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Counselors Audience

Two years in: Reflecting on counseling during a pandemic

Compiled by Bethany Bray March 1, 2022

This month marks two years since the World Health Organization (WHO) declared the outbreak of the SARS-CoV-2 virus, more commonly known as COVID-19, a pandemic. At the time, there were more than 118,000 recognized cases of the coronavirus in 114 countries and just under 4,300 deaths attributed to it. Those numbers have now climbed to more than 430 million confirmed cases and close to 6 million deaths worldwide.

Pandemic is not a word to use lightly or carelessly,” said WHO Director-General Tedros Adhanom Ghebreyesus in his March 11, 2020, announcement. “This is not just a public health crisis, it is a crisis that will touch every sector — so every sector and every individual must be involved in the fight. … Let’s all look out for each other, because we need each other.”

His prediction that the virus would touch “every sector” has proved true for the counseling profession. Counselors have met challenge after challenge brought on by the pandemic, including adopting and adapting to telebehavioral health, supporting clients’ and students’ shifting needs and managing overbooked caseloads as a surge of new clients sought help. In addition to these professional challenges, clinicians have had to attend to other needs in their personal lives such as caring for family members or recovering from the virus themselves. 

The past two years have demanded creativity, advocacy, flexibility, compassion and a seemingly endless list of other qualities from counselors. And for all counselors, it has been a learning experience. Counseling Today recently contacted an assortment of professional counselors from around the country to ask what the pandemic has taught them. In this article, they share their reflections and their lessons learned in their own words.

 

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It takes a lot to be a person today.

There have been times over the past few years when I’ve wondered: Who am I to be sitting in the therapist chair? When I decided to become a counselor, I never expected to live and work through a global pandemic. COVID-19 has left me feeling vulnerable and grateful, with many other emotions pulsing within me at various times. As I’ve heard others exclaim quite passionately these past few years, “This was not on my vision board!”

As a therapist, I believe the most important aspect of my job is to simply hold space for others. Holding space implies creating a safe platform between individuals that fosters empathy, compassion and healing. It says that each person welcomed into the dialogue is so incredibly special that time is invited to stand still while they process life together. Therapeutically, holding space empowers a client with the opportunity to feel all of their feels and process life experience(s) with empowerment and confidence.

Today, I find both myself and my clients collectively sharing the same trauma. A global pandemic impacts each of us on every level of our experience, from our basic needs to existential thoughts of “Why are we here?” and “How did this even happen?”

Sometimes I feel like we’re in this strange paradigm of history and science fiction colliding into our actual experience. Despite our global situation, all of our individual anxieties and fears still exist as life continues to flow, even during worldwide crises. It takes effort to separate the individual from the collective experiences, as life is truly merging on every level, from how we work and go to school to how we communicate with our peers at our most intimate levels.

There has never been a time when I have needed to be more present and honest with my own vulnerabilities, both personally and professionally. While holding space for others, I have often felt safe being held in the space of my clients. We are walking each other through these uncertain times, and I am grateful for the many hands I have held and [for] those who have
held mine.

Jen Monika McCurdy is a licensed professional counselor (LPC) in St. Louis who owns and operates a private practice, JM Wellness. Her passion is to empower her clients to live the life they most wish to live.

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I remember sitting at home as a new mom holding my baby as the world shut down and COVID-19 changed everything. Nobody knew what to expect, but it was the beginning of a collective experience that has forever changed us.

We have been forced to grieve unimaginable losses, change many plans and accept our lack of control at the same time as we suffered other hardships like job losses, closed schools and being unable to visit relatives. Clients who already felt behind in the relationship world had to grapple with an extended break from dating.

Simple decisions, like spending time with family or friends, were suddenly filled with complexity. At times we thought we were safe, excited to drop our fear and feel more normal, and then a new variant or surge hit. We have learned to pause more, not take things for granted and recalibrate our expectations.

In the past as a counselor and coach, I’ve related to my clients and their experiences, but through COVID-19, we were all experiencing similar anxieties and hard decisions simultaneously. I’ve also had to adapt professionally and learn to put my own pandemic stress and anxiety aside to hold space for my clients.

There is something empowering about remembering we can adapt and be resilient; I believe we underestimate our ability to change. Somehow, through some very dark, isolating and scary moments, we have found our path. Pre-pandemic, we might not have believed we could, but we have confronted the illusion of control and learned to live with more ambiguity.

Professionally, I have grown to love working from my home office and speaking to clients from their homes. Many of my clients who used to be out and about 24/7 have soaked in the benefits of solitude. Through healthy self-care habits, creating structure and routine at home, and staying connected, we have all changed in ways we would have never predicted. Watching these lessons play out in therapy has allowed me to feel just as connected to my clients, even though it has been years since we have sat together in the same office.

Personally, although I grieve the lack of normalcy in my daughter’s early years, I will be forever grateful for the extra time we have had together.

Rachel Dack is a licensed clinical professional counselor (LCPC) and dating and relationship coach who owns a private practice in Bethesda, Maryland, and specializes in dating and relationship issues and anxiety.

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The counseling world we once knew has been shaken by COVID-19 in ways no one could have imagined. Our routines, no matter our age or stage, have been shattered, and we’ve only ever been given the option to pick up and make sense of the pieces. The one thing that all healers and journey goers alike have in common is the uncertainty married to the pandemic, which doesn’t allow for normalization. “Normal” already had a loose definition to begin with, but COVID-19’s reign has shaken up every case of normalcy. Even with everything upside down, we’ve all been striving to find a new normal, and one thing we’ve learned from COVID-19 is to keep going.

The clients — journey goers and brave souls — were forced to face challenges alone, but they were able to hear and validate their own opinions in the process. People learned they could be their own biggest support system and how to really take care of themselves. With extra time placed in their laps, they learned that they deserve more.

In regard to clinicians, if anything, we’ve learned to focus on what matters. This pandemic forced a shift in our thinking and redirected our perspectives, but ultimately, we’ve become undeniably resilient. We’ve made meaning of struggles — our own and of others’ — and found a way to show up every day.

As far as me, I’ve learned to trust the process and honor not only the struggle but also the strength we’ve had no other option but to find. We don’t have to find a new normal when we can help to create it. I was able to fall in love with this profession all over again, but this time in a different shade of light.

And to my fellow colleagues and all healers alike, keep showing up. You are needed, you are valued, and you are necessary. With that said, make sure you’re saving some of that care, concern and love for yourself because you deserve it too.

To quote Maya Angelou, “You may not control all the events that happen to you, but you can decide not to be reduced by them.”

Mykia Hollis-Griffith is an LPC, licensed marriage and family therapist associate (LMFT-A) and owner of a private practice, The Mindful Life Company, in Killeen, Texas.

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When the COVID-19 pandemic began, the world was overwhelmed with fear for themselves [and for] loved ones and fear of what was to come. All the while, mental health workers, doctors, nurses and other “essential” workers were dedicated to ensuring their needs were met. It was during this time that I learned the most about myself, my clients, the counseling profession and mental health overall.

Although I live and work in the small town of Erie, Pennsylvania, I realized that our struggles and fears were the same as the world’s struggles and fears. Living in a smaller town did not mean that I or my fellow Erieites were exempt from the issues plaguing the larger cities, but instead it meant that I could make a larger impact on the lives of those around me. I began to reflect on who I was professionally and what type of environment I wanted to provide to my clients, specifically those struggling with the weight of the pandemic.

I decided that I needed and wanted to provide a safe space for people to be who they are and to have open conversations about the pandemic, past traumas or other concerns. As my practice began to flourish, I noticed that people needed an outlet and found themselves at my office. Clients wanted to share, they wanted to feel better and, most importantly, they wanted
to grow.

I too wanted to grow. I found myself wondering if the counseling field was where I needed to be full time. As a professional counselor, witnessing the dedication shown by my clients was nothing short of amazing, particularly as the pandemic became scarier and more unpredictable.

It was then that my question was answered. I knew where I needed to devote all my professional time and why it was important to my growth as a person and a professional. The constantly changing landscape of the world due to the pandemic has forever changed how I view mental health. I have found that people are more honest about their struggles, more open to seeking help and more committed to themselves.

Throughout my counseling career, a major focus has been on helping clients build healthy, positive relationships [and] a foundation for the life they dream of, and grow into the person they want to become. The experience of counseling people through the COVID-19 pandemic has reaffirmed that my therapeutic approach is necessary and relevant.

Chelsea Curlett is an LPC and has been the owner of a private practice in Erie, Pennsylvania, for six years.

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We found ourselves in over our heads without a view of what was ahead. The rapid change and uncertainty forced us to adapt.

The first lesson I learned during the pandemic was that crafting masks out of whatever material I had on hand was difficult but doable. I assembled the first COVID-19 masks for my family with the help of a dusty sewing machine. At first, there was only one mask per person, which was not sustainable since they needed daily washing for repeated use each day. As the pandemic deepened, the skills of those artisans who crafted and sold masks permitted us to order and obtain multiple masks custom-fitted for each person. I was grateful.

This creative connection to the people making the masks around the world set the stage for many of the lessons I learned [that were] continually reinforced during the pandemic.

All life centers around relationships and is impacted by connection, location, choice and privilege. Relationships that I reflected on during this time related to the human condition and the context in which shared human experiences exist. Consequently, my own experience has been informed by my relationship to myself and how I relate with others. All relationships occur in context.

This notion had me consider how I relate to the past, present and future — through experiences and expectations [and] within the context of what is known and unknown. Throughout this process, I embraced stillness, commotion, loss, gain, choice, understanding and peace.

Change is difficult, but like making masks with whatever scattered materials are available, it is doable. I encourage all to consider how you have changed and adapted and found ways to connect your relationships to meaning and purpose, goals and aspirations, grit and determination, hope and healing.

Carrie B. Sanders, an assistant professor of counselor education at Radford University in Virginia, has a background in school counseling.

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I used to have a competition with myself on the drive home from my office. Cranking up the music, I’d dance in my car and tally how many other drivers I could get dancing when stopped at red lights. It was my way of shaking off the heaviness of the day. When COVID-19 hit and I got sick with it [the virus], I lost both my commute and the energy to dance.

When going through similar experiences as our clients, we need to take care of ourselves and our own reactions first. I know this is an obvious one, but I had to truly dig through this lesson in a different way during the first year of the pandemic. This past year, I completed my internal family systems Level 1 training. In learning to care for my own internal parts and helping clients to care for theirs, I gained a lightness that allowed me to better care for clients without carrying their burdens.

I continue to learn, repeatedly, how to say no in order to say yes. This means saying no to more work. Time off — and truly away from the responsibility of mental health care — is not just for fun; it’s a necessity. It also means setting boundaries. I sometimes need to say no to bids for my compassion by those outside my immediate circle in order to continue to say yes to my clients.

I continue to see fewer clients than I did pre-COVID, which I acknowledge is a privilege of working in private practice. To balance out the impact of my clinical load, I also prioritize other parts of my career, such as writing and freelance editing, and other nonclinical ways to share my expertise. 

Last week, I walked out my front door with my dog after closing my laptop, bundled up against the cold, dancing as I shook out the day. Whatever you do to shake out your day, I hope that you find a way to do it in the midst of the pandemic. And if you dance in your car or on your sidewalk after your final client today … let me know because my competition is back on.

Johanna Bond is a licensed mental health counselor (LMHC) in private practice in Rochester, New York. She is also a writer with prior work appearing in The New York Times, HuffPost and Psychology Today.

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I have learned the importance of presence on a deeper level during the pandemic. Being able to show up during this time as an anchor for clients’ nervous systems has been a powerful tool. Utilizing coregulation and resonance has been pivotal in working with clients with trauma.

In order to show up more fully in this way even across digital platforms, I took a course on mindful awareness and resonance in eye movement desensitization and reprocessing (EMDR) and completed rapid resolution therapy training, both of which focus on the connection between the client and the therapist and working within that relationship to shift the client’s experience, even if it’s brief therapy. Although the two trainings are very different, they both rely heavily on therapeutic presence.

The theme of learning about presence also flows into my personal life, as I’m so grateful to the people in my life supporting me so that I can support others.

Hillary Cook is an LCPC who owns and operates Idaho Trauma Therapy in Boise, Idaho.

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March 2020: A defining moment in our lives. There is before COVID-19 and after COVID-19. While there have certainly been other defining moments in our lifetime, none has lasted as long or affected as many individuals as this pandemic. The astonishing breadth, width and depth of this pandemic feels fictional — except that we are all living this collective trauma.

Having been a counselor and counselor educator for over 35 years, I felt competent to continue to assist my clients through this time. My basis for working is systemic, so incorporating an extended system did not seem difficult. I was wrong in many ways.

It seems to me that there were stages that we all went through during this time. Beginning in spring 2020, clients seemed to be optimistic about the length of time and severity of the virus. We continued to focus on the challenges they presented for counseling with a mention of the limitations that lockdowns, etc., were creating. However, some felt the isolation more than others.

The second stage, I believe, began around fall 2020. Schools were or were not reopening, work was still from home, [and] counseling was mainly on virtual platforms. A sense of frustration, fatigue and losing control of their environment began to appear in sessions. Many [clients] started with concerns about their external world — the pandemic, the political environment, climate changes. These challenges blended into their own personal work. In fact, in some cases, they overshadowed their personal issues. Feeling that they had no control over the world “outside” left some of them with an attitude of defeat.

The next stage came with the delta and omicron variants. My clients express not only frustration but [also] a sense of hopelessness in changing the world situation that is impacting each of us. This, of course, impacts the changes that are available for them in their personal choices. Lack of extended support, entertainment, travel and most interactions creates a loneliness that is nonrelated to their personal or relational challenges.

My professional journey has been somewhat the same as my clients’. I have learned to use virtual counseling, and while adequate, it lacks the connection of in-person work. I have dealt with the same feelings of frustration, isolation and lack of “normal” social interactions that support my sanity.

My work has become even more focused on mindfulness as well as other techniques and skills to quiet anxiety and relieve depression. Further[more], I endeavor to assist clients in understanding what they can control, what is beyond their control and how to advocate for what they deem worthy in order to make a difference, thereby gaining a sense of control.

Patricia W. Stevens is an LPC and private practitioner in Louisville, Colorado, who is a clinical fellow of the American Association for Marriage and Family Therapy.

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As a professional counselor, I have learned how important connection truly is. Both in private practice and within a university setting, young adults fear loneliness more than the virus itself.

I never thought I would adjust to telehealth, but to my surprise, I felt connected to my clients. Connecting remotely, whether from a bathroom, basement, car or the client’s own bed, allows for a more vulnerable experience. The client isn’t coming to your office, but rather you are meeting them in their space. I have found that clients open up more readily when they are in their own space. Vulnerability breeds connection.

During this time, I am reminded of how much we need people rather than “stuff” to make us happy. It’s amazing how much active listening, eye contact and empathy can transfer online.

In nearly 20 years of experience, I am seeing loneliness and loss of motivation as top reasons young adults seek help. The pandemic is also intensifying symptoms of anxiety and depression. People want to see each other. In America, isolation is a punishment.

The best way to help clients is to encourage connection, but how do we do this in the midst of a pandemic where we are told to refrain from in-person social interactions? I have found that people are amazingly resilient and adept at connecting. Netflix movie dates, FaceTiming, online gaming groups, working remotely, virtual coffee breaks — it’s amazing how technology is helping us stay united.

Three years ago, after working in a university for 16 years, I decided to open up my own private practice. Six months later, the pandemic hit, and my appointments went from in-person to 100% virtual. I think I learned more in the last two years than I ever would have without being forced to go online. In a sense, I was learning and adapting with my clients. Shared experiences breed connection.

Life surprises us. I was surprised that I am able to connect and ignite change in clients who are not sitting right in front of me. I am humbled by the resilience I see in my clients and myself. My advice is to go into things with an open mind. You may be surprised at what you find.

Nicole Lowry is an LPC with a private practice in Erie, Pennsylvania, and is the assistant director of the Personal Counseling Office at Penn State Behrend.  

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In these last two years, I have learned several valuable lessons, [the most important of which is that] telehealth can be a viable and accessible way to provide therapy. As a clinician practicing in a remote and rural part of the country, I valued the ability to provide flexible appointments to clients who often have systematic barriers that limit their access to counseling services. [This work has] reminded me of the importance of hope in managing life’s challenges and facilitating posttraumatic growth. It reoriented me and a lot of my clients toward appreciating the mundane and ordinary parts of life, which coincidentally were the most noticeably absent during the pandemic.

The analogy that “we are all in the same storm but not in the same boat” has been a valuable reminder regarding the differential impact of the COVID-19 pandemic throughout the global community. It emphasizes the diversity of outcomes within these collective experiences by reminding us that while we may all be in the middle of the same storm, we are impacted in a different way. Either we have a sailboat of skills and resources, a lifeboat of support, or we are out in the middle of the ocean with neither. During this time, I witnessed clients navigate challenges related to isolation, health, finances, child care, transportation, food, employment, education, racial disparities and mental health. I was often reminded about the importance of a strong therapeutic alliance and how it was nurtured and strengthened by the shared commiseration of dealing with uncertainty and the collective empathy of navigating existential fears while managing everyday stressors. 

While dealing with the mishaps and challenges of technology has required patience, telehealth has been invaluable in allowing me access to clients’ lives in ways I may never have been able to from the confines of my office. Some of my clients lacked resources to engage in sessions privately and would use their vehicles [for sessions]. Others — often younger clients — were more at ease in the virtual platform and enthusiastically shared their relief [of] not being in-person. I am grateful for those clients who invited me into aspects of their lives that are not often visible in a clinical office. Sharing virtual spaces required a vulnerability that further deepened my understanding of who they are as people.

As a BIPOC [Black, Indigenous and people of color] clinician, it is not unusual that I find myself managing the parallel experience of racial injustice with my clients. This became magnified during the pandemic and required me to lean toward social justice advocacy while also prioritizing radical self-care to continue providing ethical counseling services.

Portia Allie-Turco is an LMHC and counselor educator in Plattsburgh, New York, who specializes in the treatment of historical, racial and complex trauma. 

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In April 2020, I was hospitalized for 11 days with COVID-19, pneumonia and sepsis. I sought advice from a colleague about what details to provide my patients, keeping in mind that their physical health was not at risk because of telehealth. She was shocked that this was my concern.

The next day, I was scheduled to present at a virtual conference. I called the organizer and gasped, two words at a time, that I could … still do … the presentation. Baffled, she forbade me, demanding I take care of myself. When I was discharged, I told patients I’d return to teletherapy the following Monday. Without exception, they said they wanted me to focus on my recovery.

I didn’t want to disappoint anyone and was committed to fulfilling my duties to my patients and colleagues. It took weeks to understand that I was the only one with these worries and the only one who wasn’t putting my health — physical and mental — first. That experience launched a self-care journey that altered my clinical outlook and practice.

A few weeks after I was discharged, I started trauma therapy to stave off posttraumatic stress disorder. I disclosed this to my patients, hoping their takeaways would be that a person in therapy isn’t broken or incapable of thriving — and being proactive can sometimes prevent problems.

Now, I have firm work-life boundaries. My patients don’t always like them, but they recognize the value in having a therapist who takes care of herself. I model this behavior because it’s what’s best for my patients — whether it’s them doing it for themselves or me doing it to be at my best for them. They understand the need for “me” time, and several have commented on their increased distress tolerance when they can’t get an appointment [at] the exact time they want or [when] I don’t immediately respond to an email.

In my practice, all clinicians — myself included — are required to take a minimum number of days off annually, which don’t carry over. I want therapists [on my staff] who take breaks and prioritize what matters to them, and, honestly, it leads to greater work enjoyment.

Because COVID-19 has increased access to care via telehealth, I’ve found boundaries to be more critical than ever. If we want to provide our patients with the best resources, then we as their therapists need to be at our best — and that’s not possible without time away from our work.

Stephanie Woodrow is an LCPC and owner and clinical director of the National Anxiety and OCD Treatment Center in the Washington, D.C., area. She was an inaugural recipient of the Emerging Leader Award from the Anxiety and Depression Association of America and is an active member of that organization as well as the International OCD Foundation.

 

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Keeping up with telehealth regulations

The laws and regulations that govern counselors’ use of telebehavioral health are, for the most part, decided at the state level — and that can make it difficult to keep track of changes during extenuating circumstances such as the COVID-19 pandemic, says Lynn Linde, the chief knowledge and learning officer at the American Counseling Association.

However, the exemptions that many states enacted to loosen regulations at the start of the pandemic to expand the use of telehealth have mostly expired, Linde says. This is the case not only for professional counseling but also for many other health-related professions. 

Today, telebehavioral health may no longer be an option for some professional counselors — especially if a client is not physically located in the same state as their practitioner. Rules vary widely, and what is allowed for telehealth in one state may not be allowed in a neighboring state, Linde notes.

Telebehavioral health regulation “is still all over the place, but it’s much more limited than it was. Most states have gone back to their ‘old’ regulations” that were in place before the pandemic, says Linde, who is also a past president of ACA. “It’s not what counselors want to hear, but it’s the reality of where we are.”

Now more than ever, it’s incumbent on individual counselors to stay up to date on telehealth regulations in their respective states. One silver lining to the pandemic is that many state licensing boards are putting more information, details and updates on their websites — much more so than before the pandemic, Linde says.

“Telehealth is a wonderful way of working with clients, but we encourage [counselors] to ensure that they have the skills and are qualified to do it, are observing appropriate security and confidentiality measures such as using encrypted programs, etc., and [are] ensuring that they can legally do it by continually checking with the licensing board where their client lives,” Linde emphasizes.

One measure aimed at alleviating some of the disparity between states regarding telebehavioral health is the interstate Counseling Compact project that continues to gain momentum. The compact, an initiative that would allow counseling practice across state lines in those states that have adopted the compact, is finalized and will take effect once 10 states pass legislation to adopt it. Language in the agreement ensures that any state that adopts the compact will allow counselors to use telebehavioral health permanently.

Two states, Georgia and Maryland, passed legislation in 2021 to adopt the compact. This year, more than 20 states are in the process of introducing or furthering legislation to adopt the compact. Leaders involved in the project, including Linde, expect that the compact will reach the 10-state threshold before June 30, when many state legislatures end for the season. Ohio and Florida are making good process on such measures, and bills have been sponsored in more than 15 other states, Linde says. 

[Update: Alabama became the third state to sign the Compact into law in early March.]

Launched in 2019, the compact project is a partnership between ACA and the Council of State Governments’ National Center for Interstate Compacts. Once a 10th state adopts the compact, the compact will become live, and those 10 states will form its governing body. Counselor practitioners should be able to begin submitting applications roughly six to nine months after compact commissioners are named and a commission is established, Linde notes.

Compacts are “the way of the future” to best treat clients, she says, and many other health professions — from social work to dentistry — are working on similar compact projects to make licensure and regulation more uniform and responsive.

  • Stay updated on the progress of the Counseling Compact by visiting counselingcompact.org.
  • Find out more about the ethical standards for telebehavioral health and other important information at counseling.org/COVID19.
  • See Section H, “Distance Counseling, Technology, and Social Media,” of the 2014 ACA Code of Ethics at counseling.org/ethics.

Flamingo Images/Shutterstock.com

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Learn more

 

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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.

Why your own therapy is so important as a counselor

By Scott Gleeson February 28, 2022

One stigma Francesca Giordano would like to vanquish in the mental health professions is the notion that therapists do not need their own therapy. Giordano, a retired counselor educator and the principal partner of Veduta Consulting in downtown Chicago, says there may be no greater resource for a clinician — including supervision and personalized self-care — than regularly meeting with a therapist. And yet, clinicians’ perceptions of themselves in the opposite chair remain a blockade.

“I think in the history of our profession, there’s sometimes been a negative association with the idea of being a wounded healer, that by going to our own therapy, we are perceived to be too damaged to help,” Giordano says. “That label gets in the way instead of being able to see a clinician going to a therapist and doing their own continual work as a strength.”

Giordano’s sentiments echo a call to action in the counseling profession that has often been stampeded over by a multitude of available workshops and seminars that focus on clients’ needs first. 

“Counselors are inclined to put clients’ interests before everything else,” says Stephanie Burns, an associate professor and coordinator of the clinical mental health counseling program at Western Michigan University. “The problem is that counselors can often put themselves last and overlook self-care for themselves. Much like with clients, counselors can avoid help-seeking behavior like therapy because of fear of feeling incompetent and ashamed. It becomes, ‘I’m a counselor, so I should be able to handle all of this.’ That type of self-sacrifice mindset can ultimately lead to depression and burnout.” 

Stephannee Standefer, the associate program director of Northwestern University’s online master’s in counseling program, says a clinician can be masqueraded by their own shame in taking a no-counseling approach. “When I hear from students or counselors, ‘I don’t need therapy,’ I actually hear them saying they want to distance themselves from their woundedness or pretend it doesn’t exist,” Standefer says. “But if you don’t face your own pain regularly, it limits your ability to be an effective counselor.” 

Self-awareness over self-demolition 

Like many mental health professionals, Judith Fawell, a licensed clinical professional counselor and certified alcohol and other drug counselor, felt drawn to the field based on her own experience with therapy. The same foundational principles that she developed in her own therapy still foster self-awareness now. 

“As a therapist, more than anything I’ve learned in school or the field, I draw from my memory working with my own therapist and the wisdom I got from that. It was like having the best mentor and someone who saved my life at the same time,” says Fawell, a recipient of the 2020 Award of Excellence from the Illinois Mental Health Counselors Association.  

“I saw firsthand how one could benefit from seeing a therapist,” Fawell continues. “In essence, my therapy was part of my training too.”

Giordano, a member of the American Counseling Association, says that “training” period of counselors doing their own work before entering the profession is wholly necessary. She also thinks it is best to keep therapy ongoing while seeing clients. 

“My belief is that the relationship you have with a client is the conduit for change, and you have to do your own therapeutic work to use yourself as a vehicle,” says Giordano, a former Illinois Counseling Association president. “My philosophy is pretty strong on the importance of therapy and ongoing therapy. Not just for students and young counselors but [for] experienced practitioners. That’s super important. It’s a false dichotomy to think that we’ve already done our own work and are ‘fixed’ or finished growing.”

Standefer agrees that the self-awareness developed from therapy is key. “When I do my own work, I know where I end and where the client begins,” she says. “I become aware of my own reactions to a client’s narrative, and I can hear it in a way that’s therapeutically effective for the client. I’m able to challenge my assumptions and raise awareness to countertransference.”

Fawell says it is naïve to not expect some clients to draw out countertransference and that counselors who are in therapy themselves often have a wider container for the psychological complexities that clients bring into session. 

“As you help people, clients are going to trigger you in all kinds of ways,” she says. “They’re going to hit your nerves from the past. You have to work through those in order to be the best helper you can be. Therapy can also help you become self-aware to know whether … to refer out or not.”

Both Fawell, a member of the Illinois Professional Counselor Licensing and Disciplinary Board, and Giordano, a former vice chair on the disciplinary board, say they have noticed a correlation between clinicians who inadvertently harm their clients and clinicians who have not done their own therapy.

“I’m totally convinced that there’s a relationship to clinicians’ own stress and making poor decisions that affect clients and get them into trouble,” Giordano says. “It makes sense. When you’re not in therapy, it’s common to use defenses or block problems or even project those problems onto others. When people are in therapy, their relationship to their own problems changes. Having personal problems doesn’t have to be a bad thing, because then you have an understanding and sense of self and can integrate that into what a client is going through.”

Understanding a ‘unified phenomenon’

Burns believes counselor care and client care are a “unified phenomenon” in that they both hold equal importance to infuse the other. But too much of one form of care tends to not work in the best interest of the client. 

“It’s equally as bad if you’re focused on yourself and not caring for the client as if you’re too focused on the client and not yourself,” Burns asserts. “The more mature stance is to blend the two. That makes for a better, more therapeutic relationship with the client.”

“The best way to accomplish that balance,” Burns notes, “is through therapy. … When you’re in therapy, you’re naturally more self-aware of things like compassion fatigue and boundaries. When you’re more self-aware, you have more room for empathy because you’re giving the same thing to your clients that you just gave to yourself. Without it, then it’s easy to get disappointed in clients because of how they’re managing their life or even feel personally slighted if they don’t grow.” 

Ingo Weigold, a licensed professional counselor at Centennial Counseling Center in St. Charles, Illinois, sees his own individual therapist regularly and has been an active member in men’s groups over the years. He says he uses his own work as a way to stay humble.

“I never want a client to think I’m above them,” Weigold says. “I want them to know I’m sitting with them, exploring with them. That I’m in the passenger seat. It’d be so easy to develop a power complex in this field because people come to us at their most fragile states and are trusting. We have to treat that as a privilege, and I believe that entails us doing our own work.”

Weigold co-hosts a podcast, Drinks ‘n Shrinks, that aims in each episode to normalize mental health practices and humanize the clinician through exchanges with licensed therapists. It would be “pretty hypocritical if we were to say we’re above the therapeutic process. Just because we’re clinicians doesn’t mean we’re not human,” he says. “We go through things just as much as the next person. That’d be like a mechanic saying, ‘I don’t believe in oil changes. Those don’t work.’”

Giordano agrees that engaging in individual therapy as a counselor can help to remove any perceived hierarchy because the reflex of facing uncomfortable emotions is already in place to be modeled for the client. “When you do your own therapy, you don’t necessarily lose countertransference. You still feel it,” Giordano says. “But then you’re not afraid of it. You can use it to help the client and the therapeutic relationship instead of projecting or going to a safer place above the client out of fear.” 

Supervision and counselor friends aren’t always enough

Marina Harris, a licensed psychologist in North Carolina, meets with a group of fellow clinicians weekly to process different cases and client dynamics. “Your self-care and support can take many different forms. Every clinician has something that works for them,” she says. “Personally, I turn to my consultation group because these are clinicians I really trust. But at the same time, it’s not the same as therapy. I support every clinician using their personal intuition of when to do their own therapy.” 

Weigold admits that his own therapy can sometimes get put on the back burner, so he makes a conscious effort to supplement it with his clinical supervision sessions. 

“Supervision isn’t therapy,” Weigold admits. “It’s a weird mix of therapy processing of clients and coaching. It’s more neutral and asking the question, ‘Why am I feeling countertransference?’ But it’s not necessarily processing. We want to be self-actualized and continue growing as we’re seeing clients and going to supervision about clients.”

Standefer expresses concern for clinicians who rely solely on supervision and for supervising clinicians who inadvertently become therapists to their supervisees. 

“Supervision has four purposes: administrative, knowledge base of cases, ethics and ensuring client well-being. Counselor well-being doesn’t fall under that list,” Standefer points out. “If we’re taking up the time in supervision doing our own therapy, all four of those parts of supervision become weakened. You lose, the supervisor loses, and the clients lose. We’re cheating ourselves if we don’t do our own work before we come to supervision.” 

“It’s very hubris[tic] and prideful for a supervisor to think that they can grossly overstate their role to be both a supervisor and a therapist to clinicians working under them,” Standefer adds. 

Giordano notes that supervision has limitations when it comes to vulnerability because clinicians can get wrapped up in protecting their self-image with colleagues. “No matter how good your supervision or consultation is, there’s always that impression management component, that piece of trying to impress a boss or colleagues,” she says. “With a therapist, you can get more real and go deeper on something a client brought up or something separate you’re going through.” 

Regardless of whether counselors turn to their own therapy or trusted confidants, it is essential for them to be in a space where they can be their authentic selves and remove any mask, Fawell says. She experienced this firsthand when suffering a personal loss. “Whatever the outlet, you’ve got to be able to be vulnerable,” she says. “When my son was killed, I spent a lot of time with someone I [could] trust.” 

Exuding therapeutic growth versus self-disclosure 

Although destigmatizing mental health is necessary in the field, Harris says self-disclosure with clients about doing individual therapy as a clinician is not always wise. 

“To me, that’s more of a case-by-case and situational basis,” she says. “We always have to ask [ourselves] with that, ‘Am I sharing this to help the client and in their best interest? Or is it for a different reason?’ One way I’ll get around that is [sharing] with my clients that skills are to be learned and there are still things I’m working on. For instance, that nobody has a perfect self-care regimen.”

Burns agrees. “We do have to be really careful with self-disclosure because it has the ability to enhance the alliance or make it problematic because a lot of the worries or concerns or judgments about therapists being in therapy come from clients who don’t know how and why that’s healthy and good for their experience. They might start probing the counselor to where you’ll have to redirect the focus back to the client. Research shows that self-disclosure is highly problematic, so it has to be in the best interest of the client.” 

Weigold says counselors’ self-disclosure of their own therapeutic work becomes unnecessary when they can “wear” it or exude it with quiet confidence and noticeable self-awareness. “Clients can feel when you’ve done your own work as compared to just reading it out of a book,” Weigold says. “Even if you don’t say anything out loud, they can feel you’ve been there or know a little bit about what they’re going through. You can show them you’ve come out on the other end or are growing in the moment. I know if I didn’t have my own therapeutic journey, I wouldn’t be able to connect with clients the way I do.” 

Fawell concurs. “When a client says to me, ‘You’re so real,’ I think that’s their way of knowing I get them. Well, I’m so real because I’ve done what they’re doing.”

Standefer says her two decades in therapy often speaks for itself through a similar form of realness. “[Carl] Jung talks about the shadow self. I feel like we can only bring out the light when we test it out in reality, dissect it and reframe it. That is not something we can teach. You have to do it yourself first, and then [clients] can feel that energy.” 

Talking about our own therapy

Standefer says that whenever she shares with students or counselors-in-training that she still sees a therapist, she experiences a “vulnerability flash.”

“Every time I say it, that I’m in counseling myself, I’m very aware of what I’m putting out there, that I’m being judged,” she says. “But I’ve come to a place where I think it’s important for the benefit of other people because it changes people’s perception of ‘she’s arrived’ to more of ‘she’s arriving.’ If I don’t express [that] I’m in therapy, then I’m subject to believing what others might project onto me. I want students to see my vulnerability in that way because it can normalize therapy in the field and encourage them to not keep their best tools in the toolkit in being their vulnerable selves.”

Antonio Guillem/Shutterstock.com

Giordano says there is a macro impact when counselor leaders discuss doing their own therapy on a micro level. “It’s so important for counselor educators to talk about their own therapy,” she says. “Because not mentioning it at all then reenforces the stigma, and [students] can develop this distortion that older clinicians don’t seem to need therapy, so they can stop their own hard work while they’re being available for clients. It’s actually the opposite. Doing your own work is what empowers you to be available to clients.

“We have to get past these ideas that someone needs therapy because they’re inexperienced or having a problem. We need therapy because we’re human and this is complicated work.” 

Giordano adds that the modeling that comes from therapy has a trickle-down effect from a cultural perspective as well. “If a therapist represents a cultural group that isn’t known for going to therapy, whether that be race or gender, then the value of modeling takes on an added layer,” she explains.

Burns points out that private practices cannot necessarily mandate that clinicians do their own work, but it can be heavily implied or suggested. 

“The workplace culture matters,” she says. “Research has suggested that age isn’t a factor on whether clinicians take care of themselves with self-care. What is a predictor is working conditions in a workplace setting. That means it really does start from the top and [it] puts an emphasis on not just supervisor support but supervisor modeling and leadership with boundaries and one’s own therapy.”

 

Note: The author previously held professional relationships with multiple clinicians quoted in this article.

 

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Scott Gleeson is a licensed professional counselor for DG Counseling in the Chicago suburbs, specializing in trauma and relational dynamics. He spent more than a decade writing for USA Today, where he won national writing awards from the Associated Press and NLGJA: The Association of LGBTQ Journalists. His debut contemporary novel, The Walls of Color, will be published in 2023.

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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.

What the No Surprises Act means for counselors

By Lindsey Phillips January 28, 2022

The American Counseling Association’s January town hall focused on the No Surprises Act, which aims to increase transparency in medical costs and protect clients from “surprise” medical bills caused by out-of-network care. Catherine Brandon, a partner at ACA’s lobbying firm Arnold & Porter, discussed three main requirements of this act, which went into effect on January 1:

  • Prohibiting balance billing or surprise billing (i.e., when a health care provider bills a patient for the difference between the amount the provider charges and the amount the insurance pays) for out-of-network providers in an in-network facility
  • Requiring a good faith estimate (GFE) of expected costs before scheduled services for uninsured and self-pay clients
  • Ensuring continuity of care and accuracy of provider directories

Balanced billing

Sometimes people carefully select an in-network hospital and medical provider only to discover their medical bill is much higher than they expected because they unknowingly received medical care from an out-of-network provider during their stay. This balanced billing requirement aims to prevent that potential sticker shock by prohibiting providers who are out-of-network with a client’s insurance from charging more than their in-network costs when clients receive care at the in-network facility.

Billion Photos/Shutterstock.com

This aspect of the act will probably not apply to most private practitioners, Brandon noted during the town hall held on January 19, only those providing services outside their private practice at in-network facilities. So, if a counselor works at a hospital or performs telebehavioral services while a client is staying in a hospital, for example, then they could only charge the client at the in-network rate, not the out-of-network rate.

Although the act does not dictate the out-of-network payment amount between the insurer and provider, it did establish an informal dispute resolution process to oversee any potential disputes on payment.

GFE

One of the key provisions affecting counselors is the requirement to provide a GFE to uninsured and self-pay clients before services are rendered. It is the responsibility of the provider to ask clients if they will file a claim with their insurance to know if this rule applies to them, Brandon said.

The GFE should include a clear description of provided services, including diagnostic and expected services codes, and the expected charges associated with each service. Assigning a diagnosis code before seeing a client could pose a problem and ethical issue, but ACA suggests using a general diagnosis code such as “no diagnosis” before the first session, and then counselors can issue a revised GFE after the intake assessment.

The Centers for Medicare & Medicaid Services has a Good Faith Estimate template form that counselors can use to ensure they include all the appropriate information.

The time frame requirements for issuing the GFE are as follows:

  • No later than one business day after the date of a scheduled appointment that is three to nine business days away.
  • No later than three business days after the date of a scheduled appointment that is 10 or more business days away.
  • No later than three business days after the date of requested services without a scheduled appointment. (Another GFE must be provided within these time frames if the client decides to schedule an appointment.)

Counselors can provide clients with a single GFE for recurring services (such as ongoing counseling visits), which is good for one year. But if the information, including costs, services needed or billing codes, changes at any point, then providers must issue a new GFE no later than one business day before the next scheduled appointment.

The GFE is just an estimate; it is not legally binding and may change at any point. However, if the actual charge is more than $400 above the estimate, the client has the right to dispute the charge through the new patient-provider dispute resolution process.

In addition to orally telling clients about the availability of the GFE, counselors should include a notice on their website, in their office and on-site where scheduling or questions about costs occur. And counselors should retain a copy of the GFE with the client’s record for six years.

Continuity of care and provider directories

If a counselor’s contractual relationship with a client’s insurance ends (i.e., they are no longer in network with the insurer), they must continue to accept the in-network rate for 90 days after the health plan or issuer notifies the client of the change in network status. This provision only applies to continuing care clients, Brandon noted, which include those undergoing treatment for a “serious and complex condition” — one that is “life-threatening, degenerative, potentially disabling or congenital” and requires “specialized medical care over a prolonged period of time” or that is “serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm.”

This law also stipulates that health care providers who have a contractual relationship with an insurer must submit up-to-date provider directory information to the insurer. And providers must reimburse insured clients who inadvertently relied on an incorrect provider directory and received out-of-network care or paid more than the in-network sharing amount. Counselors could protect themselves and shift the liability to the insurer, Brandon said, by stating it’s the insurer’s responsibility to maintain an updated directory in their contract with the insurer.

The U.S. Department of Health and Human Services has not yet issued regulations that would further explain and define these requirements. This means there is currently not much guidance on these regulations.

 

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Watch the full video of the town hall on the No Surprises Act at ACA’s YouTube page: https://www.youtube.com/watch?v=gy3H3col07U

 

Learn more about the No Surprises Act and these specific provisions from the following resources:

 

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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.

Growing percentage of American adults are living single

By Bethany Bray December 1, 2021

A growing share of American adults are living the single life.

The Pew Research Center found that in 2019, 38% of American adults between the ages of 25 and 54 were not married or living with a romantic partner. This number has increased significantly in the past two decades, with only 29% being unpartnered in 1990. While this population includes individuals who are divorced, separated or widowed, an increasing portion have never been married.

The number of married adults fell from 67% to 53% between 1990 and 2019, and the percentage of people who were cohabitating with a partner rose slightly from 4% to 9%. Also, the share of adults who have never been married jumped from 17% to 33% during that time period.

Men are more likely to be unpartnered than women, Pew reports. However, the one exception to this rule is among Black women, with 62% of Black women and 55% of Black men living without a spouse or romantic partner.

Overall, the race and ethnicity breakdown for Americans ages 25 to 54 who were unpartnered in 2019 was as follows:

  • 59% of Black adults
  • 38% of Hispanics
  • 33% of whites
  • 29% of Asians

This evolution of Americans’ living arrangements has also laid bare the financial and other disparities that exist between coupled and single adults. Pew found that adults who live without a partner earn less (on average) than coupled adults, are less likely to finish a bachelor’s degree and are more likely to be financially unstable or unemployed. Single adults’ median salary is $14,000 less than coupled adults, Pew reports.

These statistics create many questions for the counseling profession, including the emotional and relational needs that might arise among single individuals, says Katherine M. Hermann-Turner, an associate professor in the Department of Counseling & Psychology at Tennessee Technological University whose doctoral cognate was in couples and family counseling.

“Many counselors are likely seeing unpartnered clients or family members of unpartnered individuals for services, but what do we know about the stressors of this demographic? … The first step is [for counselors to have an] awareness that this is a growing demographic,” says Hermann-Turner, a past president of the Association for Adult Development and Aging, a division of ACA. “My antenna as a counselor, particularly someone who operates from a systems perspective and relational-cultural theory framework, goes to the potential increased need for emotional connection for unpartnered individuals rather than the economic stressors faced by this demographic.”

In addition to the financial and economic disparities, Pew also found that unpartnered adults were more likely to be living with their parents than adults who are married or cohabitating. Thirty-one percent of unpartnered men and 24% of unpartnered women lived with at least one parent in 2019, which is much higher than that statistic for partnered adults (2% for both men and women).

Hermann-Turner notes that this information raises further questions about what clients who fall into this demographic might need when working with a professional counselor.

“Are these individuals substituting the support of their family of origin for partnership or reliance on external systems of support (i.e., romantic partnership)?,” she asks. “If so, why is this the route for many individuals given the typical complexity of a family system? Is this evidence of an earlier lack of career guidance? Underdeveloped relational skills? If so, how can we as counselors begin to intervene earlier and develop these skills in a younger population? Should we be reconceptualizing family counseling to include an emphasis on adult children and their parents? … I am intentionally avoiding the ‘chicken or egg’ argument and pondering the possibility that enmeshed family systems have intentionally stunted one child’s ability for emotional independence as a way to serve the needs of the parents.”

Olga Strelnikova/Shutterstock.com

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What do you think? How might these demographic shifts affect the work counselors do with clients? How should the profession adapt to help clients and meet their needs?

Add your thoughts in the comment section below.

 

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Read more from the Pew Research Center: https://pewrsr.ch/3DeLtrm

 

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

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

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.