybody has insurance that covers it or … can afford sliding-scale therapy,” she notes. The social media content, however, “can allow some access to the beginnings of self-healing work, which is really important.” Counselors can also use social media to connect people with resources and find low-cost counseling services, she adds.

“I do not think the rise of therapists on social media is keeping people from therapy. I think it’s actually helping more people seek out therapy,” Kennedy says. Going to counseling can be scary for many, especially those who have experienced trauma, she continues, “so feeling like you already have a sense of a therapist because of social media can make you feel a lot more comfortable to take the first step in reaching out.”

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Related reading:

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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.

Behind the Book: Counseling Leaders and Advocates: Strengthening the Future of the Profession

Compiled by Lindsey Phillips March 14, 2022

The future of the counseling profession depends on the leadership and advocacy of its current and future members. But what makes a good leader or advocate and what can clinicians learn from current counseling leaders?

Counseling Leaders & Advocates: Strengthening the Future of the Profession, an ACA-published book co-edited by Cassandra Storlie and Barbara Herlihy, explores these questions by examining the personal and professional experiences of prominent leaders and advocates in the field.

The profiled leaders in this book do not name a single leadership theory that guides their work, but as Storlie and Herlihy point out in the introduction, they all “speak of leadership as a process of empowering others and as an opportunity to advocate.” They don’t “espouse a traditional view of leadership as a power-over position,” they note, “rather, they speak of ‘leading from behind,’ working ‘behind the scenes,’ and ‘leading by doing,’ not for their own aggrandizement but to move our profession forward and improve services to our clients.”

The COVID-19 pandemic and systemic racism and injustices will continue to challenge leadership and advocacy. Storlie and Herlihy hope this book will encourage the next generation of leaders and advocates who, they argue, “must embrace the complex issues facing our clients, the profession as a whole, and our national and global societies if we are to advance and continue to distinguish excellence in professional counseling.”

 

Q+A: Counseling Leaders and Advocates: Strengthening the Future of the Profession

Responses are written by editors Storlie and Herlihy. Storlie is a licensed professional clinical counselor supervisor and an associate professor and doctoral program coordinator in the counselor education and supervision program at Kent State University. Herlihy is a professor in practice and doctoral program director in the counselor education program at the University of Texas at San Antonio as well as professor emeritus in the College of Education and Human Development at the University of New Orleans.

 

How are leadership and advocacy similar and how are they different?

As counselors, it is natural for us to consider ourselves advocates. We advocate for clients, groups, families and communities and on behalf of our profession. Advocates are driven by a passion to make positive change in the lives of their clients, in the systems that contribute to marginalization and oppression of clients and client populations, and in the profession for the purpose of increasing our capacity to reach and help those in need. Yet, many of us do not consider ourselves leaders.

Leadership and advocacy are inherently related, and advocacy initiatives taken on by counseling leaders affect our world today. Most importantly, leadership in counseling has been emphasized from the servant leader perspective (a phrase coined by Robert K. Greenleaf in 1970). The leaders profiled in our book did not view leadership as a power-over position. Instead, they saw it as leading by doing and working behind the scenes for the sake of moving the profession forward and improving client services. As such, one can deduce that leadership in counseling is ineffective when leadership practices move away from our core values as professional counselors. That said, if you are a leader in counseling, you are most likely an advocate. If you are an advocate in counseling, you are most likely a leader!

 

What qualities or personal characteristics are essential to being a good leader or advocate?

Taking information from the areas of servant leadership (Greenleaf, The Servant as Leader, 1970), authentic leadership (Bill George, Authentic Leadership: Rediscovering the Secrets to Creating Lasting Value, 2003) and transformational leadership (Ronald Piccolo and Jason Colquitt, “Transformational leadership and job behaviors: The mediating role of core job characteristics,” 2006) literature, good leaders and advocates share power and allow for space to include all voices. They are genuine, relational, ethical, motivating and inspirational. In addition, given the challenging times in which we are living, it is essential for leaders to be adaptive and to help others understand the complexities of their environment to better help people deal with change.

 

How does being culturally responsive change the way a counselor approaches leadership?

We don’t know where we are going if we don’t know where we have been. By striving for culturally responsive counseling leadership, we embark on a journey in which we voluntarily accept both the privilege and responsibility of intervening. Culturally responsive leaders will help our profession become stronger and more inclusive, representing more diverse voices and combatting systemic injustices. These leaders also examine how their intersectionality (a term coined by Kimberlé Crenshaw) affects others. They focus on challenging their worldviews to uncover unconscious bias and move forward reflectively to ameliorate barriers to inclusion.

 

Leadership does not always mean serving in formal positions (e.g., president of a counseling organization). What other ways can counselors be leaders and advocates within and outside the profession?

Formal leadership is just one of the ways you can be a leader and advocate in our profession. In Chapter 3 of the book, Michael Brubaker and Andrew Wood highlight previous scholars who have shown us the importance of developing advocacy dispositions, relationships and knowledge to set up and best execute and evaluate advocacy plans. These efforts can be conducted within the counseling profession or outside the profession. We also think it’s important to carefully select counseling sites or populations you work with and partnerships that allow you to best formulate your leadership and advocacy plans. Perhaps it’s partnering with a school district or joining a local National Alliance on Mental Illness (NAMI) group to better support the mental health needs of your community. There are myriad ways in which counselors can be leaders and advocates — and as we mentioned earlier, you probably already are!

 

What are some key takeaways from the stories of counseling leaders and advocates in the book?

Ahhh … key takeaways! Well, one thing that stood out for us is how many leaders have served as role models and mentors to others within the profession, and how deeply they appreciated their own mentors. Additional principles that were woven throughout their stories were having a vision for the future, encouraging and empowering others, recognizing the contributions of others, and engaging in self-reflection. We think it is also important to point out that each leader shared their own experiences of adversity that they overcame — showing us that these individuals, who have passion and purpose, also had to dig deep to gain resilience as leaders and advocates.

 

How do counselors overcome challenges and setbacks in their career and how does this shape the leader or advocate they become?

Of the leaders and advocates we profiled, each had their own unique challenges and setbacks. As Devon Romero, Madelyn Duffey and myself (Cassie) synthesized in Chapter 17, these leaders were “People who encountered doubt and persevered in the face of grief, loss, and adversity … [and] who made mistakes and desired to learn from them. …[This] adversity shaped who they are, how they lead, and what they value.”

One of the ways counselors can overcome challenges and setbacks in their career is to use their skill sets to be reflective about what they are experiencing. Both of us have reflected on setbacks in our own careers and found it helpful to explore what we have learned from the challenging experiences. If we can use a professional challenge to bring added value to our lives, then we are navigating our professional journey with perseverance.

 

What role do mentors and supervisors play in shaping new leaders and advocates in the profession?

Mentoring is crucial for the development of new leaders and advocates. Good mentors are those who make time to be available to their mentees (often throughout several decades), who convey a belief in these mentees when they don’t yet believe in themselves, and who open doors to provide opportunities to gain leadership and advocacy experience. Mentors can also be sponsors in that they are looking out for possibilities for their mentees when those mentees are not present.

We believe that being a good role model and truly modeling culturally responsive leadership can be a valued lesson for mentees. My (Cassie’s) mentors have been and still are culturally responsive leaders and open to growth in their own development as professionals and individuals.

The counselors profiled in the book spoke with gratitude of their own mentors, and they took pride in the mentoring they have provided to others over the years. Our current leaders and advocates have a strong commitment to “pay it forward,” which seems to make it inevitable that this commitment will transfer to the next generation and to generations to come.

 

What practical advice do you have for counselors as they move into leadership and advocacy positions in the counseling profession?

In the book, we offered five suggestions for aspiring leaders and advocates. First, find a mentor. Mentors can help you navigate your way toward gaining leadership experience and learning to advocate in ways that fit with your passions. Second, start small. Most of us have difficulty even imagining ourselves ever becoming as accomplished as the leaders and advocates profiled in the book. Rather than immobilize yourself with comparisons, realize that opportunities for leadership and advocacy are all around you, and volunteer for a small opportunity to serve a cause about which you care deeply. Third, keep your balance. This suggestion serves as a reminder of the importance of self-care and life-work balance. Fourth, lead to serve rather than acting out of a need to fill a line on one’s vita or to feel important. Servant leaders are absolutely the most effective leaders we have in our profession. Last, trust yourself. If someone sees something in you, it’s because it’s already there.

 

What is the most important or surprising lesson you have learned about leadership throughout your own counseling career?

For Barbara, it was the realization that leadership is composed of a set of behaviors rather than holding a formal title or position. Many, if not most, of our leaders and advocates are working behind the scenes, fostering change and furthering social justice initiatives without a need for recognition.

I (Cassie) second all that Barbara outlined above, and I also want to point out the important need to intentionally “pay it forward” and help to mentor others’ leadership development.

 

What does being a leader mean in today’s social climate, especially considering the ongoing COVID-19 pandemic and social unrest?

That is an excellent question! In the current political and social climate, a starting point for bringing people together in peace is for us to use our basic counseling skills such as listening — really listening — in an attempt to understand beliefs and values that clash with our own. We counselors have the skills to build bridges!

We also need to ensure we can have the crucial conversations necessary to help make sustainable change. We recognize this change does not happen overnight, but we also realize that change will never happen if we don’t talk about uncomfortable topics and honor the human dignity of everyone.

 

What practical actions can leaders take to combat systemic injustices and racism in the counseling profession and society at large?

We believe that silence in the face of injustice and racism is collusion. Leaders who are in the privileged position of being respected and admired have an obligation to speak up and confront injustice and prejudice, both within our profession and in the larger world. Although practical actions may look different at the microsystem level versus the macrosystem level, counselors can tailor their actions to advocate with and on behalf of those most marginalized. Additional actions can be further developed when integrating the Multicultural and Social Justice Counseling Competencies into one’s work.

 

In the book, you call on the counseling profession “to nurture, mentor, and increase diversity among future leaders.” How can the counseling profession address the lack of diversity within counseling leaders moving forward?

One thing we can do is to monitor our own implicit biases as we identify up-and-coming leaders who might benefit from opportunities to join with us in the work we are doing. We can also remember that diversity involves the intersection of multiple identities, not just those that are visible. Many of the leaders profiled in the book were aware of their privilege and were committed to ensuring they were inclusive as they were “paying it forward.”

 

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Counseling Leaders & Advocates: Strengthening the Future of the Profession was published by the American Counseling Association in 2021. It is available both in print and as an e-book at counseling.org/store or by calling 800-298-2276.

Watch ACA President S. Kent Butler’s conversation with Cassandra Storlie in a recent episode of the “Voice of Counseling” video podcast: https://youtu.be/157o_3QrHwk

 

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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.