Tag Archives: Coronavirus

Pandemic telehealth: What have we learned?

By Bethany Bray April 27, 2021

Last year, safety precautions and restrictions brought on by the COVID-19 pandemic in early spring caused most counselors’ in-person interactions with clients, colleagues and students to come to an abrupt halt. To continue treating clients, many clinicians shifted to conducting counseling sessions through video or other digital media. For some practitioners (and clients too), it was a “like it or not” change with a steep learning curve, especially if they had not been offering any telebehavioral health services prior to the pandemic.

Now, some counselors are beginning a return to in-person sessions or a blend of in-office and virtual sessions. What did practitioners learn — about themselves and the process of counseling — while using and adapting to telebehavioral health over the past year-plus? Did counselors pick up anything that they might apply to in-person work with clients if and when they return to a traditional office setting? From Zoom fatigue to eye-opening lessons in resilience and humility, there are stories to tell.

Counseling Today recently collected insights from American Counseling Association members who have used telebehavioral health to counsel clients through some or all of the past year. Read their thoughts (in their own words) below.

 

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Gale Brunault is a licensed mental health counselor (LMHC) with a private practice, Honoring Endings After Loss (HEAL), in Amesbury, Massachusetts.

When the pandemic first hit and all physical contact with the outside world came to a screeching halt, I remember asking myself, “How am I going to continue serving clients in a meaningful and productive manner?” After all, I only knew one way to conduct business, and that was face to face. 

Using telehealth for the first time and/or phone calls as a vehicle for serving clients was extremely challenging in the beginning. I no longer had the physical presence of observing the individual, which meant
I couldn’t “time” my response effectively. Between that and dealing with technical strains, my focus shifted, and I found myself distracted by issues that had nothing to do with client needs. Not only did it become a challenge for me to stay on task, but I was expending more energy than I wanted to each session.

Over time, the program I chose became more efficient and user friendly, which afforded me the chance to focus more on improving my skill set. I no longer had concerns that telehealth was diminishing the client-therapist relationship. In fact, the process was proving to be encouraging. 

Using telehealth has taught me that anything is possible. Though initially I had concerns that it may not be a favorable vehicle for working with grief and loss, telehealth proved to be a solid match for those unable or unwilling to leave home, particularly following a major loss. One of the most difficult tasks for bereaved individuals is living in a world without their loved one. Being able to stay home and receive therapy can be extremely helpful, particularly when initially all you want to do is isolate and hide. 

Many of my clients have asked to continue using telehealth. Some look forward to coming back to the office. Either way, I will be available. 

Some of what I’ve learned since using telehealth is that while the body reveals a lot about a person, so too does the face. There is a certain level of intimacy involved when you are only focused on someone’s face. I have become more in tune to a client’s eye movement, the pauses they take, how they play with their hair, the thinking process and word choice, etc. Though all of these pieces were evident during face-to-face time, having less to look at can deepen one’s observation and assessment of client patterns and behaviors.

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Julie Hine is a licensed professional clinical counselor at a private practice in Albuquerque, New Mexico.

Having been in the field of counseling for almost 30 years, telebehavioral health has not only offered another opportunity for professional and personal growth, I also believe it has served as a catalyst to break down barriers for access to mental health services. While an entire world lives through a pandemic, common themes have risen among almost all persons. People are experiencing a gamut of emotions, often while they feel alone and alienated from loved ones and the world around them. People are feeling hopeless and helpless, riddled with feelings of nervousness. So, what happens when the entire world is feeling like this? Telebehavioral health (or telehealth) has provided an answer.

Telehealth has given access to mental health services to all persons … where [they] live. Especially in rural communities, such as those in New Mexico. Many people who live in smaller communities or on reservations do not always have access to mental health services, whether it’s because there are no counselors in their area, or they have no means of getting into an office on a regular basis. Telehealth has opened the doors for people to access services, no matter where they live, no matter if they have a car and no matter if they have gas for that car. If a person has access to a phone or computer, they can get in-person help, without actually being [there] in person. I can now provide counseling for someone who lives four hours away without even leaving my home.

Throughout all of this, communities of people have recognized the importance of positive mental health, and I have realized that self-care is a crucial gift to ourselves as counselors. If you’re a counselor providing telehealth, remember to stand up frequently, sit up straight, take breaks, rest your eyes, eat healthy snacks and, most of all, be kind to yourself. During sessions, encourage your clients to also be kind to themselves. Emotions are heightened, so remind them not to overanalyze everything, to ask for support when needed, learn to be proactive instead of reactive, and remember to laugh because nothing is permanent, and we will get through this. People are resilient.

As a clinician in the mental health community, I plan on continuing to provide telehealth services, even when returning to an office becomes a reality. That way, I can continue to help individuals, no matter the circumstances. However, I must admit, I look forward to leaving the chair in my home office and sitting in the same room, face to face, with the individuals I serve. Nothing beats human contact and smiles of hope.

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Justin Jordan is a licensed professional counselor (LPC) and certified substance abuse counselor who treats mental health issues and substance use at his private practice in Salem, Virginia. He recently completed his doctorate in counselor education and supervision at Virginia Tech and will join the faculty in the mental health counseling program at University of Wisconsin-Parkside this fall.

Transitioning to telecounseling in the spring of 2020 was an easy decision based on my family’s situation. I learned very quickly that my biases had limited my ability to see the potential of telehealth software in connecting with my clients and reducing barriers to attending sessions [prior to the pandemic]. I never intended to use telehealth software for counseling and strongly believed that direct presence with clients was essential for the relationship and perceiving my clients’ needs. While I would still prefer to safely be in their presence, I now see that with the loss of presence, what is gained is a flexibility for both the client’s and counselor’s home/work lives and a chance to see clients where they are most comfortable.

In the context of COVID-19, clients felt safer meeting online, and so did I. Beyond the context of the pandemic, clients with children had [fewer] barriers [for] adapting their child care for sessions. Clients were able to meet more easily during their lunch breaks at work without commuting. And some clients who were very anxious about going into public were able to be seen in the comfort of their home. Many of these benefits will hold true once physical distancing is less of a concern, which is why I would continue telecounseling if I were not closing my practice to start a faculty position this fall.

Additionally, as a humanistic counselor, I have always tried to diminish power dynamics and have relationships based in mutuality with my clients. Telecounseling taught me that asking clients to enter my office [in person] always comes with some authority, as having to log in to sessions from my office/bedroom, often with the sounds of young children in other parts of the house, erased that [imbalance]. I had to relinquish some of the boundaries I have worked hard to create with my physical counseling space, which came with discomfort but also a beneficial humility on my part that I was in less control — of technology glitches, distractions in my home and the state of the world. I also see that my clients often feel freer expressing themselves when meeting with me from the comfort of their own couches or other parts of their home. I have consistently received feedback from my clients that there are aspects of telecounseling that have improved the process.

One of my main suggestions to counselors and students who must choose to integrate telecounseling into their practice is to have a solid plan for backup communication when technology issues occur. Realize that host platforms have issues sometimes, clients’ hardware can have problems, your hardware can have problems, and software or internet connections can crash. Also, many clients need to be coached on how to use the technology properly, and they need to have access to a usable digital device (which most clients in my private practice do).

I also think that humility, honesty and authenticity remain key counselor traits with telecounseling, which means acknowledging when the technology is creating a barrier or problem in communication.

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Stephanie Brookins is an LPC in private practice in Columbus, Georgia, who specializes in the treatment of posttraumatic stress disorder (PTSD).

I was initially resistant to the idea of telehealth and would not have imagined that it might become a permanent part of my practice. I realize now that much of my negative view was shaped by the discomfort of the unknown and not having considered how the initial stress might resolve. My first experience with telehealth was several years ago with a client who had temporarily moved to another part of the state and wished to continue individual therapy with me. Issues regarding privacy and internet connection and overall discomfort with the technology led to a negative experience for [me] and the client, and I referred her to another provider. 

What I’ve found in the past year is that after the initial adjustment to technology and change, it’s relatively easy to forget that we are connecting via technology. However, that’s not always the case. Due to schools being closed, some clients have issues with child care and will have to interrupt their session to help their child with school or manage some parenting crisis. Other clients have plumbers dropping by or pets that want attention. Initially, some clients would attend telehealth sessions in bed, half awake and dressed in pajamas. This necessitated discussions about boundaries and structure that could be uncomfortable. 

There have been some unexpected benefits of telehealth. Clients with chronic health issues and periodic flare-ups would have to miss appointments in the past [because] they were unable to drive and physically get to appointments. Now we’re able to meet online and just limit the amount of time if needed. This has led to a decrease in last-minute cancellations. Some clients are able to access care now when transportation or time have presented limitations for them in the past. 

As an eye-movement desensitization and reprocessing certified therapist, I’ve had to adapt the mode of bilateral stimulation used in processing. I’ve been surprised at the work clients have still been able to do, even [with us] being physically apart and using self-tapping in place of eye movements or theratappers. 

With environmental safety precautions, I’ve been able to maintain in-person counseling as an option for clients during the past year. Some people are not comfortable with using technology, need the human connection of seeing a therapist face to face, or do not have reliable internet connection, so it’s been important to me to continue to offer that option. I imagine I’ll continue to adapt to my clients’ needs and will continue to provide both telehealth and in-person therapy.

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Nicole Sublette is a licensed clinical mental health counselor and certified hypnotherapist who also serves as a social justice advocate, as a public speaker, and as an anti-racist educator for the state of New Hampshire.

I have learned that telehealth makes treatment more accessible to people who might not otherwise be able to engage in treatment due to scheduling or distance. I have not found too many differences between telehealth and in-person [counseling] in my practice. However, I will have increased gratitude for in-person sessions in the future. There will not be trouble with sound or video. There will not be the interruption of therapeutic flow due to technical difficulties.

Through the past year, I have learned about my own resilience and adaptability. This was momentous for me, specifically in these uncertain times. Previously, I would not qualify myself as tech savvy. Using telehealth and adapting to an online format for treatment has expanded my growing edges and helped me to also lean into my own capacities. In uncertain times, it helped me to also learn my strengths and ability to adapt. Also, techniques that I previously thought could only be done in person, such as cognitive processing therapy for PTSD, can also be done via telehealth.

I have adapted [to telebehavioral health] by asking more somatic questions of clients and discussing how the body is handling symptoms. Asking questions about what I was previously able to observe with my eyes has opened up dialogue in ways I would not have imagined. Asking increased questions can decrease the potential for avoidance for both the therapist and the client.

To my counseling colleagues, I would say conducting sessions via telehealth gets easier with time. Utilizing the same rapport techniques that one uses in person can be very helpful with telehealth, such as asking open questions and conveying authentic curiosity. Also, address the elephant in the room about any discomfort for both the therapist and the client. Share about how you can learn together. Process together any discomforts one might have with using telehealth, then work together to create a plan to ease discomfort. Humor is also a great way to ease tension.

I absolutely plan to use telehealth in the future. It is my hope to do a mix [of telehealth and in-person counseling]. Currently, I am one of the very few BIPOC (Black, Indigenous and people of color) therapists in my state. Nationally, BIPOC [constitute] about 4% of practitioners in the mental health field. Telehealth has made therapy accessible to BIPOC folx around the state. I am able to provide treatment to clients who would otherwise not be able to travel to my office due to the distance. With continued escalating events of police brutality, therapy for BIPOC has been very critical.

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Laura Sladky is an LPC and licensed chemical dependency counselor who works as a school counselor in Dallas.

Through video/telehealth as a school counselor, I have learned that being able to quite literally see into someone’s world offers such insight into the way they organize and carry out their daily lives (pets, plants, family relations) as well as their sense of self. In short, telehealth offers the opportunity to know clients differently and inadvertently know their world beyond my office.

Throughout the past year, I have been acutely aware of my sense of justice and desire for equality. Of course, these traits are essential when developing a therapeutic alliance and conveying unconditional positive regard to a client, but on a systems and global scale, I have become painfully aware that individual problems do not exist in a vacuum, and change requires advocacy. In sum, this year was the “real life” representation of many theoretical concepts like Maslow’s hierarchy of human needs. Humans cannot be thoughtful, insightful and self-reflective if their basic needs (food, shelter, safety) are not met. Individuals’ autonomic nervous system becomes activated under threat and chronic stress (winter storms, unemployment, death of a loved one, fear of contracting a disease) and, consequently, higher-level thinking at the prefrontal cortex level is inaccessible. Moreover, I have learned about the inextricable link between humanity, trauma and the imperative nature of sensory integration. While the past year has been exceptionally disruptive and devastating in a variety of ways, our ability to make sense of our experiences and enact pro-social connection predicts our ability to recover — and not become further traumatized — by our experiences.

This year, with the social/political climate, I have asked more intentional questions to check in regarding media coverage/social media and how that has impacted the individuals I work with. Whether we are consciously aware of it or not, our brains become easily biased. Hearing a negative headline can begin a downward spiral and, before you know it, everything can seem awful. It helps me understand the level of distress knowing how much screen time people are exposed to.

In addition, helping individuals sift through what is in and out of their control (acceptance vs. change skills) and actionable steps to take to alleviate distress has been paramount. Asking questions is so important because you don’t know what you don’t know. In equal measure, not having the client in full view can impact nonverbal cues (bouncing leg, posture, etc.) but further reiterates the importance of tracking, asking questions and helping clients be aware of their bodies/ feel safe in their bodies.

It is so refreshing for those we work with to understand that we also experience undesirable situations (Zoom glitching, our pets interrupting calls, when we miss the client’s meaning) and witness how we cope in the moment. Radically open dialectical behavior therapy tells us that making mistakes is pro-social, helps us feel connected to others and eases our nervous system. For counselors who are working to connect or finding this challenging, I think briefly self-disclosing your own minor inconveniences helps build rapport with clients.

Our lives were unceremoniously upended, leaving us to confront grief and ambiguous loss daily and, in fact, it is weird even after a year. However, weird does not inherently mean bad. One of the best ways to work through the weirdness of Zoom life is to acknowledge it. In doing so, counselors can validate this experience, give it a name (awkward, different, etc.) and help facilitate the client management of these feelings.

I think offering a variety of mediums for therapy is the future of our profession, and I plan to make myself accessible through a variety of settings.

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Michael T. Greelis* is an LPC, licensed marriage and family therapist and approved clinical supervisor in private practice in Herndon, Virginia, who has seen adolescents and adults with mood and anxiety disorders and other life challenges for 25 years.

On March 17, 2020, I made a complete transition from in-person, face-to-face [counseling] to videoconferencing for my practice — about 30 sessions per week. The change was immediate for all clients from March 18 on. Based on the Centers for Medicare & Medicaid Services and [National Institute of Allergy and Infectious Diseases Director] Dr. Anthony Fauci’s statements, we either converted to virtual visits or risked our health and that of our clients if we continued in-person meetings. I saw that my clients and my colleagues reflected a high value on treatment by making this complete transition on very short notice. I learned that therapists and clients can make a major transition work with commitment and flexibility and that the work itself — face to face in person or on video — is what matters.

I immediately adapted my approach so that I focused on content rather than the medium and avoided incorrect assumptions (some cognitive behavior therapy on my part). I assumed that my clients and I would make teletherapy work and that we’d pick up on the requirements for that. What works is a focus on substance over style and letting [your counseling] style evolve as necessary.

My overall impression of videoconferencing for therapy (we call it teletherapy in Northern Virginia) is very positive. Prior to the COVID-19 crisis and emergency measures, I was a skeptic. On March 17, 2020, it was clear that I had to either migrate to teletherapy entirely or stop practicing. My ability to adapt to that change and the receptivity of my clients to make the change had a reciprocal positive effect. Every client in the transition remained in treatment, and clients who started during the virtual-only period followed a course of treatment similar to that expected during in-person times.

Post-COVID-19, I plan on a hybrid approach combining in-person with teletherapy based on client conditions and needs. This is both my preference and that expressed in very clear terms by my clients.

My advice to counseling colleagues is to focus on the work and client needs, pay extra attention to your experience of videoconferencing at the outset with each client, and ask clients how they think treatment is progressing. Also, use the special features of the medium. I’m always surprised to see that none of my colleagues use a green screen to project backgrounds more appealing than the same wall, office, etc., for every meeting. I am pushing myself to have a set of images, videos and text passages on hand [to use in sessions], if they’re beneficial. And I’m learning how to insert materials from the internet or from my files in real time during sessions.

*Greelis is advocacy chair for the Northern Virginia Licensed Professional Counselors and was involved in NVLPC’s recent survey on the use of telehealth by LPCs during the COVID-19 pandemic. See the survey results here.

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Rob Freund is an LMHC and an assistant professor at Nova Southeastern University in Davie, Florida, who also works in private practice with couples and individuals.

Prior to the pandemic, I had received training in telehealth counseling and conducted it across state lines in Florida and New York, where I was dually licensed. The format therefore wasn’t too strange for me, but the frequency of my utilizing it was more challenging. I, like many, experienced “Zoom fatigue” from using telehealth communication platforms exclusively. I learned that more so than usual, pandemic notwithstanding, I needed to separate myself from my workspace and engage in deep, deliberate self-care in order to bring my best self to the therapy space. Spending time in meditation and communication with nature became essential for me. I also realized just how much value there is in shutting off the computer and disconnecting so that I can better reconnect with my clients.

One aspect of this work that I do plan to bring to my in-person therapy is the utilization of technology in the therapy space itself — using my tablet to bring up materials for discussion, real-time sharing of resources, using digital drawing tools to portray and invite collaboration with the client. It has provided an opportunity to evolve the tools I bring into the space.

We rely so much on being in the room with clients that the absence of many shared experiences of the space — behavioral cues of seeing the full body, the opportunity to have natural eye contact patterns, smell and other sensory cues — is at times disorienting. What’s fascinating is to experience the human capacity for adaptation. I noticed myself beginning to have heightened attention to the sensory information that I did have access to — facial cues, speech patterns and nonverbal speech cues — and adjusting my work accordingly. We can be remarkably resilient, and I found clients to be the same.

I do think there are concrete things that counselors can do to facilitate adaptation to this new model of conducting therapy. Firstly, developing grounding strategies and preparatory work for before and after the session is personally important to the clinician, particularly if you are working/living in a smaller space. Secondly, I would encourage counselors to pursue training in emotional communication and recognition of nonverbal behavior. The Paul Ekman Group has excellent training resources for recognizing micro- and subtle expression displays, and books like Unmasking the Face: A Guide to Recognizing Emotions From Facial Expressions (by Paul Ekman and Wallace V. Friesen), Emotions Revealed: Recognizing Faces and Feelings to Improve Communication and Emotional Life (by Paul Ekman) and What Every Body Is Saying: An Ex-FBI Agent’s Guide to Speed-Reading People (by Joe Navarro and Marvin Karlins) are excellent for expanding one’s nonverbal/emotional acumen.

Like any tool, telehealth has its pros and cons. The portability and absence of commute often benefited [me] and my clients. However, I noticed that for some, there is increased value in experiencing therapy outside of the home environment.

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Grace Hipona is an LPC at NeuroPsych Wellness Center P.C. in Fairfax, Virginia, who holds a doctorate in counselor education and supervision.

The pandemic has challenged me to view the counseling process from a different perspective. It has challenged me to be more flexible and to reassess my own coping strategies. It has tested my resiliency and ability to continue helping others while I navigate my own circumstances. The process has given me the opportunity to truly connect with clients, since we are all experiencing the pandemic at the same time. Even though we may not discuss the pandemic directly, I am aware of how we may be impacted. I also continue to evaluate and monitor my own thoughts and emotions so the client’s perspective is primarily front and center, and I help support them based on their lived experiences.

Prior to the pandemic, my overall impressions of telebehavioral health were neutral to negative. However, since March 2020, I have only used telebehavioral health to provide counseling services. Through this time, I have shifted my thoughts and feelings, and I now have a more positive outlook on telebehavioral health. I appreciate the convenience and flexibility it provides. My clients appear to have similar feelings and thoughts about telebehavioral health. I have had several mention that they likely wouldn’t have participated in counseling if this opportunity was not available.

Our practice continues to assess and reassess the role that telebehavioral health plays in counseling. We have a provider meeting at least once a month, and since the beginning of the COVID-19 pandemic, we consider all the benefits and challenges. However, we have not made any long-term decisions about the role of telebehavioral health. Being able to partner with health insurances will be a guiding factor. If health insurances continue to cover telebehavioral health, it will provide flexibility. Moving forward, I believe in our field, and across other fields, providing opportunities for either or both [in-person and telehealth] will be one of the lasting impacts of the pandemic.

To better connect with clients, my counseling approach has shifted over the past year to being more directive or straightforward. In other words, if I am at all uncertain about how I am interpreting a client’s thoughts or feelings, I directly ask. For example, I say, “I am not sure how you are feeling or what you are thinking right now. Do you mind explaining it to me further?” Generally, clients have been appreciative of the opportunity to clarify their perspective.

To emit levels of sympathy, empathy and understanding, I find myself amplifying my facial expressions, nonverbal cues and verbal statements in general. For this reason, I believe remote counseling can be more exhausting. Reflexively, I place more effort in self-care so I can recover and refuel for future sessions.

The use of formal assessments or evaluations has also become more integral in my counseling process. Aside from the initial intake, I found using formal brief assessments intermittently beneficial to help support my clients. I also verbally make a concerted effort to ask evaluation-related questions such as “How are you feeling today — better, worse or about the same?”

 

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The future of telehealth

Insurance coverage has expanded and regulations regarding telebehavioral health have been relaxed in many states out of necessity during the COVID-19 pandemic. Will these changes remain as pandemic restrictions are loosened and many helping professionals return to in-person office settings? Find out more in our online article “The future of telehealth: Looking ahead.”

Also be sure to read this month’s “Risk Management for Counselors” column on page 8 of the print version of Counseling Today‘s May magazine, available for ACA members to download here.

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Action steps to learn more

  • Read Section H, “Distance Counseling, Technology, and Social Media,” of the 2014 ACA Code of Ethics at counseling.org/ethics.
  • Search for articles with the tag “coronavirus” at ct.counseling.org.
  • Browse ACA’s continuing education offerings by topic, including telebehavioral health, at aca.digitellinc.com/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.

Feeling the strain: The effects of COVID-19 on children and adolescents

By Laurie Meyers April 23, 2021

One of the most contentious — indeed, at times, vitriolic — public health debates of the COVID-19 era has revolved around the safety of opening schools for in-person classes. For some politicians, the push to open seemed to be influenced by optics — a signal that states were “open for business.” At the same time, parents have struggled to help children and adolescents with their schoolwork and other aspects of distance learning and have longed for a safe way to get back to a less chaotic educational experience. Some parents were forced to leave their jobs to take care of children and still cannot return to work. Teachers and other school staff have expressed concern for their own safety and the safety of their families and students. 

Everyone agrees that online learning is not ideal for most students — and can be virtually inaccessible for marginalized populations — but in many areas, it seemed like the safest option. However, mental health professionals, educators, parents and community activists remain apprehensive about the negative effect that the lack of in-person instruction and interaction with peers is having on the mental, emotional, social, developmental and academic well-being of children and adolescents.

There has been much confusion about how often children and adolescents get COVID-19 and how likely they are to spread the coronavirus. Recent guidance from the Centers for Disease Control and Prevention (CDC) stated that while fewer children than adults have had COVID-19 in the United States, the number of cases among school-age children was rising. Not only can children and adolescents be infected and get sick, but they can also spread the virus to others. At the same time, the CDC revised its guidance for physical distancing in schools in March, saying that 3 feet of distance (as opposed to 6 feet) is sufficient in elementary, middle and high schools where masks are worn and where community transmission is low.

In many states, teachers and other educational system personnel have received vaccinations. School districts are implementing physical distancing protocols, and the American Rescue Plan Act of 2021 passed by Congress in mid-March includes money to improve building ventilation. With these developments, many schools that weren’t already open were planning a return to in-person education, either full time or on a hybrid basis. 

Amid all the debating and planning, one group has been noticeably silent: the students themselves. Many children and adolescents are struggling with a feeling of powerlessness, says Adam W. Carter, a former school counselor who is currently the coordinator of the trauma-informed counseling graduate certificate at Northern Illinois University’s Department of Counseling and Higher Education. “We’re not asking children if they want to go back to school, if they feel safe,” he says. “We’re making decisions as adults with [the needs of] children almost as an afterthought.”

The lack of agency in decisions regarding in-person schooling is not the only area in which many children and adolescents feel voiceless, say the sources Counseling Today spoke to for this article. Like adults, children and adolescents miss their friends; are frustrated by the inability to get together with others without fear of infection; mourn the loss of celebrations and the marking of milestones; are afraid that they, or a loved one, will get sick; and are tired of spending so much time in front of a computer screen. 

In other words, they have all of the stress but not as much control as adults do, notes Carter, an American Counseling Association member. Children and adolescents often don’t know how to talk about — or, for that matter, recognize — how the pandemic is affecting them. 

For example, “Children may not know how to talk about how they miss getting together at school or with friends,” says ACA member Barbara Mahaffey, a licensed professional clinical counselor and executive director of the Scioto Paint Valley Mental Health Center in Ohio. They might ask often about visiting others but not recognize that they’re having stomachaches and other psychosomatic effects because they’re lonely, she adds. “Children may not ask for help, and parents may not recognize a child’s distress,” Mahaffey says. 

Many parents are experiencing significant worry and stress about their finances or how they can keep their family safe from COVID-19. They may also be grieving the loss of friends or family members who have died from the coronavirus. Parents often believe that it’s best to shield their children from these concerns, but the reality is that kids pick up on the underlying fear without understanding its source, say Mahaffey and Carter. 

The strain on children and adolescents is showing. According to the Nov. 13, 2020, issue of the CDC’s Morbidity and Mortality Weekly Report, child and adolescent emergency room visits related to mental health began increasing in April 2020 and remained elevated through October 2020 (the latest date for which statistics were available). Compared with the same period in 2019, emergency room visits related to mental health rose 24% for children ages 5-11 and 31% for those ages 12-17. 

Missed connections

Children and adolescents want to be with each other, Carter says. Absent in-person classes and social activities, it is difficult for them to figure out how to interact. This generation is used to socializing through social media platforms and chat apps, but after spending six to seven hours online each day for school, interest in electronic gatherings has diminished throughout the pandemic, he says. Being in the company of others all day virtually but rarely if ever getting the opportunity to interact in person has produced a particular kind of loneliness for children and adolescents.

Counselors are also finding it difficult to connect with these clients online. Once the pandemic began and counseling shifted online, Sarah Zalewski, a licensed professional counselor (LPC) who specializes in child and adolescent counseling, knew she needed a new way to engage her clients. At the time, in addition to her private practice, Zalewski was working as a school counselor in a Connecticut middle school. 

“When they come into my office, I always have toys,” she says. “They love to play, [and] I do too.”

The toys functioned as an icebreaker, with students and young clients finding it easier to open up while their hands were busy, explains Zalewski, an ACA member. But with that icebreaker gone thanks to the abrupt end of in-person sessions, she had to start thinking of alternative ways to connect. “I didn’t want to do the traditional grown-up thing, like, ‘How was your day? What was school like?’” Zalewski says.

Zalewski thought about what she had been doing herself to cope with the stresses of the pandemic. One of her favorite coping mechanisms: playing video games. Given the popularity and ubiquity of video games, she decided they might offer a great way to bridge the gap with young clients.

In the beginning, Zalewski mainly discussed the games with her clients, asking them what games they liked and why. Whenever role-playing games entered the discussion, she explored what characters her clients typically chose to inhabit. Did they pick a warrior or a priest? How was the character similar to them? How was it different? In what ways did the character reflect who the client wanted to be in real life? “Why do you want to be a druid?” Zalewski might ask. “What is it about druidism that is really cool?” 

Zalewski emphasizes that counselors who try this approach need to know or learn the language of the games. “Gaming is a culture,” she says. “Use cultural humility. If you don’t know, for example, what a druid is — [because] it’s different in different games — ask. They love to talk about it.”

Eventually, Zalewski began playing the games with her clients. They start in Google Meet, where they do all of their communicating. They then use an online link or gaming platform. Zalewski has multiple screens, and clients often use tablets. 

Sometimes the games are relatively simple. For example, Zalewski recently began playing Connect Four with a young client as an exercise in frustration tolerance (because the client doesn’t always win). When a client expresses frustration during the course of a game, Zalewski probes for the source. Is it truly about the outcome of the game itself or is it frustration at a person in the client’s life that is coming out during the gaming session? Sometimes the frustration is really about the situation that children and adolescents find themselves in with the pandemic, including feeling like they no longer have the ability to do the things they once enjoyed.

Game-based problem-solving helps clients build coping skills as they are playing, Zalewski points out. In addition, she often directs young clients to use relaxation techniques that she has taught them, such as square breathing (breathing in for four counts, holding for four counts and then breathing out for four counts).

Zalewski also likes to use Roblox, an online platform that features various games and also gives users the ability to create their own games (a function that she likens to sandbox therapy). By creating games or even leading Zalewski through a virtual obstacle course, young clients can develop a sense of leadership, she says. 

Children and adolescents are struggling with the lack of social contact during the pandemic, Zalewski says, and this is often manifesting in anxiety, depression, anger and withdrawal. The isolation is particularly difficult on clients who have depression and attention-deficit/hyperactivity disorder, she adds. 

Because physical activity helps with mood levels and basic functioning, Zalewski tries to get her young clients moving through games such as Just Dance, Ring Fit Adventure (a fantasy adventure world that uses physical exercise to navigate in-game movement), and other virtual reality games.  

To keep clients moving, Zalewski will often give clients “homework” (with parents’ permission), asking them to play a game a certain number of times between sessions. Zalewski also encourages clients to engage in social interaction. Just like any other skill, social skills will atrophy if you don’t use them, she says. 

Many role-playing games enable users to communicate with each other in chat boxes. Zalewski says there are also “clans” and “guilds” that gamers can join. Another resource she likes is Discord, a platform that allows users to discuss games and other interests on secure topic-based text channels. 

Zalewski says her clients laugh at her for her enduring love of Pokemon Go. Still, she feels it is an encouraging way for children and adolescents to get outside with parents and interact with others in a safe, physically distanced way as they collect Pokemon.  

School daze

Although some children and adolescents are doing well with virtual learning, in general, it’s not developmentally aligned to child and adolescent needs, says ACA member Jennifer Betters-Bubon, an LPC and former school counselor. “We know young kids need to move,” she says. “They thrive on environments that provide sensory stimulation and movement. Even in traditional high school, kids get to get up and move through hallways and can interact with friends.”

“We have kids who are on Zoom for hours and not necessarily getting up,” continues Betters-Bubon, an assistant professor of counseling at the University of Wisconsin-Whitewater. “It’s fatiguing for their brains and bodies, [and] it doesn’t lend itself to building relationships.”

When adults feel the fatigue of too much screen time, they can usually disconnect, at least for a little while. “When children get tired, adults are still in charge,” Carter points out. And if a child asks to take a break, parents or caregivers may think that the lack of structure will cause them to fall behind. “They may not understand that children have the same need to disconnect,” Carter says.

Betters-Bubon is noticing a lack of motivation in the children and adolescents she sees in her practice. She believes that’s in part because schoolwork isn’t as engaging without the connection to other people and the school itself. “It can feel like ‘What is the point of doing this work?’” she says. Betters-Bubon points out that on top of COVID-19, students are dealing with the impact of racial trauma and other significant stressors, all of which influence their view of whether their current math assignment is really relevant right now.

Betters-Bubon says some of her younger clients are so disengaged that she has shifted the focus of her work to their parents. She has sought to keep middle and high school students engaged by asking them to create things between sessions such as a vision board of how they’re coping with their anxiety and then sharing their creation with her.

Now that many schools are opening up, at least on a hybrid basis, Betters-Bubon and other counselors say they are witnessing excitement among students about reuniting with friends, mixed with a lot of trepidation. Many of Betters-Bubon’s clients are experiencing anxiety — about the possibility of getting COVID-19, about catching up academically or, in some cases, about starting at a new school without the normal transition. Betters-Bubon has been doing a significant amount of exposure therapy work with child and adolescent clients. This involves having them imagine a list of scary things that they might encounter and working up to doing each one in ascending order. In some cases, she has been able to reach out to school officials to ask them to allow her clients to at least see the inside of their new environment before classes start. 

Betters-Bubon acknowledges that it’s a strange new world for students returning to school. Even the nature of recess has changed. Because of the need to maintain physical distance, her son’s elementary school no longer allows balls on the playground. Students just kind of stand around and concentrate on keeping themselves separated, Betters-Bubon says. As a result, they’re not engaging those gross motor movements essential to healthy growth that they used to engage when they could run around, climb on equipment and toss balls. Betters-Bubon wonders what the implications might be if this scenario becomes normalized. 

Some schools have implemented sensory paths in hallways with different obstacles to run and jump over, Betters-Bubon says. She’d like to see more of those, particularly outdoors. Noncontact games that involve actions such as students moving to different parts of a circle can also be an excellent way to keep children moving while still remaining physically distant, she says.

LPC Melissa Brown works with an Atlanta-area community behavioral health center as a mental health counselor in a local school district with a majority Black student body, most of whom live in poverty. The community has been hit hard, both by COVID-19 itself and by the economic devastation of the pandemic-induced recession. 

The school district has been on a hybrid schedule since January. Brown has tried to give students a sense of normalcy by providing that one thing that will be consistent. “When we meet, this is going to be your safe place,” she tells students. “We can talk about anything and do anything you want.”

Many of the children still worry that they or their loved ones will get sick, so Brown holds family sessions to help students and their families develop a plan to stay safe. The children are used to having a plan for what happens if there is a fire in the school, so the idea of coming up with something similar for home seems natural to them, she says.

In sessions, they talk about teaching kids how to wash their hands, come up with examples to demonstrate what 6 feet of physical distance looks like, and discuss why they can’t see their grandmother, uncle or friends today. They also look at alternatives, such as driving by a friend’s or loved one’s house or mailing them a picture.

Brown also tells parents that they have to be honest with their children. They can’t hide information that they think might be harmful because their children are likely to be exposed to it anyway through social media, the news or friends. Instead, parents can be their children’s first source of information, Brown says.

Grief and trauma

Brown has encountered a substantial amount of grief connected to the pandemic, particularly in elementary school settings. After attending a funeral every Friday for a month, one little girl asked Brown if it was wrong that she didn’t cry anymore. 

Brown frequently uses play therapy and art therapy to help younger children explore their feelings. Eventually, the little girl was able to process her feelings and contextualize them, such as, “This person who died was a friend of my mother’s, and I didn’t really know her” and “This was my grandfather, but he was sick with cancer, and I know he’s in a good place now.”

Zalewski has helped young clients process the loss of grandparents and pets. She notes that furry family members have become even more vital companions during the pandemic. 

One child particularly liked the idea of creating a memorial for a beloved dog. So, with Zalewski’s help, the client created a space on his island in Animal Crossing, a social simulation game that gives players the ability to build and create things. Zalewski and the child found a virtual dog and gave him a red bowl to drink from. The child’s real-life dog had enjoyed being outside and sniffing flowers, so they also created a fenced-in area with flowers, the drinking bowl, a sofa (in case the dog wanted to curl up) and a radio for the dog to listen to. Players in Animal Crossing can pick the radio’s music, so the child chose happy songs because they wanted the dog to be happy.

“Creating it was very powerful, and then [the child was] able to visit [the memorial],” Zalewski said. She suggested that the child share the memorial with their mom and dad, which ended up being an emotionally significant experience. They discussed how losing the dog felt to each of them and were able to mourn together, Zalewski says. She believes the process helped to normalize grief for the child. Mom and Dad were sad too, but they were getting through it, and the client could as well. 

“Now Mom and Dad and the kid can talk more comfortably about the dog,” Zalewski says. “It’s OK to be sad. Sadness won’t break you. It’s OK to share the happy stuff too.” 

Zalewski has also helped child and adolescent clients navigate the loss of loved ones such as grandparents. Many kids are hesitant to share some of their feelings about loss because they are afraid it might be painful for the people around them, Zalewski says. She helps young clients express their grief by inviting them to have a conversation with her about the things they remember about their grandparents or other loved ones who have died. “Everyone has loss,” she says. “I help them access the good memories.” 

These memories are often funny, such as how the grandparent always made the client a cup of coffee or tea, and the client always drank it, even though they thought it tasted terrible. Or they might remember a unique sweater that their grandmother made for them. 

“Many times, kids haven’t grieved before, and they don’t know how to do it,” Zalewski says. She provides a safe place to explore the feelings of being really sad and missing a loved one.  

Moving forward

“We are not holding space for children to be scared to return to in-person learning, especially with the increased safety protocols in place,” Carter says. “Masks, no touching, no singing, playground shut down — all of these things can be scary, yet we expect children to be able to turn that off and learn as usual.”

As schools continue to open, Betters-Bubon believes that a trauma-informed approach with a schoolwide focus on relationships is essential. “Integrated within a trauma-informed approach is social-emotional learning, embedding sensory strategies into the classroom and allowing for voice and choice,” she says. “It also would include a focus on staff wellness. School counselors would focus on teaching and assisting all staff in understanding the impact of trauma on the brain and on student learning, including helping schools carve out specific ways to build relationships.”

Betters-Bubon would also like to see more collaboration between schools and outside mental health counselors to focus on building resiliency in children and adolescents. This may involve taking a wider systemic view and working with the critical adults in students’ lives, she says. “I could see an increased need for family counseling in an effort to create systemic change within families that ultimately helps children and adolescents.”

 

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Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@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 future of telehealth: Looking ahead

By Bethany Bray April 22, 2021

During the COVID-19 pandemic, many counselors adapted to counseling clients via video while in-person appointments were not possible or severely restricted. Correspondingly, insurance coverage expanded and regulations regarding telebehavioral health were relaxed in many states out of necessity.

Now, as pandemic restrictions are being loosened and some helping professionals return to in-person office settings, many counselors are wondering about the future status of telebehavioral health. Will all the “old” regulations suddenly return, or will changes introduced during the pandemic remain long term?

Lynn Linde, the American Counseling Association’s chief knowledge and learning officer, says that a number of factors point toward telebehavioral health remaining a viable option for counselors in the months and years ahead.

“People have discovered that there’s a tremendous desire on the part of clients to continue telehealth, and that’s what will drive this,” says Linde, who is also a past president of ACA. “I think states aren’t going to be quick to go back to the way things were. … Counselors traditionally have not received a lot of training in telebehavioral health. We all have had to learn how to live a Zoom existence and get work done remotely — and people’s perspectives [about telebehavioral health] have changed.”

Regulation of telebehavioral health for professional counselors varies state to state. Prior to the pandemic, a handful of states had statutes that allowed for the use of telebehavioral health under counselors’ scope of practice. During the pandemic, other states relaxed and expanded the regulations surrounding telebehavioral health via executive orders from governors of regulation boards, Linde explains.

Now, more than a year later, state legislatures in several states are considering omnibus bills that would allow for the use of telehealth permanently, Linde says.

“There has been a lot of push by [state] governments for health insurance companies to cover telehealth. I think now that the efficacy of telehealth is being demonstrated, insurance companies are going to view things differently,” Linde says. “As telehealth expands, they’re going to have to rethink some of their policies around reimbursement. Some of them already are, and some states are also putting pressure on them to change. This is a huge change in the field of medicine and mental health. It’s partly counselors and clients becoming accustomed to doing things differently, and regulators and insurance companies noticing the difference.”

Telebehavioral health is also a major aspect of the interstate counseling compact project that has been gaining momentum this spring. The compact, an initiative that would allow counseling practice across state lines, is finalized and will take effect once 10 states pass legislation to adopt it. In March, Georgia was the first state to pass such legislation, followed by Maryland.

Language in the agreement ensures that any state that adopts the compact will allow counselors to use telebehavioral health permanently, Linde says. 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, it will become live and those 10 states will form its governing body.

Leaders involved in the project, including Linde, expect that the compact will reach the 10-state threshold in the summer of 2022. There is a “critical mass” of states — more than 20 — that have shown interest in joining the compact in the coming year, she says.

“It’s not a question of if we will have a compact but when,” Linde says. “We’re really seeing progress, and there is excitement [among those involved].”

Convenience and improved access

The increased use of telebehavioral health among counselors over the past year-plus has shed light on its benefits as well as how it can improve access for clients who face barriers to in-person treatment, Linde notes.

“The pandemic, in many ways, showed the deficits in our mental health delivery system,” she adds.

Telebehavioral health has allowed clients who struggle with transportation and other barriers, as well as those who live in communities or areas without a counselor, to access counseling more easily. It has also benefited college students who had to return home — often to a different state — when many campuses closed in the spring of 2020 and shifted instruction online, Linde notes.

“Necessity is the mother of invention. When everything locked down, everyone was scrambling on how to continue services. One year later, [telebehavioral health] is no longer a one-off. It’s become more of a way of doing things,” Linde says. “Counselors are trained to do face-to-face, in-person counseling. That’s our training. But we’ve seen that it is possible to pick up on some of those cues that we usually depend on seeing in person [during sessions]. It’s not the horrible situation that a lot of counselors thought it would be it. Actually, it can be very positive, and there can be benefits and time savers both for counselors and clients.”

Photograph of a person sitting with a laptop in front of them and several paper notebooks, taking notes

 

  • Read more on this topic in a feature article, “Pandemic telehealth: What have we learned?” in Counseling Today’s upcoming May magazine.
  • Find out more about the ethical standards for telebehavioral health and other important information on ACA’s COVID-19 resource page here.
  • Also see Section H, “Distance Counseling, Technology, and Social Media,” of the 2014 ACA Code of Ethics at counseling.org/ethics.

 

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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.

COVID-19 and the ‘casino effect’

By Todd Monger April 15, 2021

Providing mental health services during a pandemic is a perspective changer. A few weeks ago, I happened to work with three clients back-to-back, providing counseling services through telehealth. COVID-19 has opened a door, and a necessity, to being creative in how we provide services and mental health support. It has also revealed an interesting parallel.

As I worked with these three college students who were struggling with issues related to depression, isolation, lack of energy and anxiety, I realized they were all engaging in counseling from the same environment: a basement or bedroom from which they had not left the entire day. Not because of the debilitating effects of a clinical diagnosis, but rather because they had no need to.

It is well known that casinos spend significant resources honing the psychology of their gambling venues to tap into the gamer’s five senses. Casino designers create an environment that lulls their customers into a trance during which they can lose their financial capital as quickly as they lose their sense of joy, self-esteem and inner peace. There are no clocks or windows. Scents are used that research has shown can increase gaming up to 53%. Customers are well-stocked with free drinks and snacks. All of this is done with the purpose of encouraging gamers to pull that lever or roll the dice one more time.

It has occurred to me that COVID-19 has had some similar effects on our psyches. If recognized, we might use these observations to inform our understanding of some of the mental health pitfalls that our clients are currently experiencing, similar to the way we are informed of the trappings of organized gaming.

Time

Casinos work hard to keep customers hooked to their games. One way this is done is to remove anything that informs the player of time. Clocks and windows are almost never seen because these objects would risk informing those on the gaming floor that they have been there too long or have other things that need their attention.

The coronavirus demanded that many of us work or attend school from home. It has become apparent that our living conditions can affect our mental health in ways we do not readily recognize. Many people’s workstations reside in dark bedrooms or basements in which natural light is limited or eliminated completely. To improve contrast and reduce screen glare, those who are working or attending school from home may draw their curtains. The information that daylight provides about the time of day — morning, noon, night — is effectively lost.

It used to be common to get our news and entertainment via predictably scheduled TV shows and movies. Some even carried time stamps (the 6 o’clock or 10 p.m. news, for example), prompting us to consider our proximity to bedtime. Now we stream our news and television shows with little thought given to a set schedule. We routinely engage in “binge-watching,” which is akin to staring at a slot machine as it rolls around and entices us with “just one more pull” before we go (and then still don’t leave). Whether it was beating rush-hour traffic, catching a school bus, coming home from work or attending evening activities, these actions subtly informed us about the time of day and regulated us biologically, providing a healthier existence until the threat of COVID-19 arrested these tells.

COVID-19 is affecting our sense of time and, as such, impacting our biological regulation of sleep, diet and exercise — three ingredients that can help either protect us against or make us more susceptible to depression and anxiety. For these reasons, I recommend that individuals pay greater attention to their work and entertainment environments. Set structures that encourage relocation and movement. Although it is potentially less convenient, consider watching your entertainment on a different screen and in a different room than where you work or sleep.

Maintain morning rituals and evening activities that help inform what needs to be happening at each point in the day. Consider investing in a dawn simulator alarm clock, and be mindful of the sunrise and sunset and how they can be included in one’s daily schedule. Committing to a balanced and regulated lifestyle during the pandemic will promote improved mental health, rest and rejuvenation.

Comfort

If you want to help a person lose their money, or their mind, keep them as comfortable as possible. Casinos provide free food and drinks, with incredible customer service, so that gamers never feel the pressure to leave. It’s a sedentary existence to sit at a slot machine or a card table as it eats away at hard-earned resources.

In a somewhat similar fashion, the COVID-19 pandemic has restricted us to our living areas. At first, this was a celebrated comfort for some — easy and seemingly weightless. Those few extra minutes in bed. Never having to get out of your sweatpants. Your living room becoming your office, your entertainment center and your bed. Days and weeks can go by as groceries are delivered to one’s house.

Suddenly, leaving home for any small amount of time feels like a chore or, worse yet, home has become a security blanket and leaving becomes anxiety producing. The more comfortable we are, the more everything else seems like “work” — and certainly less pleasurable.

Metaphorically, I have thought of this as being akin to an astronaut whose “antigravity muscles” (neck, calf, back) begin to atrophy due to underuse after five to 11 days in a weightless environment. Upon returning to Earth, gravity suddenly feels like a heavy weight, and what previously seemed normal is now crushing, unpleasurable and anxiety producing. To mitigate these known effects, astronauts intentionally exercise every day while in outer space, using resistance bands and other adapted machines to keep muscles working.

In a similar way, individuals need to keep working out their social and mental muscles. I fear that when the COVID-19 pandemic is finally over, some people will struggle with the “gravitational pressure” of social engagement because that muscle has atrophied through underuse during this time of physical distancing.

Mental stimulation

Casino floors are loud. Between the lights, colors, bells, sirens and laughter, it’s little wonder they are often referred to as “playgrounds.” Upon first entering such a place, it seems filled with possibility and excitement, but it doesn’t take long for that sound to become numbing. Research on gaming design tells us that casino games are made to “sound like winning” to increase a person’s drive to engage. Casinos, from the games to the artwork, are designed to draw one in like a moth to a flame. I imagine this is similar to receiving a “like” on a social media account, the new dopamine hit of the 21st century.

It is no surprise to hear that living through COVID-19 is boring. So many people and places we took for granted have been taken away or locked down. The world has been filled with fear, and in many cases, technology has been the answer to keep us safe.

As we continue to use our digital “slot machines” to connect to the world around us, one unintentional effect is that we steadily increase the amount of access we have to passive, yet exciting, communication. It reminds me of learning how food can become a delivery system for sugar, which tastes delightful and delivers an immediate energy rush, but leaves one feeling tired and sluggish soon after. And when we feel tired, we consume more sugar for a quick pick-me-up, resulting in a vicious cycle. Under the COVID-19 pandemic, when our brains feel bored, we are tempted to watch more lights, more colors, more bells to stimulate away the silence and isolation. Much like in a casino, this can trick us into feeling like we are winning when, in reality, we are running ourselves into the ground due to a lack of true novelty.

Dopamine, sometimes referred to as the pleasure neurotransmitter, is actually increased when we think of or engage in something that is novel. Technology can be an amazing delivery system of novelty. However, during this time, it is important that we also find novelty outside of the “casino.”

I have challenged clients to create their own journals titled “Things I learned during COVID-19” and then fill them with experiences, activities and photos. Creating novelty does not have to be hard. It can be as simple as making your own campfire and toasting s’mores, cooking or baking, or learning something new. The process of both planning and physically doing new tasks increases movement and engagement and uses our entire neuro-network to improve mental health. The process of delayed gratification —thinking about something exciting or interesting in the future —also increases dopamine.

Living life in a pandemic is challenging in so many ways. But if we allow it to, it can also birth creativity, intentionality, resiliency and new insights. Even though we find ourselves wandering around our homes in a seemingly numb state at times, it does not have to mean that “the house always wins.” My encouragement to you and those you love is to close the laptop or smartphone, get up from the bells and whistles, step away from the artificial lights, and walk outside to reconnect with a world that is missing you.

 

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Todd Monger is a licensed professional clinical counselor, national certified counselor and approved clinical supervisor who has been providing clinical services for 20 years. He currently serves in private practice at Stable Living LLC, where he provides equine-assisted psychotherapy. He has also served as the executive director of student development at North Central University in Minneapolis for the past 17 years. Contact him at todd@stableliving.us.

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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.

Starting a counseling career in the time of COVID-19

By Lindsey Phillips March 30, 2021

Many counselors can easily distinguish between what their professional career looked like before the coronavirus pandemic started and what it resembles now. But for most new professionals, counseling in a pandemic is all they have known. COVID-19 has shaped almost every encounter they have had with clients and colleagues alike. And the careers that have greeted them upon graduation have looked dramatically different than the ones they prepared for in school.

Hannah McGrath, a recent graduate from the Master of Divinity/Master of Arts in counseling dual degree program at Wake Forest University in North Carolina, always wanted to be a counselor. But as she acknowledges, “This [experience] is not how I thought things would go after I spent four years in graduate school.”

In March 2020, McGrath returned from spring break to discover that she would have to finish her counseling internship virtually. Many of McGrath’s clients, who were university students, had gone home for spring break and did not return to campus because of the pandemic. Some of them were out of state, which meant she was unable to provide counseling to them. Professors and supervisors scrambled to make sure she had the documentation she needed to do telebehavioral health and to help her find clients so that she could complete her internship hours in time.

It’s difficult to anticipate the long-term implications of beginning a counseling career in the time of COVID-19, but McGrath and four other new professionals agreed to shed light on the ways the pandemic has shaped them — and their future outlook on the profession — thus far.

Rethinking a counseling career

Kathryn Beskrowni, a provisionally licensed professional counselor, had concerns about starting her new counseling career even before the pandemic reached the United States. In January 2020, she had just finished her internship at Terrace House, a group practice located in St. Louis. She was apprehensive about leaving a steady job as a learning and development manager at College Bound St. Louis, a nonprofit that empowers students from economically disadvantaged backgrounds to achieve undergraduate degrees, to become a counselor clinician — a career she knew would depend heavily on building a suitable caseload.

Before graduating, Beskrowni, an American Counseling Association member who specializes in relational issues and life transitions, applied to a few jobs in private practices, hospitals and other mental health organizations. After not hearing back from anyone for over a month and a half, her career anxieties only solidified. “I had a two-month period where I didn’t know what I wanted to do,” Beskrowni recalls. “I had to emotionally prepare for this new life I was stepping into.”

She decided to reach out to her former intern supervisor, Christina Thaier, a licensed professional counselor (LPC) and the founder and director of Terrace House. Together, they discussed Beskrowni’s future as a counselor. Through their conversations, Beskrowni realized that one of her biggest hesitations revolved around the limiting feeling of only doing therapy.

Fortunately, Thaier worked with her to create a position that addressed all of Beskrowni’s goals and concerns and would allow for her to grow professionally. So, Beskrowni joined the team at Terrace House both as a therapist and assistant director of community relations (a role in which she helps to oversee and recruit counseling interns).

A few weeks later, COVID-19 made its way to the United States, and all the uncertainty surrounding the pandemic heightened Beskrowni’s career anxieties and concerns about financial stability yet again. Ultimately, she decided to keep her job at College Bound St. Louis, which provided steady pay and hours, while also transitioning into her new role as a professional counselor.

For about six months, she juggled both jobs, switching back and forth between her two work laptops — a privilege she had because of the ability to work from home during the pandemic. “It took me a really long time to feel safe and comfortable enough to fully commit to the unpredictability of a counseling career, so I held on to [the nonprofit job] for longer than I needed,” Beskrowni says. But she’s happy that she finally did become a counselor, and she’s excited about the future direction of her career.

Readjusting career plans

Before the pandemic, Darius Green, a recent graduate of James Madison University’s counselor education doctoral program, planned to find a full-time position in counselor education. He was willing and able to move anywhere. But the pandemic changed things. He wasn’t sure how much the pandemic would affect college enrollment and university faculty hiring, and he was anxious about the job search process and his own financial stability. “I worried if I would be able to find a job in counselor education, and if I did find one, I worried about the risk of that position being eliminated,” he says.

Green, an ACA member whose research interests include wellness, diversity, social justice and counselor education, did apply to some counselor educator positions, and he even scheduled a few interviews. But he ultimately decided not to pursue that career path because he didn’t feel prepared for the several hours of virtual interviews and teacher demonstrations, and given the uncertainty surrounding the pandemic, his willingness to pick up and move just anywhere had dissolved.

“Originally, I felt willing to move just about anywhere to get my foot in the door, but the pandemic shifted my priorities and values,” Green says. “My top priority wasn’t having a job in counselor education [anymore]. My top priority was having a job with benefits and a stable income.”

In part for that reason, he decided to continue working as the assistant coordinator of the James Madison University (JMU) PASS Program, which supports student learning and success in challenging courses at the school. Although he applies some of his counseling skills to this position, the job itself isn’t counseling focused. So, he also works part time as a counselor at the ARROW Project, a community mental health organization in Staunton, Virginia.

Even this part-time position came with new challenges. “I was nervous because I hadn’t been trained to do telebehavioral health,” Green says. “I’m fairly tech savvy, but [with telebehavioral health], there’s just a lot more to think about.”

The pandemic caused Green to readjust his career plans, but it also gave him the opportunity to work from home. This has allowed him to balance his full-time job at JMU and his role as a counselor at ARROW, which otherwise would have involved a 20-minute commute.

Green isn’t sure if a career in higher education is sustainable or obtainable right now, so he wants to keep his options open by working toward his counseling licensure. He also knows his experience as a counselor clinician will strengthen his curriculum vitae if he does decide to pursue jobs in counselor education down the road.

Growing pains

Rachel Wyrick, a master’s student in the counseling program at the University of Missouri-St. Louis (UMSL), was looking for an internship position right when the pandemic hit the United States. Wyrick wasn’t sure if they would be able to find placement with so many agencies focusing on switching their practice to telebehavioral health. After a few weeks of silence, Wyrick finally got the email they had been hoping for: Terrace House offered Wyrick a position as a counseling intern.

Wyrick had felt like they were hitting their counseling stride during their practicum a couple of months before the COVID-19 pandemic. Wyrick had become more comfortable with clients, and Wyrick’s initial nervousness was slowly waning. But when everything went virtual, Wyrick’s anxiety shot back up. In many ways, Wyrick felt like they had to start over by learning how to do therapy using telebehavioral health — something that was not on their radar before the pandemic.

Wyrick specializes in relationship issues, trauma, posttraumatic stress disorder and LGBTQ+ populations. Because Wyrick works with clients experiencing trauma and uses somatic therapies, Wyrick had reservations about how effective telebehavioral health would be. But Wyrick embraced the change and discovered they can still build a strong rapport with clients virtually. In fact, in many ways, Wyrick finds it more intimate. Because they are sitting face to face with clients, Wyrick can easily read the microexpressions on the client’s face via screen.

“And for my style of counseling, it actually really suits me and the populations that I serve,” says Wyrick, who was named UMSL’s clinical mental health master’s student of the year this past December. It can be comforting to clients to be in their own space and to see their counselor as a “real” person in their own space, Wyrick explains. Wyrick notes that when clients ask about Wyrick’s plants or artwork in the background, it often seems to jump-start a stronger connection.

Wyrick still oscillates between weeks of feeling connected to clients and weeks of feeling unsure and inadequate. “Will it always feel this way, or is this a normal part of the process of growing as a professional?” Wyrick wonders. Wyrick hasn’t had much practical experience outside of the pandemic, so it’s hard for the counselor-in-training to know what might be unique to the pandemic and what is simply typical growing pains.    

Difficulty finding a job

After moving to New York, McGrath noticed there were more jobs for social workers than for counselors. That’s when she learned that some states privilege different mental health workers. Social workers have a longer history in New York than do licensed professional counselors and, in turn, more job options. Many of the types of jobs McGrath had assumed would be open to her — such as being a counselor in a hospital — were not.

McGrath applied to every counseling job she could find, but many of the places didn’t respond or told her they were hiring only fully licensed counselors. “I felt like I had no job options,” she says. The fact that New York City had to shut down because of the pandemic didn’t help, she points out. Nothing was business as usual.

Finally, in June, she found a job working with a foster care agency as a mental health counselor-limited permit.

Looking back, McGrath realizes the pandemic heightened her anxiety around her job search. She felt a sense of panic and urgency to find a job. If she could do it all over again, she says, she would slow down and take her time during the process.

During graduate school, a visiting speaker told McGrath, “Your first job doesn’t have to be a perfect job, but it can be the perfect teacher.” She is taking that advice to heart as she continues navigating her counseling career during an uncertain and challenging time.

Building a caseload

After graduating with a master’s in counseling from the University of Mary Hardin-Baylor in spring 2020, Mika Smith-Tjahja, now an LPC associate at Firefly Therapy Austin in Texas, put a lot of pressure on herself to instantly build up her caseload. “I was hard on myself at first,” she recalls. “I had high expectations about getting a certain number of clients each week.” When that didn’t happen, she felt discouraged.

At the beginning of the pandemic, Smith-Tjahja was averaging one to three clients a week for about two months. Her supervisor reminded her that it takes a while to find clientele, so she trusted the process. Smith-Tjahja’s caseload has since doubled, but it is still below the number of clients she would like to average per week. She recently accepted a second counseling job at Connected Heart Therapy in Austin and hopes this will build her client base even more.

Smith-Tjahja, who specializes in anxiety, depression and trauma, wonders how much the pandemic has affected her ability to build a caseload. A few referrals have told her they prefer to wait until in-person therapy resumes, so she knows that it’s a factor.

Smith-Tjahja has started thinking outside the box to find people who need help right now. She joined a Facebook group for mental health professionals in Austin to share and request referrals. She has found the group to be a great resource both for referrals and networking.

She has also suggested to her supervisor the idea of creating a low-fee closed counseling group for individuals who are interested in therapy but can’t afford the higher fees. The group would benefit the community while simultaneously teaching Smith-Tjahja more about the community’s counseling needs and informing others that she is available and eager to help, she explains. Smith-Tjahja is also interested in doing pro bono work in the future, once she feels more settled in her role as a professional counselor.

Finding support amid the isolation

Smith-Tjahja says her biggest challenge throughout the pandemic has been the isolation, especially in terms of not being able to interact in person with colleagues. She imagined trading her graduate school cohort for colleagues in an office or hospital. Instead, she works from home, alone. Because that feeling of community isn’t there anymore, she created her own virtual community — a support group for LPC associates like herself. When she reached out on social media to find others to join her group, she was surprised by the response: More than 50 people joined. They meet once a month, and they recently invited a certified public accountant to present on how to manage taxes for one’s private practice.

She also reached out to her former cohort and formed a peer support group. In their last meeting, they all echoed Smith-Tjahja’s sense of isolation and agreed that they needed this group because they had missed the sense of community it offers.

McGrath acknowledges that it can be challenging to feel connected to other mental health professionals right now. She communicates with her colleagues through emails and phone calls. Sometimes, she says, when she doesn’t get a reply within a couple of days, she wonders if her colleagues are busy, if they are ignoring her or if they think she is a bad therapist.

Wyrick likewise admits that it’s easy to fall into self-doubt, especially when everyone is isolated from each other. The Terrace House internship program tries to address this by pairing new professionals with other new professionals who are a few months or years further along in their careers. Wyrick has benefited during their internship at the Terrace House from having a mentor. Wyrick has had virtual coffee dates with their mentor, which provided a semblance of an in-office interaction.

Supervision is also critical. “It’s hard to know where you stand as a new professional right now,” Wyrick says. “Having a well-seasoned professional reflect back what they see — whether it be strengths or growing edges — is really helpful.”

“Normally we’d have these [professional] experiences with peers and be able to compare … and all develop together,” Wyrick continues. “Without that, our supervisors are our main source of reflection and validation … of how hard this experience has been and the strength that we’ve shown.”

Green encourages counselors to remember that not everyone comes from a privileged background and has the same opportunities and resources. Therefore, it is important for established counselors to reach out and support new professionals, especially as they try to find their footing in the midst of an ongoing pandemic, he says.

Professional connections provide not only career opportunities but also emotional and social support, notes Green, a member of both the Association for Humanistic Counseling and Counselors for Social Justice, which are divisions of ACA. People are less inclined to reach out virtually, so it can be isolating at times, he points out. He had several mentors schedule virtual meetings in the fall, but those meetings have slowly decreased in the succeeding months. Green tries to lead by example, taking the time to message his colleagues as well as other new professionals.

After the pandemic, McGrath looks forward to meeting her colleagues in person and building work relationships that will help her grow professionally. She says she wishes she could just pop into a colleague’s office right now and ask a question or chat about how their week is going. But until that is possible, she advises her fellow new professionals to make efforts to connect with other mental health professionals in whatever way they can.

Establishing work boundaries

Working from home has caused the boundary between work and personal life to become blurred for many new (and seasoned) professionals. As McGrath points out, it’s often difficult for counselors to have set work hours when they are seeing clients six days a week. “The longer the pandemic has gone on, the harder it’s been to keep those boundaries,” she adds.

“Establishing work boundaries is already a struggle for new professionals,” Wyrick says. The pandemic only adds to this problem. Wyrick’s workspace is in the bedroom, which means they can answer emails at all times of the day. It’s also tempting to take on clients outside of scheduled work hours, Wyrick points out. Wyrick often thinks, “What’s one more hour?”

Wyrick has had to create a routine because their partner is a professor who is working from home as well. When Wyrick is working, they shut the door and turn on a white-noise machine. This signals Wyrick’s partner not to interrupt.

Green says the amount of email he receives seems to have increased during the pandemic. It often overwhelms him, he confesses, and he spends a substantial amount of time sorting and prioritizing these messages. Smith-Tjahja also finds herself checking her email constantly because she is trying to build up her clientele right now. She says she hopes to establish a better schedule for checking and responding to emails after she has more clients.

Wyrick says working from home has taught them a lot about their personal work patterns and values. Before the pandemic, Wyrick took pride in always being plugged in, but now they realize that mindset is not in line with their values.

“At the beginning of this [pandemic], we had no idea how long it was going to be, and the optimists of us thought it was going to be a short time. So, that allowed things to be a little chaotic and wild at first,” Wyrick says. “I was thinking very much in emergency ‘go’ mode, but now I’m trying to be very mindful about creating habits that are going to be sustainable over time.”

Finding opportunity in the chaos

Smith-Tjahja experienced several significant events in her life during 2020, but they looked different because of the pandemic. She graduated with a master’s in counseling, but the ceremony was virtual. She got married, but it was not the ceremony she had hoped for. She and her husband bought their first house, but her parents weren’t able to go look at houses with her. Smith-Tjahja feels happiness for these milestones but also a simultaneous sense of grief because these events didn’t follow the traditional route she had expected.

But the pandemic also opened up new career possibilities for her. A year ago, Smith-Tjahja assumed she would probably work in a hospital until she was licensed. Working in a private practice was a distant dream, but that dream became a reality this fall. After getting her provisional counseling license, she reached out to a counselor she had kept in touch with throughout her graduate program to see if the counselor needed any help at her private practice, Firefly Therapy Austin. The counselor offered her a job.

During quarantine, Smith-Tjahja also decided to get trained in eye-movement desensitization and reprocessing (EMDR). She could easily take the classes from her home and didn’t have to spend money on travel, food or a hotel. This training has opened up another career opportunity. She reached out to another counselor who just started Connected Heart Therapy, a private practice offering EMDR to the Austin community. They offered Smith-Tjahja a job as a part-time counselor, which will allow her to continue her EMDR training.

Wyrick describes their initiation into professional counseling as a trial by fire. Although it wasn’t the start to Wyrick’s career that they had hoped for, it has given Wyrick confidence in their ability to rise to the challenge and their capacity for growth. Wyrick hopes the experience of practicing during a pandemic will encourage and allow new and seasoned counseling professionals alike to rethink the ways that they do therapy and how they can best serve their clients.

The uncertainty that the pandemic generated and the sudden shift to telebehavioral health muted some of the traditional milestones for emerging counselors, including graduating and starting a counseling career, Beskrowni points out. She hopes that other new counseling professionals will still take the time to celebrate their accomplishments and find a sense of freedom in their evolving possibilities.

 

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

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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.