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Pushing back against fatphobia

By Bethany Bray November 30, 2022

“I feel fat today.”

This is a phrase that Justine Trumbetas, a licensed professional counselor (LPC) in Pennsylvania, says she often hears from clients who live in bodies of all kinds of shapes and sizes. And this seemingly simple statement contains a lot for counselors to unpack with clients.

More often than not, this thought stems from weight stigma or bias that the client has internalized from external sources. This can include anything from an offhand comment a friend makes about needing to work out to “earn” her slice of birthday cake to a medical doctor who advises weight loss for a presenting concern that is unrelated to the patient’s body size.

Trumbetas, who specializes in helping female clients with anxiety and body image-related issues, says that when clients use language such as “I feel fat” or “I feel gross,” she uses it as an opening to help them begin to recognize their emotions and negative thought patterns as well as how these thoughts affect their value and self-worth. The first step is to replace the word “fat” with a more factual, accurate word, she notes.

“I tell them that fat is not an emotion, so we can’t feel it. And we work to replace that, find the word they need … and tap in to what they’re feeling, [such as] defeated, let down, sad. And then we dig into why they feel that way,” says Trumbetas, an American Counseling Association member who has a counseling practice providing online sessions to clients in Pennsylvania and Florida. “There’s much more than feeling fat. There is a lot more underneath it. Are they comparing themselves to other people [or reacting to] something that they saw or heard from others? Typically, when we dig in, I find that their worth is tied to their body and how others view it.”

Pervasive weight stigma

Thin bodies have been idealized and prioritized in U.S. culture and society for centuries. This shows up in everything from themes in advertisements and television to the overuse — and misuse — of the body mass index (BMI) as a benchmark for health by medical professionals and others.

Weight stigma carries the message that “there’s something wrong with your body simply because of the size of it,” says Jennifer DiGennaro, an LPC with a private practice in Grand Rapids, Michigan. And it’s traumatic for an individual to be bombarded by a lifetime of messaging that implies that their worth is tied to their body size or ability to lose weight, she adds.

“We live in an eating disorder culture and a body-shaming culture,” says DiGennaro, who specializes in helping clients heal from trauma, body shame and eating disorders. “We carry this myth that everyone can control their weight,” she continues, but “there are many, many, many reasons that someone is living in a larger body, and it may have nothing to do with what they eat or how much they’re moving.”

When talking with clients and colleagues, DiGennaro finds that using different words to name this phenomenon can help others understand the stigmas surrounding weight, depending on the context and their familiarity with the issue. Weight stigma can also be described as fatphobia, fatmisia, sizeism, weight bias, weight-based discrimination, fatism or size bigotry. No matter what it’s called, fatphobia is “thinking you know things about a person simply by the size of their body, and we don’t,” DiGennaro says. “And arguing on that point is reinforcing weight stigma.”

When unpacking and dismantling weight stigma, it’s important — both for counselors and clients — to consider the full context of the messaging they receive about weight loss, nutrition, body size and related issues, says Kaitlyn Forristal, an ACA member and licensed professional clinical counselor who studied fatphobia’s influence on diagnosis decisions made by counseling graduate students in her 2018 doctoral dissertation. This includes the fact that many companies stand to benefit from keeping this stigma alive and prevalent, she adds, noting that the weight loss industry in the United States was worth $72 billion in 2018.

Trumbetas says that nearly all her clients use language in sessions that indicates they have been negatively affected by weight stigma. This ranges from describing feelings of worthlessness to noting that they had a “bad” weekend because they indulged and ate a slice of pizza, she says.

Her clients have often internalized microaggressions and messaging they’ve received from a number of sources, but she finds that the most influential are social media, their family of origin and the medical profession. Many clients talk about being raised in an atmosphere where the adults were always on a diet roller coaster, Trumbetas says, so it was common for them to make comments such as “You shouldn’t be eating that.”

She has also worked with clients who have stopped going to medical appointments because they don’t want to be judged and have assumptions made about them based on their weight. Because weight bias is deeply embedded in the medical profession, some doctors’ initial and go-to recommendation for larger-sized patients is to lose weight without finding out the context surrounding what’s bothering them, she explains.

Reconnecting to self

The counselors interviewed for this article agree that clients who have been negatively affected by weight stigma often need a combination of counseling work that focuses on quelling negative thought patterns, tolerating discomfort and reconnecting to a body that external forces have caused them to disconnect with and hate.

An important first step is educating clients on what weight stigma is and how prevalent it is in our society as well as offering the message that “your worth, your identity and your value is not in your appearance,” says Stephanie Dutson, an LPC who specializes in helping adult clients with trauma, anxiety and body image-related issues.

Dutson says she often emphasizes to clients that a body is for living in, not for looking at.

She finds that weight stigma often causes clients to feel guilt or shame about what they are or are not doing to maintain their appearance. And that guilt or shame “affects a person’s health so much more than an extra 20 pounds does,” says Dutson, who lives in Birmingham, Alabama, and has a counseling practice providing online sessions to clients located in Utah, Wisconsin and Alabama. “The research shows time and time again that social life, stress management and moving your body in a joyful way — not weight or size — are what promote health. Diet culture really squashed that intuition for most people, and [unlearning weight stigma] comes back to trusting themselves and finding connection to intuitive knowing.”

Many of Dutson’s clients have strong feelings of shame or disgust associated with their bodies, especially with parts that are often sexualized or idealized in popular culture and media (such as the abdomen, chest and arms), she notes. Dutson focuses on helping clients who feel this way regain comfort and feelings of safety with their body, including “tuning in” to parts of their body that they’ve “tuned out” or disconnected with because of weight stigma, she says.

For example, she may ask a client to gently touch or look at parts of their body that they have tuned out (e.g., a soft belly post-pregnancy) in a mirror at home. Then Dutson processes the experience and emotions the client felt at their next session. She also encourages them to spend more time doing this exercise as they become increasingly comfortable with their body. The aim, Dutson says, is to help clients gradually reconnect to their body.

Many clients have such negative feelings associated with their body that they aren’t able to look at their entire body in the mirror at first. She encourages them to start small with a handheld mirror to view one part of their body, such as an arm or leg, and eventually add additional areas.

“I tell clients to expect some feelings of discomfort, but to try and find an area of the body or [amount of] time that is moderately uncomfortable while still tolerable so they don’t become flooded or overwhelmed,” she explains.

A powerful aspect of these exercises, Dutson notes, is helping clients recognize and begin to fully feel emotions — including discomfort — in their body. “I don’t know a client with body image issues that is entirely comfortable with their emotions because emotions are so often experienced within the body,” she adds.

Trumbetas also finds mirror work helpful, and often suggests that clients focus on learning to thank their bodies for its strength. She prompts clients to think of things that their body has done for them, such as allowing them to smell their favorite scent or heal from sickness or surgery.

This is quite a perspective flip for individuals who have harbored animosity toward their body for a long time, she notes.

If a client makes a comment such as “I hate my thighs,” Trumbetas says she would prompt the client to spend time looking in the mirror and thanking those thighs for getting them where they want to go and being able to do things like climb stairs or walk their dog.

“Being kind to yourself in this way can be a foreign concept,” she acknowledges. “I tell my clients consistently that to get comfortable, you have to become uncomfortable.”

As clients practice looking at their body in the mirror, she suggests they take an empowering stance she calls the “Wonder Woman pose.” To do so, the client meets their own gaze while standing with their hands on their hips, holding their head high, chest out and shoulders down. Trumbetas will model the pose for clients during sessions and encourages clients to try it with her. Standing in this way can decrease anxiety and boost confidence, she says.

Trumbetas says she receives a lot of positive feedback from clients about the Wonder Woman pose, and many report that it’s helpful to do whenever they’re feeling anxious or need to feel better about themselves and reconnect to their own power.

Identifying triggers

Reconnecting to oneself in counseling allows clients not only to better understand their own emotions but also to pinpoint how it feels when they are affected by negative messaging about body size and appearance, notes Dutson, an ACA member.

“Understanding the core emotion of what a trigger brings up for you gives you a better road map of how to deal with that emotion,” she explains. “Most of the emotions that come up around body image are disgust, shame, anxiety or guilt. And when clients have that [emotional] self-awareness, they can ask, ‘What is the core emotion that I’m feeling?”

She then guides them to find ways to care for themselves when shame and other painful feelings arise, such as focusing on empathy and self-compassion.

For example, a client may be visiting an aunt who makes a comment that the client has gained weight since she last saw her or talks incessantly about her own weight loss behaviors or successes. Dutson will process this interaction with the client and prompt them to identify the emotions they felt and how they would like to handle a similar situation in the future.

She finds it helpful to prompt clients to track the moments that produce a visceral or intense emotional reaction regarding body size. Depending on the client’s situation and preference, she has them recount triggering situations to her verbally or write down details in a notebook or journal. She then guides clients to think about who was there, what was said, what emotions rose to the surface, what they were doing and feeling leading up to the interaction, and other aspects surrounding this triggering experience. Clients who reflect in this way eventually notice common threads of people or topics that activate them, she notes.

It can also be helpful, Dutson says, to suggest that clients write out a script or statements they’d like to use the next time they are in a triggering situation. Depending on where they are in their healing, this can include asking the other person not to talk about weight or body size in that way.

Trumbetas also helps clients identify and manage triggers, and one of the first things she does with clients who have been affected by weight stigma is to suggest they do an “audit” of their social media accounts to unfollow people and pages that spread body-negative messaging.

DiGennaro adds that helping clients talk about messaging related to weight stigma also requires counselor practitioners to suppress the urge to reassure or comfort clients who make statements such as “I feel like people are judging me.” A counselor’s role, DiGennaro emphasizes, is to be honest because people may very well be judging the client. Instead of offering reassurance, counselors can help the client unpack how they feel about such thoughts, recognize their origins and become intentional about the relationship they have with these thoughts and the way they affect their mental health, she says. Then they can help clients find and set boundaries to keep from internalizing harmful messaging going forward.

DiGennaro often helps clients plan for social interactions or family gatherings by guiding them to explore their values and identify what they are and are not willing to disclose or talk about.

“It’s a huge piece of healing work to first know what you need and want, then be able to put it into words and ultimately decide to share it with the appropriate people,” she says.

DiGennaro sometimes invites clients to constructively use the anger they may feel about issues related to body weight and size. “There is a lot to be angry about with the way our bodies and feelings about food have been manipulated by diet culture,” she says. “One pattern I often see is when a client takes the unconscious anger evoked by weight stigma and turns it against themselves with punishing or chaotic food behaviors. So once the anger becomes conscious [through counseling,] I tell clients to channel that appropriately outward. Feeling and acknowledging rightful anger allows for the setting of essential boundaries to protect from further harm from weight stigma.”

Rethinking restriction

Helping clients identify and work toward goals is often an important part of counseling. But what if a client is focused on a goal to diet or lose weight?

The first thing to remember is that it is outside of a professional counselor’s scope of practice to advise clients on nutrition, exercise, weight loss or other topics related to physical health. (For more, see Section C of the 2014 ACA Code of Ethics at counseling.org/ethics.)

Weight loss is not a behavioral or mental health issue, DiGennaro stresses. Whenever a client mentions a goal of weight loss in a counseling session, she uses that opportunity to dig into why they want to set that goal — and what outside influences might have contributed. She uses motivational interviewing and asks questions such as “What would it mean to you if you lose weight?” to explore the client’s underlying reasons.

Knowing the reasons behind their weight loss goal will also help counselors determine the best approach for the client. Maybe the client says they want to lose weight because of negative comments they’ve heard from family members. “If you dig into it, they might be actually fine with their body, but they’re sick of hearing comments at family gatherings,” DiGennaro says. “In that case, we need to work on boundaries.”

Another client, however, may realize that their core reason for wanting a smaller body size is a desire to feel more confident. In that case, DiGennaro says she would focus on counseling techniques that boost the client’s self-confidence without attaching it to their weight or body image.

“Food and body issues are often the tip of the iceberg,” DiGennaro says. “I have never worked with a person who discovers their heart’s desire is to be thin. It’s always more along the lines of finding peace, receiving love and finding meaning in life.”

Similarly, Trumbetas says that when a client mentions in session that they’ve lost a certain number of pounds, she avoids praising or encouraging them, which would reinforce weight stigma. Instead, she responds with a question such as “How does that make you feel?” to explore the context of the client’s statement.

Trumbetas uses these conversations to emphasize that weight and health do not mean the same thing, and that “fixating on one aspect of health leads to unhealthy thinking,” she says.

Clients sometimes tell her, “If I can only lose this amount of weight, I’ll be happier.” But she reminds clients that being thin will not magically make them into someone they will love. Instead, she focuses on helping them learn to avoid comparing themselves to others and strengthen their self-love (both love of their body and their whole self).

DiGennaro is a certified intuitive eating counselor, so she also offers clients who talk about dieting psychoeducation on intuitive eating and explains that research indicates that most people who diet eventually gain the weight back, plus extra.

“Trying to control your body [via dieting] often comes from a place of punishment and restriction. I see it as ultimately a disconnection from self,” she says. “Instead, I help clients get curious about what it might be like to reconnect to themselves from a place of nourishment, self-care and truly listening to their body. And this is complex work because often … there were protective reasons they had to disconnect from their bodies and reconnection must be done in a trauma-informed way.”

DiGennaro acknowledges that this perspective shift does not come easily for clients, and it often takes many sessions before they begin to replace the unhealthy thought and behavior patterns they’ve adopted to cope with a lifetime of weight stigma.

Dutson also focuses on helping clients shift their perspective away from a restrictive view of taking things away (including food) to one that allows them to consider adding supportive elements to their life. To do this, she often prompts clients who are healing from the effects of weight stigma to identify and add things to their life that bring them joy, nourishment and comfort. This can be anything from dancing to their favorite song to connecting with a supportive friend.

There is so much more to wellness than body size, and the importance of social support is often one of the biggest contributing factors that clients overlook, especially those who have negative feelings about their bodies, Dutson adds.

“Asking ‘how can we add meaning, nourishment and joy to the body?’ is a more realistic and hopeful approach [to wellness] than restriction and taking things away,” she says.

Unlearning bias as a practitioner

Hilary Kinavey and Carmen Cool, co-authors of the 2019 Women & Therapy journal article “The broken lens: How anti-fat bias in psychotherapy is harming our clients and what to do about it,” note that researchers and mental health clinicians alike have reported on the “prevalence and negative implications of weight stigma in psychotherapy” since the 1980s.

“It is our lens, our gaze and the assumptions behind it that are the problem,” wrote Kinavey and Cool, who are both LPCs. “Diagnosis by sight is inaccurate and essentially biased. We simply cannot know who engages in overeating and who engages in restrictive eating based on the size and shape of the body in front of us. As professionals, it is our ethical duty to unpack and address this prejudice and to shift our focus and commitment to the human being who inhabits the body.”

The counselors interviewed for this article also recommend that counselors consider their own internalized weight bias to ensure they don’t inadvertently reinforce those biases in their interactions with clients.

“No one deserves to be treated badly because of their body shape, size or ability,” Trumbetas says. “If a counselor has their own negative views, they need to look inward and work on themselves — with another therapist if needed.”

Weight bias creeps into counseling, Dutson says, when a practitioner makes assumptions about a client based on their body size, such as how active clients are, how they feel about their body or what they might need to address in therapy. In turn, this can influence the questions clinicians ask (or don’t ask) and the issues they cover with the client.

staras/Shutterstock.com

“We have to recognize as counselors that we live in a society that values certain bodies over others, which can be ableist and elitist,” Dutson says. “We need to understand how marginalizing it can be to leave those beliefs unchecked. It’s not a stretch to say that our culture believes that certain genes, illnesses and conditions [that affect body size] are somehow inferior.”

Forristal, an assistant professor of clinical mental health counseling at New England College in Henniker, New Hampshire, agrees counselors need to do their own work to recognize and unlearn harmful beliefs about weight and body size. “Unless we intentionally and actively unlearn fatphobia the way we do with unlearning racism and other stereotypes, we are at risk for perpetuating this harm to our clients and communities,” she stresses.

A good first step counselors can take to combat this, Dutson says, is to decouple morality from food and body issues — both in the language counselors use in session with clients and in the way they think about things personally. This includes the questions a practitioner asks during the intake process with new clients, she adds.

Food is not good or bad, and it can be a comfort without inducing guilt. Counselors should refrain from talking about their own body or weight loss in sessions or asking leading questions of a client that reinforce weight stigma, Dutson says.

Instead, she advises counselors to borrow from mindfulness techniques and approach food and body issues from a nonjudgmental, observational lens. “We’d all benefit more from that,” Dutson acknowledges, “and modeling that for your clients is very powerful.”

Forristal says that refraining from making assumptions — either positive or negative — about a client based on their body size or shape is a good start toward ridding professional counseling of weight bias. Weight stigma is a barrier to care and help seeking, so counselors who want to combat this should mention on their website and other promotional materials that eradicating fatphobia is a goal of their clinical practice, she adds.

In their article, Kinavey and Cool suggested that counselors ensure that their office space is accessible and welcoming to larger clients, which includes having chairs that accommodate a larger person comfortably and a waiting room that does not include decor or reading materials that reinforce fatphobia, such as fashion magazines.

Forristal also encourages practitioners to address any power imbalance that can affect the therapeutic relationship such as the counselor having a larger body than the client or vice versa. A client with a thin body, for example, may not feel comfortable reporting the extent of their issues with a counselor who is larger out of fear of offending them.

Counselors should not hesitate to check in with clients and ask how they feel about discussing body image issues with a practitioner who is a different size from them to ensure that they are comfortable, Forristal adds.

“We can never address these issues if we’re too uncomfortable or unwilling to broach them in the room with clients,” she says. “If a fat client expresses body image concerns to a thin counselor, the counselor can name that they hold privilege as a thin person and check in with the client about their reactions around that. Much like it doesn’t help to take a ‘colorblind’ approach when working with BIPOC [Black, Indigenous and people of color] clients, it isn’t helpful to ignore the differences in body size and power in the room.”

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Resources for counselors who want to learn more:

The National Eating Disorders Association’s page on weight stigma: nationaleatingdisorders.org/weight-stigma
The Association for Size Diversity and Health: asdah.org
The National Association to Advance Fat Acceptance: naafa.org (Visit the “learn” menu to download a brochure with suggestions and guidelines specifically for therapists.)
Hillary Kinavey and Carmen Cool’s 2019 Women & Therapy journal article, “The Broken Lens: How Anti-Fat Bias in Psychotherapy is Harming Our Clients and What To Do About It”: org/10.1080/02703149.2018.1524070

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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 the body matters

By Katie Bascuas June 27, 2022

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

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

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

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

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

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

Brain-body connection

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

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

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

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

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

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

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

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

Improving self-regulation

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

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

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

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

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

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

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

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

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

Filling a gap

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

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

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

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

Skepticism

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

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

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

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

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

Challenges

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

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

Eugene Titov/Shutterstock.com

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

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

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

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

Try it for yourself

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

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

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

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

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

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

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Contact the counselors interviewed in this article:

Kimberly Hanson: contact@heartcoreccw.com
Whitney Norris: whitney@lrcplc.com
Nancy Skocy: nskocy@msn.com
Mike Wendt: mwendt@sherman-counseling.com

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

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

Self-diagnosis in a digital world

By Lindsey Phillips March 28, 2022

For better or worse, social media posts about mental health, paired with the ease of Googling one’s own symptoms, are enticing many people to self-diagnose. In fact, a 2021 Vox article, “How mental health became a social media minefield,” asserted that social media is becoming known as the “WebMD for mental health.”

Some clinicians appreciate the self-awareness that can result from social media postings and online searches about mental health, whereas others focus more on the potential harm that self-diagnosis can cause. Counselors need to be aware of the hazards of self-diagnosis, but many in the profession believe they can also use it to gain insights into the inner world of their clients.

Micheline Maalouf, a licensed mental health counselor and owner of Serein Counseling in Orlando, Florida, chooses to focus on what she can learn from a client’s self-diagnosis. In her practice, she has noticed more clients asking if they have a particular mental health disorder because of social media content. Recently, a client told her they thought they might have obsessive-compulsive disorder (OCD). When Maalouf asked why, the client explained, “I saw this TikTok video about signs that you may have OCD. I resonated with some of the symptoms but not all, so I’m not sure if I have it. My situation wasn’t exactly like the person’s in the video, but it got me thinking.”

ImYanis/Shutterstock.com

Maalouf asked more questions about the symptoms from the video that had resonated with the client, and she also educated the client on the process of determining a diagnosis, emphasizing that it is not as simple as matching symptoms from a checklist. Disorders manifest differently for everyone, she told the client, and depend on many factors, including life experiences, gender, race and more. But Maalouf also reassured the client that their awareness about OCD symptoms was “important information … because it could be the first step in figuring out if something is actually going on.”

Maalouf, an American Counseling Association member who specializes in treating anxiety, depression and complex trauma, says she is thankful for conversations such as these for two reasons. First, it means the client has some self-awareness, which is a good thing, she says. And second, it provides her with more insight into her client and the potential issues they need to work on in session — regardless of whether the issues match the client’s self-diagnosis.

Searching for answers

People are hungry for mental health answers, observes Lindsay Fleming, a licensed professional counselor (LPC) with a private practice, Main Street Counseling Solutions, in Park Ridge, Illinois. They want to learn how a potential diagnosis or certain symptoms are affecting their lives and ways to better manage them. What’s hard, she says, is “when someone is doing that by themselves and doesn’t have a professional guiding them” and helping them understand it.

“A lot of people like to have that diagnosis because it explains [what’s happening],” says Tristan Collazo, a licensed resident in counseling at Wholehearted Counseling in Virginia Beach and Carrollton, Virginia. “Some people think it’s stigmatizing, but a lot of people find hope in it because it finally — for once in their life — explains what’s going on.”

Kaileen McMickle, an LPC and founder of Inner Ascent Counseling in Rice Lake, Wisconsin, often works with clients who are struggling with anxiety disorders. She finds the more anxiety a person has, the more likely they are to seek information about what they are experiencing. “It can be hard to feel so isolated and not know what’s going on,” she notes. “People just want certainty. And with Google and social media, it’s so easy to go [online] and try to make sense of what they are experiencing.”

McMickle specializes in treating anxiety, trauma and OCD, and she frequently sees self-diagnosis with clients who have OCD. They often wonder if what they are experiencing is “normal.”

“We all have intrusive thoughts. We all engage in safety behaviors in some way,” McMickle explains, “but OCD can feel a lot different … [and outside] the ‘normal’ range of behaviors,” such as feeling compelled to tap one’s car 10 times before going into a grocery store or spending two hours trying to find “just the right” products. “People want to know what’s happening to them; they want to know what they’re experiencing,” she says.

Collazo says that a couple of his clients initially self-diagnosed because they identified with a particular trait of a disorder. Someone may see a video about how controlling behavior and manipulation are traits of narcissistic personality disorder, for example, and fear that they have the disorder because they engaged in this type of behavior once in a past relationship. They might have been upset and accused their partner of not loving them, for instance. Making such a statement can be a form of manipulation used by someone with narcissistic personality disorder, Collazo notes, but he points out that it is also something many people who don’t have the disorder might blurt out in the heat of the moment.

It is human nature to sometimes relate to a disorder or disease after learning a little bit about it, Collazo says. “We probably all have traits from different personality disorders,” he observes, “but it takes certain criteria to have an official diagnosis, which people don’t often understand. They may have a trait or symptom [from a personality disorder] … but that does not mean they have that disorder.” In his social media posts, Collazo tries to debunk the tendency to self-diagnose based solely on resonating with a particular trait.

That is why it is so important to help clients distinguish between symptoms or traits and an official diagnosis, says Shani Tran, a licensed professional clinical counselor. If a person sees a post about how an inability to sleep, a lack of energy and feelings of sadness are symptoms of depression, they may assume they are depressed because they are struggling with one or more of those symptoms. But having trouble sleeping could be the result of an array of issues, Tran notes, and not necessarily evidence of a mood disorder.

Tran, owner and founder of The Shani Project, a group counseling practice in Minneapolis, attempts to personify anxiety, depression and trauma on her TikTok account as a means of educating others about mental health issues. She has noticed people resonating with some of her mental health “characters” by commenting, “Oh, that’s so me.”

In her online posts, Tran makes a point of saying, “these may be the signs of” rather than “these are the signs of” to underscore that just because someone resonates with a particular trait in one of her videos doesn’t mean that they necessarily have a diagnosable disorder.

For example, someone can experience a trauma and not have posttraumatic stress disorder (PTSD). It often depends on functionality. “Whenever a diagnosis is being made, there has to be an area of the person’s life” — social life, personal life, work or school — “that they aren’t functioning in for it to be a diagnosis,” Tran notes. Even if someone with a mental health issue is high functioning (meaning they function at a higher level than others with the same condition), thereby making it more challenging to determine a diagnosis, there is often a change in the severity or duration of symptoms from how they were functioning before to how they are handling things now, she adds.

Tran hopes her social media content will invite conversations about mental health and get people who relate to some of the symptoms she highlights to consider talking to a mental health professional. Her book Dope Therapy: A Radical Guide to Owning Your Therapy Journey, which she wrote to help people navigate therapy from start to finish, will be published this summer.

McMickle observes that “when people self-diagnose, they are looking for information about themselves, and that can be a really helpful, positive thing. That might mean they’re experiencing some discomfort or emotional dysregulation and they want to change that.” But given the potential for misinformation online, she also cautions counselors to ask clients where they are getting their knowledge of symptoms and disorders and to be careful about any resources — especially social media accounts — that they provide to clients.

Potential dangers

As counselors know, accurately diagnosing mental health conditions is complex, requiring years of education and training to truly understand the nuances. Social media, however, tends to simplify this process and often reduces psychological theories or disorders into brief snippets or common stereotypes. For example, a social media post might boil diagnosis down to “Signs you are with a narcissist” or “Things you didn’t realize were ADHD.” Or a meme may depict someone with “avoidant attachment” agonizing over their choice of either cutting someone out of their life or clinging to the person so the person won’t abandon them.

These types of posts don’t address the complexity of mental health issues or any new research on the topic, such as how attachment is a pattern and not a fixed state, says Ilyse Kennedy, an LPC and licensed marriage and family therapist. “So, people may think certain things about themselves or may resonate with something without having all the nuisance behind it of what that actually means,” she says. Kennedy notes that it has taken her years of studying attachment disorder and reading several books before understanding her own attachment style.

Some clients who self-diagnose come to counseling wanting to receive that same diagnosis from a professional, but people don’t necessarily think about how certain diagnoses could affect them long term, Tran says. For example, some diagnoses could alter the type of life insurance policy someone can get or hinder their ability to obtain security clearances for their job, she points out. Understanding the potential long-term implications makes her careful and cautious when diagnosing clients, she says.

Tran reframes clients’ attempts at self-diagnosis to emphasize their symptoms. If someone asserts that they have depression, for instance, because they are having trouble sleeping and don’t have much energy, she focuses on those symptoms, which could be because of depression or because of anxiety, PTSD or just daily stressors. “People come to therapy looking for answers, but [therapy] is actually very informational,” Tran says. She spends substantial time asking questions and gathering more information about clients: “Tell me more about this low energy. Is it when you wake up? Does it happen at social functions or when you are doing schoolwork?”

Another problem is that anyone, regardless of their qualifications (or lack thereof), can post what might be interpreted as “expert advice” on mental health issues online, which can lead to widespread misinformation. Even people who are well-intentioned can misread or misunderstand mental health information and portray it inaccurately online, causing others who are simply looking for answers to be misled, says Fleming, an ACA member who specializes in attention-deficit/hyperactivity disorder (ADHD).

Social media algorithms, which filter content based on people’s interactions, can also play a role in leading someone toward an incorrect self-diagnosis. The first thing people see when they open up TikTok is the platform’s feed of recommended videos, called the For You page. If someone resonates with a TikTok video about ADHD, for example, and they “like” it, then their For You page begins to show them more ADHD videos. This creates a type of self-fulfilling prophecy, Fleming says, because the person begins to feel that they are “meant” to see the videos.

According to Collazo, this misinformation has the potential to create a nocebo effect — someone develops certain negative or harmful side effects or symptoms because they believe or expect that they will occur. In other words, a social media post saying that people with these particular symptoms have a particular disorder could cause someone to feel that they do, in fact, have the disorder or cause them to engage in behaviors that confirm it.

Given the potential for error when it comes to self-diagnosis, McMickle explores what that particular self-diagnosis means to the client and how it affects the way they view themselves or approach certain situations. Learning about a diagnosis online has the potential to reduce the stigma around it and instill hope in the person that they too can get help, McMickle notes. But if they are self-diagnosing without also seeking professional assistance, or if they are misdiagnosing themselves, then they are potentially stuck in a difficult place and not getting the help they need, she says.

Potential benefits

On a positive front, social media can foster a sense of community and belonging for those who are looking for mental health answers. Discovering online videos and communities of other people who share similar symptoms and struggles, especially for stigmatizing diagnoses such as bipolar disorder, can be rewarding and encouraging, says Kennedy, founder of the group practice Moving Parts Psychotherapy in Austin, Texas.

People typically have a general idea about anxiety and depression, but Kennedy says social media has opened the door for more discussions about trauma and neurodivergence, including diagnoses such as autism and OCD that have often been highly stigmatized.

Kennedy, who specializes in trauma work and individuals with trauma related to dissociative disorders, recalls that when she was first making her professional website eight years ago, colleagues advised her against mentioning trauma because it was a “complex term” and people wouldn’t understand it. Fast-forward to today, and that advice seems ludicrous because there is so much more awareness around trauma.

One of the biggest benefits to the rise in self-diagnosis, at least when prospective clients follow up and seek professional help, is that it provides counselors with insight into the client’s inner world and how they perceive their experiences, Kennedy says. She notes that she has experienced more female clients resonating with social media content on ADHD lately in part because people are just beginning to highlight how the diagnosis can look different in women than in men. When clients tell Kennedy they think they have ADHD, she can use their self-diagnosis to help them reframe how they view their experiences. These clients can then consider their difficulty starting tasks through the lens of neurodivergence rather than as an inherent flaw within themselves.

“Self-diagnosing [online and through social media] can help people identify how they feel and what they’re struggling with,” Fleming says. “It can also be the only place people have access to mental health information.”

From her perspective, client self-diagnosis can provide more context, and the more information she has about the client, the more likely she will be able to help them. A self-diagnosis of ADHD, for instance, gives her the opportunity to ask about when and why the client feels distracted. Are they bored and having trouble focusing, or are they anxious about all they have to do later that day?

McMickle finds that with OCD, the more insight clients have, the better the outcomes. If they realize on their own that they might be experiencing compulsions, obsessions or intrusive thoughts that are interfering with their quality of life, then they may come to counseling more prepared to make changes to improve their situation, she says.

Online mental health searches can be a slippery slope, however, McMickle warns. People can find useful information about what they are experiencing, she says, but they can also “go down a giant rabbit hole with any disorder or any medical problem” and get lost in the possibilities of what is happening to them. There is a difference between being genuinely curious and wondering “Do I have this disorder?” and ruminating about all the ways that a diagnosis is affecting your life, she stresses. That’s why it is important for counselors to do a thorough assessment and figure out where clients are getting their information and how it affects the way they view themselves and their world, she says.

The need for validation

Counselors must be tactful when reacting to a client’s self-diagnosis, always keeping in mind how much courage it takes to seek help, even if the self-diagnosis proves to be off base. Counselors who don’t handle this situation well risk making clients feel invalidated and turn away from getting the help they need.

Validation with self-diagnosis is crucial, Collazo stresses, because it’s likely that other people in the client’s life have told them that their symptoms or potential diagnosis is “just in their head” or that they “just need to put a smile on it.” Therapy is the one place where they can finally hear someone reaffirm that they are not “sad for no reason” and they are
not “broken.”

Collazo first listens and validates clients’ thoughts and feelings about a potential self-diagnosis. Then he explains about diagnostic criteria and, depending on the client’s needs, offers to do a formal assessment. “If their self-diagnosis was right, then great,” says Collazo, “but if not, then counselors [can] offer hope; they can still help the client” get better.

McMickle also errs on the side of validating clients who come in with a self-diagnosis, even while exploring their symptoms further. If a client states that they have had a panic attack, for example, then McMickle would acknowledge that they’ve experienced some type of pain or discomfort (regardless of whether the occurrence was an actual panic attack). She would also ask about the context surrounding the assumed panic attack, any other symptoms the client is experiencing and what the client knows about panic attacks from online or social media.

Learning how to navigate a client’s self-diagnosis without invalidating the client is a crucial skill, McMickle says, because the therapeutic relationship is the cornerstone of effective counseling. “No matter what clients come in with — right or wrong, accurate or not — they’re coming in [to] a really vulnerable space,” she says. “It’s so important that we are really understanding and sitting with them and holding space for them so they can continue talking about things that are upsetting to them and come back for better assessments.”

Collazo acknowledges that it can be difficult to balance validating with assessing the accuracy of someone’s self-diagnosis. He finds that asking questions and remaining curious are good approaches to learning more about what the client is experiencing while maintaining a healthy therapeutic relationship.

Kennedy also relies on questions to discover more about the self-diagnosis. She may ask a client, “What does it means for you to have that diagnosis? Why does it feel important to have it? Does it help you better understand yourself or better learn coping tools? Does it give validation to your pain?”

Even if clinicians disagree with a client’s self-diagnosis, they can still validate the client’s feelings, Tran asserts. If a client says, “I’m feeling sad, and I think I have depression,” she rephrases the statement by saying, “So, what I’m hearing is you are feeling sad. Can you tell me more about that?” This language allows her to clarify what the client is experiencing and provides her with more insight.

The need for a safe space

Recently, after TikTok videos about Tourette syndrome went viral, doctors started noticing an increase in teenage girls who were suddenly experiencing verbal and motor tics. Tourette syndrome tics are unique to each person, so when doctors from different geographical regions observed similarities in the girls’ tics, they started to suspect that social media was playing a role. However, the evidence was anecdotal and overlooked other contributing factors (such as anxiety and stress). Others fear that blaming social media could further stigmatize Tourette syndrome, especially for young women, making it harder for people to disclose symptoms
to professionals.

Likewise, counselors sometimes forget how difficult it is for people to ask for help, Fleming says. By the time someone calls or is sitting in the counselor’s office, they have typically invested a lot of thought and energy in making that decision.

Fleming cautions counselors to avoid hinting at any negative reaction they might have to a client’s self-diagnosis. They should refrain, for example, from saying, “Oh, everyone has that diagnosis on TikTok.” Reacting in disbelief or dismissal could be harmful to the client.

To make it easier for clients to disclose potential diagnoses or symptoms that resonate with them, Fleming invites clients to text her anything they might be hesitant to mention in session, such as their eating habits or a potential self-diagnosis of an eating disorder. She doesn’t respond to the text, but at some point during the next session, she says, “You texted me that you wanted me to check in about your eating habits. How’s that been going for you this week?” If the client still doesn’t want to talk about it, Fleming doesn’t push it any further in the moment but makes a note to try again in a future session. The important thing is for counselors to give clients a safe space to bring things up so they can address it when they’re ready, she says.

Counselors also must be aware of their own preconceptions and stereotypes about certain disorders. Kennedy has noticed that some clinicians may be quick to dismiss a self-diagnosis of bipolar disorder, for instance, because the client exhibits healthy boundaries. Because of stereotypes, even some counselors may incorrectly assume that this isn’t possible for someone with bipolar disorder. Or, if the counselor is fond of the client, they may be hesitant to give the person such a stigmatizing diagnosis.

It is particularly important for clinicians to create a safe, welcoming space for younger clients and avoid dismissing their thoughts and feelings around self-diagnosis. “Adolescents are still trying to figure out who they are, and they sometimes latch on to things that aren’t them” in the process of discovering more about themselves, McMickle says. For example, adolescents often pull away from people, especially their parents, as they form their own identities, but this behavior is similar to traits associated with borderline personality disorder, she notes. So, if they see a video about that disorder, they may worry that they have it and interact with the world as if they do have it.

Kennedy has noticed that with some younger clients, self-diagnosing may be more about needing someone to see their pain or seeking validation from their parents than about being accurate. But it is still important to validate and explore this diagnosis, she emphasizes, even if it doesn’t align with what the counselor is noticing in session.

From self-diagnosis to self-awareness

“Self-diagnosing is giving people more [of an] ability to advocate for themselves and say, ‘No, I think I have this, and this is why,’” Fleming says. “It’s giving people a voice within the professional world.”

It’s also helping to normalize mental health. A few years ago, Fleming often had to reassure clients that it was OK to have anxiety or ADHD. Now she’s having fewer of those discussions because with the increase in self-diagnosis, the stigma around mental health is also lessening.

In addition, social media is helping people develop a sense of self-awareness related to mental health. “People feel less isolated and have a deeper understanding of themselves,” Maalouf says. Many of her TikTok followers leave comments on her mental health videos such as “This explains so much,” “I thought I was the only one” and “This is helpful because now I understand what’s happening with me.” She’s also noticed (based on comments and messages) that this awareness sometimes results in people seeking out counseling to find ways to manage or cope with these issues.

Tran has noted an increase in self-awareness among clients and prospective clients as well. In fact, she considers self-diagnosis to actually be “self-awareness around symptoms.” Before the COVID-19 pandemic and the rise of mental health on TikTok, Tran would get emails from potential clients saying they were looking for a therapist and she sounded like a good fit. Now, she’s noticed the emails are more detailed: “I’ve been struggling with sleep, and I want to have a better relationship with my brother. I’m looking for a therapist with these particular values. Are you able to help me?”

When someone has a general idea of what they are experiencing, they tend to seek out a clinician who specializes in the mental health issue with which they are struggling, McMickle says. This also helps her when she needs to refer someone because it gives her an idea of what type of therapist the person is searching for.

Counselors can make self-diagnosis more of a collaborative process in session rather than viewing it as “dangerous” or “misguided.” If a client comes to Kennedy thinking that they have a certain diagnosis, she goes through the criteria with them and asks what resonates with them. When clients seem to want or need a particular diagnosis assigned to them, she asks about the reasoning behind that. Is it to get accommodations at work or school? Is it to get medication? Is it to have peace of mind and a better understanding of themselves? If clients do need accommodations or medication, Kennedy will recommend a more formal assessment, but if they just want to understand what they are experiencing and find ways to manage it, then she uses their self-diagnosis as a framework to learn more about the client and help them find a treatment plan that works for them.

“When a client comes in with a self-diagnosis, it’s a very brave act,” Kennedy says. “It’s very brave and vulnerable for them to be testing this theory out with you. It’s brave and vulnerable that they’re letting you into their inner world in that way. It can be such a powerful space in the therapeutic relationship to welcome it [the self-diagnosis], even if you don’t quite see it or even if it doesn’t feel ‘right’ for the client. It still allows us to learn so much more about them and to have a moment where we really welcome their vulnerability and create more safety in the therapy room.”

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Read more in an online companion piece to this article, “The rise of counselors on social media.”

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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.

Counseling outside the box

By Bethany Bray February 25, 2021

Clients bring an unending range of presenting issues, personalities, life histories and challenges into counseling. Fortunately, counselors also have an infinite supply of tools for forging therapeutic bonds, meeting clients’ needs and helping clients tell their stories.

Counselors need only flex their creative muscles to find approaches that can bolster trust with clients and speak to each person’s unique life experiences and worldview. Exploring a client’s interest in skydiving as a metaphor for self-awareness and trust? Discussing a favorite dish or recipe as a prompt to get a client talking about family-of-origin issues? Assigning a client to play video games online with peers as a first step toward addressing social anxiety? The sky’s the limit.

Counseling Today contacted several counselors who are using interesting, fresh or different approaches to help their clients and students. We hope that you will be inspired by their ideas and possibly use them as a jumping-off point to think outside the box in your own work.

Sparking connection with photos

As the adage goes, a picture is worth a thousand words.

American Counseling Association members Brandee Appling and Malti Tuttle believe the truth of this saying holds up even in counseling settings, especially in the age of smartphones, when photography is ubiquitous. Why not leverage that by asking clients to bring photos and images into sessions, they reasoned. Prompts such as “bring in an image that represents you feeling happy” or “bring in an image that represents your family” can be eye-opening for clients and clinicians alike, Appling and Tuttle say.

The duo, former school counselors who met while working as co-coordinators of the school counseling program at Auburn University, have found that “phototherapy” can encourage dialogue and boost empathy and connection in counseling. This can be especially true in group settings, with child and adolescent clients, and with individuals who struggle with speech or whose primary language is not the same as the counselor’s.

Photos and images introduce “another mode of communication” in counseling, says Tuttle, a licensed professional counselor (LPC) who is an assistant professor and school counseling program coordinator at Auburn.

“Photographs can bring insights into someone’s life that we might miss when talking — things that the client can’t verbally express or doesn’t think to,” adds Appling, an LPC and approved clinical supervisor who is now an assistant professor in the Department of Counseling and Human Development Services at the University of Georgia. “It helps to break down walls [in session] and makes it easier for the client to talk about something that’s concrete rather than [topics] that are in the air, so to speak.”

When Tuttle and Appling have used this approach in school settings, students have often been able to display photos on their cellphones. If students don’t have access to a cellphone, they may be able to check out digital cameras from the school, or the exercise can be widened to include printed images such as postcards or magazine clippings, the counselors say.

The counselor’s role is to prompt conversation by asking questions about the client’s image and then allowing the client to reflect and speak. The counselor should never try to interpret the image or impose their feelings about it, Appling stresses.

“This is not to be used to diagnose [clients]. This is not meant to be a stand-alone tool but part of a range of counseling tools,” Appling notes. “It’s one thing that we would use, but it’s not the only thing we would use. It should be part of the therapeutic process, one tool to use in an interrelated system.”

In group settings, an assignment to bring in an image that “represents you” can help participants get to know one another, build connection and create a sense of belonging, Tuttle says. Asking group members to explain why they chose their image can prompt meaning-making, empathy and recognition of others’ viewpoints and perspectives. It can also provide the group leader a glimpse into each group member’s personality and emotions.

The exercise “builds a sense of universality and connection with one another, [prompting] conversations that might not happen organically,” Tuttle adds.

She suggests spurring dialogue in sessions (whether individual or group) by asking open-ended questions such as:

Why did you choose to bring this particular photo?
What meaning does it hold for you?
What would you title this photo, and why?

Appling has used this approach with a group she ran for students who were going through family transitions (e.g., divorce, a death in the family, living in foster care). When asked to share an image that represented the changes they were going through, one student brought in a photo they had taken of a unique seashell.

The seashell “was a representation, for them, of where they had been,” Appling recalls. “It looked very different than any other seashell that I had ever seen, and I initially didn’t recognize the image as a seashell. We talked about how water had changed it and eroded it. The seashell represented [the student] but also the growth and change they were experiencing.”

This intervention can also be flipped, with the counselor bringing in a photo for clients and students to discuss. When presenting on this intervention at conferences and trainings, Appling and Tuttle use an image of an aging set of concrete steps with vegetation growing through the cracks. They ask participants:

What do you think this image means?
What emotions does it elicit?
What does this photo remind you of in your own life?

Despite being shown the same image, participants typically share a wide range of thoughts, reactions and associations regarding the picture, Tuttle and Appling say. Some people see resiliency and growth in the vegetation, whereas others see decay and despair in the cracked steps.

“It’s really interesting to be able to see the perspective of each participant,” Appling says. “It’s a lesson that we all see things very, very differently and that it depends on the things we have been through, our different lenses. It’s a lesson that we all bring different experiences and viewpoints.”

Walking (and running) the walk

Counselors can use a seemingly unlimited number of running-related metaphors to encourage clients: It’s a marathon, not a sprint. Keep putting one foot in front of the other. Focus on the mile, not the marathon. You have to learn to walk before you can run.

But for Natae Feenstra, an LPC with a private practice in Smyrna, Tennessee, this approach goes beyond the metaphorical. An experienced runner who has completed multiple marathons, she sometimes conducts outdoor counseling sessions with clients as they run and talk, side by side. As a counselor who specializes in “running therapy,” Feenstra offers running sessions for clients who are comfortable with and interested in donning their sneakers and hitting the trail with her.

“For the client, it’s first and foremost a counseling session,” says Feenstra, who is working on a dissertation on running as a therapeutic treatment for trauma as part of a doctorate in counselor education and supervision through the University of the Cumberlands in Kentucky. “A goal to get to a certain number of miles is never part of a client’s treatment plan. The goal is improvement of mental health, and running is a tool for that.”

Counselors have long known the benefits that movement and exercise can have on mental health, including stimulating the release of endorphins, dopamine and other brain chemicals. Engaging in movement and exercise also offers opportunities for processing thoughts and mindfully focusing on one’s breath and stride.

“Natural bilateral stimulation — that’s all that running is. Rhythmic movement of large muscle groups, and we know that can bring amazing benefits to our brain,” explains Feenstra, a former school counselor who recently transitioned into private practice. Running therapy also offers the built-in ecotherapy component of enjoying sunlight, fresh air and views of nature as she and the client run and talk, she adds.

Feenstra’s approach is individualized. If a prospective client requests running sessions, Feenstra agrees only after having at least one consultation to get to know the client and their presenting concerns and determining whether the approach would be a good fit. She also offers walking and walk/run sessions, as well as traditional, stationary counseling sessions.

During the COVID-19 pandemic, Feenstra is conducting all of her traditional counseling sessions via telebehavioral health. She continues to offer in-person running therapy for clients who are comfortable doing that, while following health guidelines concerning physical distancing as much as possible.

Above all, she suggests running only if the client is comfortable with it. She points out that clients don’t need to be experienced runners to engage in this approach. She modifies each session to the client’s ability and comfort level. “It’s never about the pace or distance of the run. It’s about the movement, going alongside the therapeutic conversation,” says Feenstra, a member of ACA.

Feenstra has seen significant improvement in clients presenting with anxiety and depression who engage in running. Her clients have also self-reported boosts to their self-esteem, self-efficacy and overall wellness.

In addition to the mental health benefits that running provides on it own, these mobile sessions can help strengthen the counselor-client bond and support clients who might otherwise struggle to open up in a more traditional therapy setting, says Feenstra, who is also a certified running coach with the Road Runners Club of America. “Some people are intimidated by eye contact or other aspects of face-to-face sessions, or being in an office with a power differential. For some people, [running during counseling] can help them speak more freely,” Feenstra says.

This was recently the case for an adult male client on Feenstra’s caseload who presented with severe depression and anxiety. During the COVID-19 pandemic, his condition had worsened to the point that he was no longer leaving home.

When Feenstra and the client began meeting, counseling sessions were the only time the man ventured out. They eventually transitioned to mobile sessions, beginning with a walk/run mix to fit the man’s comfort level. Within a few sessions, his anxiety and depression had lessened so that he was leaving his house more frequently and beginning to reengage in hobbies and activities that he had enjoyed previously.

“The platform of running therapy was what prompted him to leave the comfort zone of his house. A telehealth platform would not have made him leave his house, and he was not interested in pursuing [therapy in] an office environment,” Feenstra says. “In this case, the running therapy was what helped him pursue counseling services. I think it was the running piece that was intriguing [to him], and it was so helpful to get him outside to conquer his anxiety.”

Running therapy “is not a miracle treatment, of course, but there are cases where it can make a difference, just like any therapy,” she adds. Running therapy, pioneered by American psychiatrist Thaddeus Kostrubala, has been around since the 1970s, she notes.

For running sessions, Feenstra meets the client in a park, on a trail or in another public place that she is familiar with or has checked out ahead of time. She begins by warming up with the client and chatting as they stretch. After completing a run or walk, they finish by cooling down and reflecting on the session together.

Feenstra acknowledges the potential lack of confidentiality when holding counseling sessions in a public place. She addresses this with her clients ahead of time, both with detailed language in her informed consent forms and verbally, explaining that they can pause their conversation whenever another person is within earshot.

“I let the client dictate,” she says. “I let them know that [they] can choose to lower their voice, stop talking or continue talking if they are comfortable.”

While many counselors may not be runners themselves, they could have clients who enjoy running. Practitioners don’t have to offer running therapy to leverage running’s benefits for their clients, Feenstra points out. She sometimes incorporates running by assigning clients to run outside of session (again, only if they are interested and able) and then uses that to prompt counseling work in their next session together. Running provides an opportunity to relieve stress, tap into the subconscious and process thoughts away from the distractions of life, Feenstra explains.

Clients may find it helpful to keep a journal to record their thoughts, questions and discoveries made while running. This can be used as a self-development tool or as something the client brings into sessions, Feenstra notes.

“Since the run time is often prime time for thinking, clients and counselors can discuss [in sessions afterward] how the run went and what their thought process was like on the run,” Feenstra says. “Also, since running has an innate mindfulness component, this [aspect] can be used as a counseling tool. The counselor might give the client a thought to ponder or a mindfulness activity to meditate on during their run time.”

Movies and moral development

One of Justina Wong’s clients had served a long military career as a sniper with a special forces unit. His experiences in service, including multiple deployments overseas, had left him with posttraumatic stress disorder and a relative inability to show or express his emotions. When he did, it often manifested as anger. His relationship with his wife and family was becoming increasingly strained, and one of his children was beginning to fear him.

In counseling, what clicked for this client was Wong’s suggestion that he watch two movies that, on the surface, were geared toward children: Charlotte’s Web and Inside Out. Wong’s client was able to see himself — and many of the emotions he was having trouble identifying and expressing — in the moral arc these movie characters experienced.

“The response that he had was very powerful,” says Wong, who completed an internship at a nonprofit that serves military veterans and their families as part of her master’s in counseling program at the Chicago School of Professional Psychology. As they processed the movies together in session, “We talked about healthy coping skills and unhealthy coping skills. He began to open up more about what he saw and experienced in the military. He had a very hard time differentiating [between] feeling angry and feeling sad, which is common among this population. Feeling angry is accepted, but feeling sad is seen as [a] weakness or being undependable.”

Cinematherapy, or using movie storylines, characters and themes as a therapeutic tool, can be particularly helpful with child or adolescent clients and those who struggle with depression, trauma, loss or social anxiety, Wong says. It’s also useful for individuals who might not respond well to more traditional counseling interventions and those who have trouble opening up to a counselor, she adds.

Clients can observe and learn from movie characters’ struggles, growth and perseverance in the face of challenges throughout their story arcs, explains Wong, a member of ACA. Clients “can feel like they’re not alone because someone else [a movie character] is going through a similar thing. They can see a character’s unhealthy behavior, coping skills and what they did or didn’t do to manage. It can help clients communicate and voice their emotions and understand what their values are.”

A counselor can either assign a client to watch a particular movie (that the practitioner has vetted) outside of session, or the counselor and client can watch film clips together in session. Either way, the important part of the intervention involves the therapeutic discussion afterward, Wong says.

Wong, a recent graduate of the Chicago School, prompts dialogue with open-ended questions. For Inside Out, these include:

Which emotions do you consider to be positive, and which do you consider to be negative?
Tell me about a time when you suppressed a particular emotion and, as in the movie, your “island” started falling apart.
What islands do you have in your life?
What role do joy, sadness, anger, fear and disgust have in your life?
Describe a time you felt embarrassment, shame or guilt regarding something from your childhood.

Wong stresses that cinematherapy must be individualized when used in counseling. Practitioners should carefully consider whether the approach is a good fit for each specific client and appropriate for their presenting concerns and therapeutic goals. She uses only movies that she is very familiar with and has prescreened. Her list includes About Time (2013), Mulan (1998 animated version), Yes Man (2008), The Lion King (1994 animated version), Eternal Sunshine of the Spotless Mind (2004), Toy Story 3 (2010) and others.

“You really want to do your due diligence and make sure you’re using this intervention to the benefit of the client,” says Wong, a certified trauma professional. “If you don’t, it [watching movies] just becomes a recreational activity.”

The therapy goals of Wong’s veteran client included mending his relationship with his family and being able to have conversations without becoming triggered and angry. As a grown man and hardened military veteran, he initially bristled at the idea of watching children’s movies. But when he began to understand how they could help him strengthen his family relationships, he agreed. He watched Inside Out with his entire family and discussed Wong’s therapeutic questions afterward with his wife.

When Wong suggested he watch Charlotte’s Web, she warned him about the movie’s sad ending because he had never seen it before. Even so, Wong recalls, he was very upset in the following counseling session. As they began discussing the movie, the client realized that he identified with Wilbur’s feelings of isolation and loneliness. The pig’s friendship with the spider, Charlotte, reflected the camaraderie he felt and the bonds he had formed with the soldiers in his unit, some of whom had not made it home alive.

“He put two and two together and understood that when Charlotte dies, she couldn’t return home with Wilbur, and he [the pig] was angry, sad and in despair. [The client] had served in special forces and had lost many friends and was trying to bury and push away his troubles. … After processing it [in therapy], he understood why I chose that movie for him to watch,” Wong says. “The lightbulb turned on for him when Charlotte and Wilbur have a conversation in the movie and she tells the pig that she can’t return home with him.”

Wong talked these issues through with the client, supporting him as he processed, during which he began to show emotion and cry — a major breakthrough for someone who had appeared emotionless and “very by the book” at intake, according to Wong.

The movie discussion spurred the client to open up to Wong. He disclosed that during one of his deployments, several soldiers he was in charge of had died as they worked to secure and occupy an area. The area was eventually retaken by insurgents, and the client wrestled with feeling that his comrades had “died for no reason,” Wong says. He struggled with moral conflict and felt frustrated and betrayed by his commanding officers and the government. “It was powerful progress. He was able to talk about that, which he had never [done] before,” she says.

When used intentionally, cinematherapy can be a powerful tool, Wong notes. She was inspired to explore the approach after hearing Samuel T. Gladding, a past president of ACA and a professor of counseling at Wake Forest University, present on a range of creative interventions, including cinematherapy, at the International Association of Marriage and Family Counselors conference in January 2020. “It’s up to the counselor to be as creative — or not — as they want to be,” Wong says. “I never thought of myself as a creative counselor, but when I heard Dr. Gladding’s presentation … I guess I’m more creative than I thought I was.”

Once upon a time

As a doctoral candidate at North Dakota State University, Robert O. Lester recently taught a class on group counseling to first-year, master’s-level counseling students. Most students, Lester notes, came into the class with an innate understanding of empathy, but as the class neared its end, he looked to delve deeper, teaching empathy in an applied manner.

He turned to fairy tales. Lester asked students to write a tale that illustrated some of the challenges they had encountered and the personal growth they had experienced over the span of the class. The assignment had just two requirements: Begin the story with “Once upon a time …” and don’t make fun of any tale shared in class.

The exercise succeeded in opening students’ eyes to a greater understanding of empathy while spurring the growth of their professional identities. It also equipped them with a creative intervention that can be used with clients in counseling sessions. Going through the “imaginative labor” of observing one’s self in unfamiliar places or scenes expands our concept of what is possible, Lester explains.

“Many students began with ‘I don’t have a story to tell,’” says Lester, a school-based counselor and ACA member. “You don’t need to have gone through some great suffering; you just need to be up close to your own desire and belief. It’s the distance of suffering that empathy can’t cross. It was an assignment to bridge the distance between ourselves and others by keeping the desire and suspending the disbelief. It’s about a willingness to let other worlds be possible. This is the initial move of empathy.”

Weaving one’s experiences into a fairy tale can be a helpful exercise for counseling students and clients alike because the stories are compact and give the writer the satisfaction of identifying a coherent story arc and conclusion, even if it’s not a happy one, Lester says.

Writing fairy tales “is expressive, playful and may surprise you. It can loosen the tongue for serious talk. Letting people become a little more enchanted and surprised with themselves would have a lot of possibilities [in counseling]. Then, it would be on the counselor to facilitate a good discussion afterward,” says Lester, who is now living in California and working as a counselor at an alternative-education high school while he completes his doctoral dissertation. “One of my favorite things about this [intervention] is when we surprise ourselves. … It can certainly break some of the narrative ruts we can get into.”

In counseling sessions, prompting clients to express themselves through fairy tales could be a good fit for “any situation where you want someone to begin trying on differences,” Lester says. “Organizing our experiences into an imaginative story — a story where there’s room for enchantment, and the marriage of emotion and imagination — [can be beneficial] for clients who operate with a lot of constraint in their life, either self-imposed or imposed by culture or external forces, especially if they’re having trouble imagining themselves otherwise.”

Fairy tales offer students and clients a chance to cast themselves in new roles, organize their experiences into a sequence, and reflect on the challenges they’ve overcome and how they’ve grown from start to finish, Lester explains. In turn, they gain an appreciation for their belief of what they’re up against and their desire for how they go on.

This benefit was magnified when Lester invited his counseling students to share and discuss their fairy tales in class. This enabled them to see how different each of their journeys were.

“At the deepest level, I was hoping the fairy tale project would be a hermeneutical project [and] part of their professional identity development — marrying your own worldview into the profession [and] taking the feelings of others seriously and compassionately, especially those who don’t experience the world as we do,” Lester says. “They are just beginning in counseling and have to learn to honor others’ worldviews. This fairy tale [assignment] was a compact way to help them begin by rendering their own experiences as unusual and in need of close reading.”

One of Lester’s students wrote an impactful fairytale about a protagonist named Mia. She lived in an idyllic village where everyone knew one another and worked according to their talents — except for Mia, who spent much of her time alone, reading. Although she liked her fellow townspeople, Mia felt something was missing in her own life, Lester says. She harbored an intense curiosity and sense of imagination that many of her neighbors did not share.

Her story took a turn when some creatures from the outlying forest visited her and asked for her help. An ancient well where they lived, deep in the forest, had dried up. The well was the source of the creatures’ magical powers.

Kindhearted Mia knew she had to help and journeyed into the forest, where she found the well in shambles. Her heart broke for the forest creatures, and at a loss for what to do, Mia began to cry. As her tears flowed, they filled and restored the well. Mia’s compassion had saved the day. Not only had she revived the creatures’ source of magic on her quest, she had also discovered her own sense of purpose.

In class discussions afterward, the student who wrote Mia’s tale talked about feeling alienated in the small town where she grew up. Everyone in town seemed to know how they fit into the fabric of the community, but this student was never able to find her niche, Lester says.

Her fairy tale was a beautiful description of this concept. “She [Mia] is looking for a world where her tears have a place and can do something on behalf of others,” Lester explains. This paralleled the student’s own struggle to find her way and cultivate her professional identity.

“We all go through growing up and forming identity, but her fairy tale elevated the experience,” Lester says. “Suddenly, Mia’s tears could do work and were life sustaining. I find that incredibly moving — that language of having permission to cry, because you don’t know what wells your tears might replenish. To me, that’s a whole other order of coming to apply empathy. [Learning empathy] begins with ourselves and becoming empathic with some of the pain and beauty of growing up. … There’s something poetic in that everydayness.”

Culinary therapy

Each of the elements in chef Samin Nosrat’s 2017 cookbook, Salt, Fat, Acid, Heat, can be used as therapeutic metaphors in counseling work with clients, suggests Michael Kocet, a professor and chair of the Counselor Education Department at the Chicago School of Professional Psychology.

If a dish doesn’t have enough salt, it can be bland, but if the cook oversalts the dish, it becomes inedible. “One little [extra] pinch of salt can ruin a dish,” Kocet says. “Talk that through with the client: In life, what do you have that’s not enough or too much? What in your life is that extra pinch of salt? Is it unleashing an opinion on a family member? How can we control that?”

Similarly, acid is very powerful and must be wielded correctly, as in ceviche, in which citrus juice is used to cook the dish without heat. Continuing the metaphor, a counselor can ask a client about the “acid” they have in their life. “Maybe their sarcastic humor is biting. Talk about when that can be useful and when it can be hurtful,” advises Kocet, a licensed mental health counselor and approved clinical supervisor who provides pro bono counseling at the Center on Halsted, an LGBTQ community center in Chicago.

Food, eating and cooking are so intertwined in most people’s life histories, perspectives and preferences that they can become beneficial tools when leveraged in counseling, says Kocet, who taught a course on “culinary therapy” when he was a professor at Bridgewater State University in Massachusetts. Although he no longer teaches that class, he continues to weave culinary elements into his work with clients and students in Chicago and has provided workshops and trainings on the topic.

In addition to tapping into a bountiful supply of culinary-related therapeutic metaphors and conversation starters, counselors can consider giving clients the assignment (when appropriate) of cooking a dish at home and debriefing in session afterward. The dish doesn’t need to be anything complicated, Kocet emphasizes. It could be a peanut butter and jelly sandwich or a simple salad, he adds. Cooking or preparing food mindfully, no matter the recipe, can prompt reflection. Tracking experiences in a cooking journal may also benefit clients who respond well to this approach.

“Food is often a binding element,” Kocet explains. “If I have a client who is struggling in a relationship, I might have them cook a recipe that represents their relationship and talk about that [in session afterward]. Or if a client and their partner are from two different cultures, I might have them cook a meal that incorporates elements from their two cultures. … One aspect to [help] forge cultural connection with clients is to discuss food: what they grew up eating and what was ‘celebration’ food. That’s one way to get to know the client a little more. Clients are often really proud of food and cultural traditions, and it’s one way to connect and break down barriers in a counseling setting.”

Assignments for a client to cook with a partner or family member can prompt bonding and offer a fun and creative way to work on healthy behaviors introduced in counseling, Kocet adds. Also, cooking “failures” don’t have to be failures when talked about and learned from in counseling. Perhaps a client forgot an ingredient or strayed from the recipe. How does that parallel the choices made and lessons learned in their life outside of the kitchen?

Even time spent cleaning up and washing dishes after cooking can serve as a mindfulness exercise, Kocet points out. Practitioners could suggest that clients take time to reflect on how they felt stepping outside of their comfort zone to try a new recipe as they clean up the kitchen and feel the dishwater on their hands.

Kocet has developed a culinary version of the genogram mapping tool that he uses with clients to delve into family issues. He keeps a small collection of cooking spices and a sleeve of mini paper cups in his counseling bag. As he begins the exercise, he lines all of the spice containers up on the table and asks the client to select a spice that represents them and other members of their family circle. The client pours a little bit of each person’s spice into a separate cup. Eventually, a constellation of spice-filled cups is displayed in front of them.

Kocet prompts the client to talk through why they chose that particular spice for each person. Cinnamon or red pepper flakes might signify either a warm personality or a hot temper, Kocet points out. The exercise encourages clients to talk through issues related to their own identity and helps the counselor better understand how the person views their family network, Kocet explains. Similarly, questions that invite discussion of traditions and memories surrounding food can encourage clients to reflect and open up, while giving practitioners additional context on clients’ families of origin and related emotions.

Kocet, an ACA member and a past president of the Society for Sexual, Affectional, Intersex and Gender Expansive Identities (SAIGE), a division of ACA, specializes in grief counseling. “If a client is missing someone they lost, such as a grandmother, it can bring comfort to cook a dish that she used to make,” he says. “Cooking uses all the senses — we can connect with loved ones through the tastes and smells [involved] in the act of cooking.”

As with any counseling intervention, practitioners must be mindful of the ethical ramifications of incorporating cooking and culinary elements into therapy and consider whether it is appropriate for each individual client, Kocet stresses. Clinicians should practice caution in using the approach with clients who struggle with disordered eating, and cooking assignments should not be given to clients who have a history of suicidal ideation or self-harm because knives and other equipment could be involved, he says.

Kocet plans to continue exploring the use of culinary elements in counseling and is in the early stages of a research study on therapeutic cooking as a coping tool for the isolation, anxiety and depression people have experienced during the COVID-19 pandemic.

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Staying within scope of practice

Practitioners considering the use of nontraditional approaches in client sessions must always keep the profession’s ethical guidelines in mind. Professional counselors’ licensure guidelines and scope of practice vary from state to state. Practitioners must ensure that any approach, whether a widely used talk intervention or one of many complementary methods such as aromatherapy, reiki, yoga, acupuncture and others, fall within their state’s scope of practice regulations before using them with clients or students.

In addition, counselors must consider the potential risks to client welfare, whether the approach is evidence-based (which is called for by the 2014 ACA Code of Ethics), and their own level of competency in using the method.

Consult the 2014 ACA Code of Ethics at counseling.org/knowledge-center/ethics.
Read more on this issue in the September 2018 Ethics Update column, “Counselors are doing what now? Exploring the ethics of complementary methods,” available at counseling.org/knowledge-center/ethics/ethics-update-columns.
More questions? Schedule a consultation with ACA’s ethics specialists by emailing ethics@counseling.org.

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Contact the counselors interviewed for this article:

Brandee Appling: bappling@uga.edu
Natae Feenstra: natae@run4yourlife.net
Michael Kocet: mkocet@thechicagoschool.edu
Robert O. Lester: robert.lester@ndsu.edu
Malti Tuttle: mst0022@auburn.edu
Justina Wong: juwcounseling@outlook.com

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

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

The forces that could shape counseling’s future

Compiled by Jonathan Rollins January 5, 2021

[NOTE: To view this article as a PDF, log in with your ACA credentials here and select the January 2021 magazine.]

In 2012, as the American Counseling Association was celebrating its 60th year as an organization, Counseling Today published an article titled “What the future holds for the counseling profession.” In that piece, 19 counseling leaders shared their visions (and best guesses) of how the profession might evolve over the coming decade.

Fast-forward to 2021, and we decided the timing was right to revisit that topic, even though we’re only nine years out (rather than a full decade) from the original article. After all, most of us would agree that 2020 felt like it lingered on for two full years, or at least well past its expiration date. It’s also virtually impossible to imagine any type of near future in which the events of the past year aren’t still reverberating and shaping our society.

Given that backdrop, we invited a diverse group of clinicians, educators, researchers and leaders in the counseling profession to answer the following question: What do you anticipate will be the most significant change, challenge or opportunity for counselors and the counseling profession over the next five to 10 years?

There’s no time like the present to look to the future.

Whitney Norris is a licensed professional counselor supervisor, a somatic experiencing practitioner, and a co-founder of Little Rock Counseling & Wellness in Arkansas.

A curious practitioner doesn’t have to look far these days to find a well-known clinician-researcher speaking to the importance of the brain and body in psychotherapy, especially in the realm of trauma. One of these experts, Dr. Daniel Amen, once said, “The biggest mistake I see is that [psychiatrists] rarely consider the brain. I often say psychiatrists are the only medical specialists that never look at the organ they treat.” In my experience, the same can be said for counselors when we consider what we now know about the inextricable connection of the mind and body.

The most significant change that has occurred during my pursuit of specialization in trauma and attachment over the past decade has certainly been an expansion of needed expertise in understanding the brain and body. The fact that the book that I’ve heard many call the “bible of trauma” is titled The Body Keeps the Score (Bessel van der Kolk, 2015) provides a good summary of this concept. I believe though that over the next 10 years, this will no longer be just the territory of trauma specialists. All mental health practitioners will need to have a solid understanding of the physiology of mental health and dis-ease if they choose to follow the latest research regarding health and healing.

To put it simply, I think it will become abundantly clear that no practitioners will have the luxury of leaving this knowledge base to the trauma specialists. I would argue that someone who doesn’t understand attachment dynamics and how those show up and impact the body/physiology of the person in front of us in the counseling room will be largely in the dark about essential aspects of the healing process.

And this idea seems to be spreading. I practice as a trauma specialist in Arkansas, a state known for being several years behind in regard to advancements in the medical and mental health fields. Even so, within the past 10 years of practice, I have gone from being very careful about even using the word “trauma” — since people were reluctant to use it — to having almost every client who reaches out to me ask specifically for a trauma specialist. Then, even a step further than that, when I began my pursuit of my credentials as a somatic experiencing practitioner in 2016, it was rare for even professionals in my area to have any knowledge of this nervous-system-informed therapy model. Now, less than five years later, it is increasingly common for clients to call my clinic asking specifically for somatic experiencing treatment, and many have even read some of Peter Levine’s or Bessel van der Kolk’s work.

As our understanding of trauma broadens and encompasses the vast majority of presenting issues our clients bring to our offices, it will become increasingly essential for us to understand the intersection of these issues and the large part played by the physiological mechanisms driving them. When I’m discussing the ins and outs of this steep learning curve with other professionals, I find that people tend to think that these new layers of learning and “complexity” must make my job harder. However, that couldn’t be further from the truth. My own ease and comfort in the therapy room now is unrecognizable compared with my work before I understood these truths about the mind and body. Not only are my clients reaping the benefits of this understanding, but I have as well, personally and professionally. My hope is that over the next 10 years, more and more counselors can also experience this for themselves.

I would recommend that anyone interested in learning more check out the work of Peter Levine, Allan Schore, Bessel van der Kolk, Bonnie Badenoch, Stephen Porges and Louis Cozolino. They each have provided beautiful contributions to the art and science
of healing.

Derrick Shepard is an instructor of counseling at the University of Tennessee at Martin and a doctoral candidate in counselor education and supervision at the University of Tennessee in Knoxville.

As I reflect on the 2012 Counseling Today article “What the future holds for the counseling profession,” I can only be impressed by the level of foresight the authors shared. Foresight regarding calls for more inclusivity, a better understanding between mental health and neurobiology, and how economic stressors placed on our clients came to fruition. Moving forward, the changing demographics of the United States will present changes, challenges and opportunities for growth in the counseling profession.

Changes: The greatest change in the next 10 years is not so much focused on the counseling profession exclusively. Instead, the changing demographics in the United States will have wide-ranging impact on virtually all aspects of our country, including the counseling profession.

Challenges: The question posed in this essay is has the counseling profession held true to its mission of being an inclusive body, not just for our clients, but also for counselor educators and counselors in the field? Are we cultivating an inclusive body that serves the needs of all communities to have access to care from those who share common beliefs, values and life experiences in the world of practice? According to Data USA, we are only talking the walk and not walking the talk. The counseling profession is still composed mainly of white (non-Hispanic) females. We see this in the pipeline of future counselors-in-training and counselor educators-in-training. If we are not taking an intentional, proactive approach to normalize counseling, and by extension normalize the profession for underrepresented minorities, we will only continue to have the same candidates.

Opportunity: As with all challenges, there are an equal number of opportunities for growth. The STEM professions, for example, intentionally and actively started promoting STEM careers with underrepresented populations. I, a first-generation, African American, cisgender male, entered the counseling profession only after my undergraduate degree and career in business did not fulfill me and after my call to serve others in their journey toward personal growth. I have never regretted my choice. Personally, I have coached underrepresented students in a TRIO program yearning for the same calling but who do not see the career as a viable option. We can change that narrative, but more importantly, we must change that narrative about who can be a counselor, what counselors do and whom counselors serve.

In drawing on my business background and taking a best practice to investing, the profession needs to diversify, diversify, diversify. A homogeneous investment portfolio, or profession, is dangerous for one’s long-term growth and stability. In other words, we need to “walk the talk” rather than “talk the walk” in diversifying the profession (Manivong Ratts, 2012).

Moving into the next five to 10 years, the profession must start walking the talk by developing intentional and systematic marketing and proactive recruitment strategies that convey to clients that they have access to counselors who will hear, see and look like them. Inclusive counselors who understand their life station on the Multicultural and Social Justice Counseling Competencies framework. Inclusive counselors who get their start in training programs that reflect society’s changing demographics. When BIPOC counselors are admitted into counseling training programs, they need to feel the profession belongs to them as much as they belong to the profession. Lip service is not enough anymore. Instead, training programs need to provide intentional mentoring, guidance and professional development. All too often, those standing outside faculty doors are the ones who need to be asked to take a seat. None of these growth opportunities for the profession will take place unless faculty reflect on their biases, assumptions and beliefs and ask themselves, “Do I talk the walk or walk the talk?”

Nevine Sultan is assistant professor and program director of clinical mental health counseling at the University of St. Thomas, and a licensed professional counselor supervisor, national certified counselor and registered yoga teacher in private practice.

As a counselor educator and LPC in private practice, the following themes emerge for me as I reflect on the future of the counseling profession:

Taking a trauma-focused approach: Over the last few decades, we have introjected how others define our profession and made their definitions our own. It’s not uncommon for counselors to state that we only offer brief treatment for moderate concerns, which influences how we assess client needs and approach our work. In the next decade, it is essential that counselors transcend these limitations as we assist clients with presenting issues beyond the transitory. Taking a trauma-focused approach equips us to acknowledge and understand how various traumatic experiences, whether they occurred in childhood or adulthood, may impact clients across multiple dimensions, including physical, emotional, cognitive, social-relational and spiritual well-being. Working from this perspective invites us to explore beyond explicit recollections of a traumatic event to address impact on brain and body mechanisms and to offer treatment from a holistic lens.

Taking a contextual, integrative approach: Again, we have allowed ourselves to be limited by others’ definitions of evidence-based practices. This has restricted how we practice and how we train new counselors and conduct research. It’s time we recognize that working with verbal narratives using a cognitive orientation is insufficient because it limits us to addressing faulty thinking and alleviating symptoms, minimizing and marginalizing other dimensions of human experience such as emotion, physiology, spirituality and relationality. It also keeps our clinical focus on the individual, implicitly shaming clients and overlooking the critical influence of context. In the next decade, we must explore not only what is occurring to clients, but also how it plays out within clients’ broader experience as perceptual, emotional, cognitive, social-relational, spiritual and culturally situated beings. Thus, we can process verbal and nonverbal narratives, address symptoms and their origins, honor the full personhood of clients, expand practice capacities and explore innovative approaches in training and research.

Unifying our professional identity and making portability a reality: I’m a very proud counselor. I also curl a little into myself when I attend a conference, meet colleagues from different states and realize we have different titles. How can we expect other professionals and the general public to know what to call us if we are not united in what we call ourselves? This is also troubling when I attend international conferences because how we present ourselves as American counselors is confusing at best. It’s crucial to our visibility and trustworthiness that we unify our professional identity. Furthermore, as the impact of the coronavirus pandemic is demonstrating, licensure portability is more vital than ever. Our profession is founded on advocacy and social justice. In the coming decade and beyond, let’s bring justice to our clients and profession and extend our reach beyond state borders and into the world.

Embracing global citizenship: As we work to extend our reach, and as we are humbled by the impact of the coronavirus pandemic on humans around the globe, we must recognize how self-isolating we can be as a society and acknowledge that what happens in one part of the world influences what unfolds in another. In the next decade, let’s expand our understanding of culture beyond the multicultural models we know, as they often perpetuate stereotyping and labeling. It’s imperative that we embrace our role as supporters of personal and social identity exploration and integration, and as agents of transformation and growth.

Marty Jencius is an associate professor at Kent State University and has been engaged with technology for over 40 years.

The 2020 COVID-19 pandemic thrust many counselors and most educators into using technology as a platform for doing their work. Although many questioned their ability to create a new virtual presence, most had to adapt to the situation. Our clients and students found that they also had to change their type of engagement. I think the future will hold more online practice and training than we had pre-pandemic. We have had a taste of clinical practice using technology, and there is no going back without it. Our clients and students will expect us to provide them the opportunity to grow and learn online.

What changes can we foresee with technology? We are comfortably engaged in the dynamic web (Web 2.0) using social media and interacting through the web. We are entering a greater use of the semantic web (Web 3.0) where your device looks at your work, recognizes your preferences, and then provides you with choices for products and services that may interest you. The semantic web could also facilitate counseling relationships through similar algorithms, becoming a counselor’s assistant. It could offer clients ideas such as support groups based on location and interest, tutoring options for students struggling in a particular area, and links to specific academic and mental health referrals.

Computing is becoming more ubiquitous. The user is less and less aware that they interact with a machine, and the computer integrates into aspects of our lives without our awareness. Videoconferencing 20 years ago required the user to include an external camera and microphone, loading drivers for both, and a limited software choice. Now videoconferencing with whole groups of people is possible by merely clicking a button.

We will see greater ubiquitous inclusion in our lives and adoption in counseling. Look for a future that involves counselors/clients and counselor educators/counseling trainees interacting more with computers as a natural flow of their process. Counselors and clients will more readily turn to the computer and internet-based information for use in their treatment. Of importance will be well-curated information and the digital literacy of both the counselor and the client.

I anticipate more incorporation of virtual reality (VR) platforms such as Second Life and Oculus Horizon into counseling training and practice. Practitioners and educators can develop VR platforms for clients and students that will give them an immersive experience. Some of this work in immersive environments has already started using VR headsets with clients who have posttraumatic stress disorder. These immersive experiences allow clients to anonymously, or with the guide of a counselor, engage in communities, practice social skills, have conversations about difficult topics with others, and create their VR environments that express their condition.

I do not see computers overtaking the practice of real-time human counselors. Artificial intelligence is far from replacing the human condition it takes to be a counselor. Computer-augmented counseling is the next stage in counselor-client work. What limits our advances in using computers with our clients and students is the limited access many people still have to computers. Unless there is some effort to fill the digital divide between those who have and those who do not have computers, advancing use will only increase the chasm.

Whatever happens with technology and our field, we will look back at it in the years to come and be amazed at how we arrived.

Danica G. Hays is interim dean and professor at the University of Nevada, Las Vegas. She is an American Counseling Association fellow.

Over the past several decades, scholars — particularly scholars of color — have led important conversations in the counseling profession regarding linkages among culture, intersectionality and advocacy with multicultural and social justice counseling competency (MSJCC). These conversations have emphasized counselor self-awareness, an understanding of client and community worldviews, and a call to action to minimize factors and conditions that might hinder client and group-level well-being. In essence, previous MSJCC scholarship serves as an important tool for counselors to identify and dismantle intersectional oppression while strengthening their professional identity.

Despite these conversations regarding MSJCC, questions remain, as the majority of the counseling profession continues to identify as white, and systemic and intersectional racism persists within society in general. How have counselors, as both individual practitioners and a collective of practitioners, developed and sustained conditions for racism in the profession? What components of MSJCC do we need to further critically reflect upon to identify ways in which counselors, counselor educators and researchers might perpetuate racism? In what concrete ways can the profession ensure that counselors and future counselors are representative of the increasingly diverse clientele they serve? How can white counselors serve communities from an anti-racist and intersectional approach?

Addressing these questions in a meaningful way is the task of the next decade. This opportunity begins when counselors, counselor educators and researchers are committed to exploring the role of white supremacy at a deeper level for them individually and as a profession. Racism, which serves to construct race narratives, does not occur in a vacuum perpetuated by individuals. It is upheld by a deeply entrenched set of assumptions and norms that privilege the views of whites who have traditionally held the most power in cultural, economic, educational, health, criminal justice and political systems. White supremacy, which supports racism and systems of intersectional privilege and oppression, has existed for several centuries. Anti-racism is the intentional resistance and concrete, incremental disruption of white supremacy.

The formation and development of the counseling profession has not been spared from white supremacy. Barriers to counseling — affecting to a greater extent those with multiple marginalized identities — can include insufficient health care access, limited methods of counseling service delivery, a lack of diversity among counselors, language barriers, mental illness stigma, and distrust in the health care system, to name a few. In addition to addressing a field where counselors are disproportionately white, there is a moral imperative to understand how white supremacy sustains mental health disparities among racial, socioeconomic, gender and other cultural groups. It is necessary to critically reflect on the lack of counselors who represent diverse backgrounds across the intersections and how training programs perpetuate the lack of representation. And it requires the profession to disrupt the ways in which counseling is traditionally delivered so that communities are served well.

The core of counseling hinges on relationship building. Counselors must first build an authentic relationship with themselves, uncovering their participation or encounters with white supremacy. In their anti-racism work, they must be vocal about the need for equity even when it does not personally benefit them. Through relationships with clients and their peers, counselors must meaningfully attribute personal and client narratives of systemic and intersectional racism to white supremacy. This is our opportunity to strengthen the ongoing work of MSJCC. This is our opportunity to grow our profession in the next decade.

Oliver J. “Ollie” Morgan is a professor of counseling and human services at the University of Scranton.

I recently turned 71. I have been a practicing counselor and family therapist since 1980 and a counselor educator since 1990. This is my 30th year teaching graduate counseling students and undergraduate human service providers. With the faces of so many bright-eyed and eager students in my memory, my reflections turn to preparing others for what lies ahead.

Who are the counselors we will need in the final years of this decade, this century? What kinds of people will they be? Counselor self-awareness and “self of the (family) therapist” points of view have been guideposts for me. My colleagues and I at the University of Scranton have helped to pioneer a “Counselor Fit for the Profession” statement and assessment process over the past 15 years, and it has served us well as mentors and gatekeepers for counselor preparation. I have come to believe that shaping the “practitioner of the future” is a critical task for the counseling profession. The person — she, he, they — is the point of contact for healing and critical to the work of implementing whatever method, theory or technique is used.

So, what kind of counselor do we need for the future? First, in addition to having empathy as a foundation, I would say that we need someone who is flexible and eager to learn. In my career, I have worked in agencies and in generalist private practice. I have worked as a family and marital counselor, pastoral counselor, addictions specialist, and medical family therapist with cancer patients and families. I chose each iteration of practice in part to increase my skills, to acquire new areas of expertise and to respond to local needs. It also helped to keep me fresh.

Second, I have learned the necessity of being trauma-informed and trauma-competent. It is clear that various forms of trauma mark broad swaths of practice. I have explored and published about the effects of “adverse child experiences” and other forms of adolescent and later trauma on substance use disorders and addictions. I have learned about the prevalence of trauma underneath various medical, psychiatric and behavioral disorders. It is not too extreme to say that trauma is often an unseen factor affecting the two or three most troubling (and troublesome) patients a physician will see in any given day. Counselors should market themselves to doctors as an invaluable resource for their practice. I often tell my students that trauma and addiction are the two most underdiagnosed and undertreated conditions in clinical practice. Helping future counselors to recognize and address trauma is essential for the future.

Third, I am coming to understand that trauma is also a hidden, underlying factor in one of the most troubling societal maladies we need to address moving forward — namely white supremacy and nationalism, racist demonization, and violent extremism, as well as their underlying brokenness, isolation and marginalization. Trauma is often the covert companion of racist violence toward another. Just as addiction and illness can be negative outcomes from trauma short and long term, so too can prejudice and violent extremism become twisted and toxic aftereffects of suffering. I am coming to a deeper appreciation of strategies that identify, and show promise in addressing, this malignancy: empathy, connection, humanization, providing social support, resilience-building.

As counselors, we are called to provide comprehensive care and treatment. To do so demands that we become fierce advocates for creating inclusive communities that help to bridge the divide between suffering and hope. Helping our future counselors become these advocates is our task moving forward.

Kelly L. Wester is a professor and chair of the Department of Counseling and Educational Development at the University of North Carolina at Greensboro.

Many changes have occurred within the counseling profession over the past three decades: gaining licensure in all states, strengthening professional identity, being recognized by insurance panels and government organizations, and increasing use of telehealth during the health pandemic. We have more challenges in front of us, including, but not limited to, transferability of counseling licenses across states.

The growing edge I want to focus on is one that is moving slowly: our engagement in and use of research. To some individuals, research may be a four-letter word, and to others their passion. Regardless of where you may fall on this continuum, the field of counseling needs research. Research informs and transforms a profession, influences our understanding of mental health symptoms, informs counselor training and practice, and provides evidence-based practices.

The need to engage in research has been mentioned by counseling leaders since the 1990s and was noted as one of the seven principles in the 20/20 Principles for Unifying and Strengthening the Profession. These leaders have argued that counselors need to promote rigorous research, to understand client outcomes, and to disseminate research to clients, professionals and legislators. While I believe that we have made progress in enhancing research conducted in our field, I do not believe that our field has fully answered these calls. Are we effective as counselors? I have no doubt that we are. But do we engage in research that proves this? Not as much as we need to.

Research informs the field and advocates for clients. Our field is one of the leaders in supervision and in promoting multicultural and social justice competencies — yet we are just beginning to skim the surface on examining what is effective in both of these. There is a place for descriptive research to help us understand and influence theories, to better our understanding of what is occurring — but we really truly need to engage in more outcome and process-based research. What is it that we are doing that is effective? We know the therapeutic relationship is important, but what about it truly impacts clients and outcomes? How do we take more of what we do as counselors — the developmental, strength-based approaches — and show that it truly works, instead of waiting for other mental health professions to do the research on what they implement and tell us what to do (because third-party payers mandate evidence-based practice)?

All counseling professionals need to see themselves as researchers, because they are. With every client and student who comes to your office, you have a question about them. You are trying to unearth what is going on, what factors contribute to the symptoms, and what you can do to help this client/student. This is informal research.

It is not enough to do the research. We need to disseminate it so that professionals and clients can access it. Does this mean we should stop publishing in journals? No. Publishing in peer-refereed journals is important for maintaining integrity and influencing the scientific world. However, academic writing does not always translate to practice. Nor do counselors always have access to journals. Researchers need to think outside the dissemination box. Publish in the journal, but then blog about your findings, or take it to social media in a quick blurb, make a one-minute video, create a podcast or do something else to make it accessible. Bring the findings back to the community that provided you with the information.

Our challenge: To conduct more outcome and process-based research and disseminate our findings in an accessible way.

The change and opportunity: To impact our training, practice and clients by providing services that are empirically informed.

Debbie C. Sturm is a licensed professional counselor, co-chair of the American Counseling Association Task Force on Climate Change and Mental Health, and an associate professor at James Madison University.

In 2019, Greta Thunberg told the U.S. Congress, “This is not the time and place for dreams. This is the time to wake up. This is a moment in history where we need to be wide awake.” While the specificity of the global pandemic was not known at that time, the reality of pandemics, increased natural disasters, climate refugees and migration, and racial and environmental injustices have always been in the reality of those studying the climate crisis. The global systemic complexity of the impact of climate change may seem like quite a challenge for the counseling profession, but we have a clear opportunity to educate, prepare and mobilize in response to the very real mental health crisis on our doorstep.

COVID-19 has exposed the deep interconnectedness that our belief systems and actions have on each other and underlined the imperative of personal action for the greater good. It has also reminded us that science matters and that strategic, visionary leadership is critical. But COVID-19 is the intense here-and-now microcosm for what the climate crisis will bring. And everything we as counselors learn about health disparities, mental health outcomes from crisis and who gets left behind when leadership fails is an opportunity to better prepare for the next major shift.

While we have been in personal, professional and community battles with COVID-19, we have also been wrestling with the dangers of misinformation, intense and important calls for the long-delayed commitment toward anti-racism and racial justice, and severe social and economic disparities. And Oregon, California and Washington burned. Again. As I write this, the Gulf Coast is awaiting its seventh major hurricane of the season. Suicide rates among farmers are higher than they have ever been. Climate refugees within our own country are increasing. Flint, Michigan, still doesn’t have clean water. And the environmental destruction of the past four years has increased risk of harm to more communities due to environmental injustice and environmental racism.

How is this an opportunity? Literally everything around us is screaming for the awareness that harm to one is harm to all. And we have the opportunity — the critical, here-and-now, no-time-to-waste opportunity — to step into this movement.

Our ACA Advocacy Competencies remind each of us there are countless points of insertion to which every person can find their own unique way to make a difference. We have the opportunity to recognize, validate and bring into the therapy room the reality of the fear, dread and helplessness people feel in the face of the climate crisis — eco-anxiety, solastalgia, eco-grief and trauma, and concern about future generations. We have the opportunity to develop competencies for climate-informed disaster response — recognizing that disasters have now become repeat occurrences within short periods of time. We have the opportunity to become part of conversations in our communities with climate mitigation and resilience groups by contributing our knowledge of trauma, place attachment, racial and economic disparities, and resilience. And we have the opportunity to contribute to the overall understanding of how the climate crisis will impact the mental health and well-being of our most vulnerable neighbors. All of this is well-established with solid evidence from national and international agencies. We just need to bring it into our profession.

Right now, there are so many critical issues calling to us. We should rise up to meet every single one of them. But let’s remember — we have a massive membership. With intentionality, we have the opportunity to mobilize passionate people in every direction — all tied together by the common thread of counseling. Find your opportunity to make a difference. Mine is climate change and environmental justice. Find yours … and then join other counselors to make the change.

James T. Hansen is a professor in the Department of Counseling at Oakland University whose book, Meaning Systems and Mental Health Culture: Critical Perspectives on Contemporary Counseling and Psychotherapy, elaborates on the issues presented below.

The most significant challenge to the counseling profession over the next decade will be to reconcile the conflict between effective, relational counseling and increased professional participation in the medical model. By the medical model, I mean the alignment of specific treatments with particular symptoms or disorders, such as antibiotics for infections or cognitive behavior therapy for depression. Money and status in the mental health field are highly associated with the ability of professionals to participate in the medical model by diagnosing, receiving insurance payments and developing symptom-oriented treatment plans. However, reducing clients to symptoms is at odds with the development of an optimal counseling relationship, which is the within-treatment factor that has the highest association with counseling outcomes. Therefore, there is an inherent conflict between relational counseling practice and participation in the symptom-oriented, medical model.

It is not necessary to dive deeply into research or theories to understand this conflict; evidence from ordinary experience will do. Imagine that you have had a bad day and are eager to talk to your partner about it. As you begin to talk, your partner senses your frustration, states that you are suffering from an adjustment disorder, and suggests that you might benefit from a cognitive technique, which he then begins to describe. What would your reaction be? Would this response strengthen your relationship?

As another example, recall the last time you were troubled, talked to someone about your difficulties and felt better after the conversation. What did the other person do to make you feel better? During my career, I have asked hundreds of people (mostly counselors) this question. No one has ever answered “diagnosed my problem and recommended a technique.” Virtually everyone has answered with some variation of “listened intently and tried to understand my experience.” Relational development depends on efforts to understand the experience of the other person. A medical model emphasis on the importance of external symptoms necessarily undermines efforts to understand internal experiences.

At their best and most effective, counselors are relational professionals. Unfortunately, in the current culture of work, relational professionals are generally devalued, particularly when compared to technical-medical professionals (think caregivers versus surgeons). To gain status, professional respect and third-party reimbursement, counselors have strongly advocated to be a part of the medical model. However, as noted above, the reductive, symptom focus of the medical model is antagonistic to the relational factors that make counseling effective. Indeed, the counseling code of ethics emphasizes “best practices” and “effectiveness,” yet counselor advocacy in the mental health realm often takes the form of fighting for greater recognition as quasi-medical providers. This is an identity that undermines the relational factors that have the highest association with best practices and effectiveness. From this perspective, professional advocacy is an ethically questionable activity.

I do not have a solution to this conflict. From my observations though, the dark side of advocating to become a greater part of the medical model as a means to professional advancement is virtually never discussed. Therefore, the greatest challenge for the counseling profession will be to reconcile the conflict between professional status and our identity as relational professionals. Again, I do not have a solution. However, I think we can begin where we tell our clients to begin. That is, we need to face the conflict honestly and deal with it, rather than ignore it in the hopes that it will go away.

Derrick A. Paladino is a licensed mental health counselor, a national certified counselor, and a professor of counseling and Cornell distinguished faculty in the graduate studies in counseling program at Rollins College in Winter Park, Florida.

Three thousand six hundred fifty days in the future is a lot of days — and I mean a lot a lot. Living through a pandemic can make this time seem exhausting for some, and for others, hopeful that life will begin to invite more familiarities and welcomed experiences. Though I live somewhat near Cassadaga, Florida — aka the psychic capital of the world — I have not experienced any of this talent rubbing off on me. I mean, it could be nice to live it up like Biff Tannen in Back to the Future Part II or join Bill and Ted on their excellent adventures, but that also might take the fun out of life. Nevertheless, here are a couple thoughts regarding what might impact the counseling profession.

One trend/current necessity that I believe will become a staple is telehealth. To me, we are already late as a profession in fully accepting this modality. When looking at our global and social world, connecting to those who are unable to easily make their way to brick-and-mortar practices (whether their hurdles are physical health, logistical, financial or related to mental health) just makes sense. Telehealth is a part of social justice and advocacy, and the ability to seek counseling services becomes a clear social and ecological issue.

I think the profession will see a growth in HIPAA-compliant sites and devices to increase the accessibility of this modality. In addition, a surge in telehealth scholarship will better inform telehealth ethics and laws, best practices, and counselor and supervisor education. I also envision telehealth becoming a consistent part of the counseling curriculum. One hope is that “powerful individuals” will embrace and advocate for the need of reduced-cost internet. Currently, we are experiencing this as K-12 schools have gone virtual, and it would be wonderful to see this social justice issue emerge with the backing of our profession. On the other hand, we may see an increase in nonallied mental health professional telehealth counseling. The counseling profession will need to do a solid job of defining, differentiating and advocating for licensed and certified mental telehealth practice.

Another element might be the impact of political view polarity in the counseling profession. Over the past 3,650 days, we have seen a dramatic increase in the explicitness of individual political and social stances. Though they have always been there, due to social media, Listservs, etc., we have witnessed that what once was hidden is now a big neon sweatshirt with a sign spinner next to it.

How this will shape the profession, I have no idea. But we do know that the personal is political for counselors and clients. The counseling profession champions social justice and advocacy to allow underrepresented and marginalized populations to feel safe, connected and brave during treatment. For example, we see religious symbols and other symbols of inclusivity on private practice websites to increase client comfort and connection to the process. As the country seemingly sits on a divide, will this extend to political symbols? Only the psychic mediums in Cassadaga, Florida, know.

At minimum, mental health professionals will need to hold consistent awareness of what their public social presence beams to clients, along with the potential ascribed ethical, professional and ecological impact. The counseling profession will need to spend more time with how this is unpacked and navigated.

Michelle Fielder is a licensed professional counselor, an approved clinical supervisor in private practice, and a doctoral candidate in the counselor education and supervision program at Regent University.

The year 2020 will certainly take its place in the history books for the mental distress Americans endured with the coronavirus pandemic, alterations to education and social interaction, hits to the economy and record unemployment, heightened racial tension, calls for police reform and a divisive presidential election. However, the ramifications of these events will last long into the next decade. Despite the loss, pain, confusion, frustration and disappointment of life-altering circumstances, our shared experience is heralding the continued evolution of the counseling profession.

Counseling will forever be changed by the nationwide acceptance and advocacy for the profession during the COVID-19 pandemic. The Department of Health and Human Services’ public health emergency opened the door, but the declaration by the U.S. Department of Homeland Security naming counselors as essential to the critical infrastructure of the United States paved the way for recognition on par with other mental health providers. Continued efforts for license reciprocity and portability will eventually bear fruit, lending credibility for the profession to operate across state lines with an established standard of professionalism.

The pandemic also ushered in the widespread use of telehealth to ensure public health and safety. While telehealth seemed like a niche modality before the pandemic, clients, clinicians, insurance providers, and state and federal governments quickly recognized its benefits to meet the need for increased mental health services while being mindful of social distancing protocols. The use of telehealth will not decrease as the need for social distancing wanes. Our society was already moving toward increased convenience in daily activities as the millennial and centennial generations embraced technology for online social interaction, recreation, shopping, dining, groceries, transportation and remote work opportunities. The widespread use of telehealth is here to stay.

The challenges and opportunities for the counseling profession will concern maintaining relevancy in the nation’s changing landscape. Counselors will need to further differentiate from life coaches and other helpers who do not require the same level of education, experience or licensure as future clients seek the most expeditious, cost-effective services. An increased need for counselors must be met with increased CACREP-accredited programs, to include qualified supervisors and applicable practicum/internship opportunities.

Recent history has revealed that the nation is not as enlightened in the areas of equality, justice and racial reconciliation. The pandemic revealed the financial fragility of many families and small businesses, as the loss of one or both incomes destabilized families and caused businesses to shutter. Education at all levels has been affected; students will not get back the losses of the 2020-2021 academic year, including social skill development, organized sports and club activities, or academic programs that were canceled. The loss of those experiences, especially for older students, can have a devastating effect on potential recruiting and scholarship opportunities or occupational opportunities in the future.

Insecurities in food, housing, transportation and health care caused further distress as families tried to maintain solvency. The clients of the future are going to be affected on multiple intersecting levels, which will require efficacious methods to address the complexity we are likely to see. Not only must counselors be well-versed in grief and loss, multiculturalism, social justice, advocacy and trauma-informed care, but there needs to be additional research into the intersections created by the pandemic and the life-altering changes that came with it.

Lennis G. Echterling is a professor of counselor education at James Madison University.

As a kid, I loved to dig holes in our yard, fruitlessly searching for arrowheads and other clues about our mysterious, distant past — much to the consternation of my parents. When I gave any thought to the future, I dreamed of flying cars and spaceships blasting off to the stars. These days, as a counselor educator, I find myself digging into the muck and mire of the present crises that confront our society, searching for valuable clues about our future. Throughout my career in the counseling profession, I’ve learned that the seeds of innovations and transformations are found in our most troubling times.

For this piece, I will focus on three current and intersecting crises — the pandemic, global climate change and systemic racism — that are leaving in their wake countless casualties, economic chaos and social conflict. These catastrophic conditions are vast and dishearteningly complex, but all three perils also hold promise for the future contributions of the counseling profession.

The pandemic: In the 16th century, Italy was struck by a plague they labeled influenza delle stelle because they believed the disease was caused by the stars. Today, we still retain the term “influenza,” but we now recognize that humans, not the stars, are the actual viral agents. As counselors, our focus is on humans — their struggles, relationships and potential. In our work, we have learned that in times of emergency, new things can emerge, leading to dramatic, enduring and positive changes — in individuals, families, communities and societies. Consequently, counselors are now serving as catalysts for expanding innovative telehealth practices, offering virtual crisis intervention to overwhelmed first responders, promoting best practices for primary prevention, collaborating on medical teams to treat COVID-19 patients, and providing online support groups for those who lose loved ones.

Climate change: Rapidly rising sea levels, record-setting heat waves, horrific wildfires, hurricanes whose names outpace the alphabet, and other catastrophic consequences of climate change will continue to sabotage the emotional well-being of countless citizens in every country. Therefore, future counselors will be welcomed as valued members of disaster response teams. Given our knowledge and skills as counselors, we are ideally positioned to contribute to environmental advocacy, disaster preparedness and community resilience. For decades, counselors have been influenced by attachment theory, which highlighted the need for deep and abiding relationships between children and their caregivers. In the future, it will also be our basic duty to promote, strengthen and deepen humanity’s most fundamental attachment — to the natural world.

Social justice: Both the pandemic and climate change have in common a disproportionate impact on people of color, who not only are exposed to greater risks but also have fewer available resources to cope with these threats. Black Lives Matter and other movements are engaging in social justice action to heighten society’s awareness of oppressive systems of power and privilege. By implementing diversity, equity and inclusion initiatives in counselor education programs, we can ensure that future counselors will be better prepared to embrace their roles as change agents for social justice — to challenge racialized violence, combat xenophobia, advocate for racial and gender equity, and echo the voices of the marginalized.

Addressing these and other crises will be the mission of all future counselors as we advocate for bridges that unite humans, instead of psychological walls that separate. Counselors can be the metaphoric windmills that harness the winds of change. As Shakespeare wrote, “The fault … is not in our stars but in ourselves.” True, but we humans also hold the promise to actualize, transcend, and achieve our potential. The task of future counselors is to fulfill that promise for all humanity.

Kara P. Ieva is an associate professor in the counseling in educational settings program at Rowan University.

What will counseling be over the next decade? My initial thoughts center around 2020 and the unpredictability of demands from counselors. As such, I feel like 2020 brought invaluable lessons for the counseling profession but also left us with numerous questions to answer as we begin to envision the next 10 years.

Highlighted by 2020, the counseling profession will need to address how it contributes to our society’s generational diagnosis, racism. While we continue to eradicate the stigma surrounding mental health, racism presents the greatest challenge we will face, but it is also a significant opportunity to advance the profession as an inclusive practice for all individuals. Essentially, this requires feeling uncomfortable while critically reflecting on our history and the lessons from 2020 and challenging the identity of who we want to be for future generations. As we know, complacency is harmful to the profession, ourselves, clients and society.

This is a tall order that requires a systemic and collaborative approach from professional organizations, accrediting and licensing bodies, counselor education programs, researchers, field leaders and supervisors, and individual counselors. The first step is acknowledging our history in two ways.

One, the field was founded on the need to compete in the global “space race” and increase student enrollment in STEM courses. This led to the creation of gatekeeping practices, deciding on access for opportunities in an educational setting that was founded on white norms. As a large body of research tells us, those practices still exist today for marginalized populations.

Second, counseling overall is steeped in white middle-class norms. Even though the profession evolved with cross-cultural counseling, multicultural competencies and social justice advocacy, we remain a predominately white field (conditioned in privilege), which limits access for myriad clients and potential future counselors. The counseling profession is active in multiple systems (e.g., health care, education, justice, etc.) that interact with one another. This informs the essential questions: How will counselors collaborate across systems to provide equitable access, dismantle oppressive practices, and provide strength-based interventions to increase overall mental health wellness? How will we contribute to making the world a more informed and empathetic place for all humans?

To address those questions, the next thing to consider in tandem are accreditation and licensure standards and counselor education curriculum. Programs still teach foundational Eurocentric theories across the entire accredited curriculum. Given the diversity of multiple identities of counselors and clients, it’s time we asked ourselves, “What can we leave behind in our curriculum while acknowledging the past, and what might be essential moving forward?”

We were already in a mental health pandemic, and now due to 2020, mental health issues continue to increase for all ages, from young children to adults, stemming from the pandemic, financial crises, grief and loss, racial trauma, educational trauma, political and familial tensions, and social isolation, just to name a few. Based on what we know about trauma, we will be addressing the effects of 2020 for the next 10-20 years. Additionally, we also know that trauma plays out differently with the intersection of multiple identities (e.g., gender, race, ethnicity, neuroprocessing, language, veterans, LGBTQ+, etc.) and circumstances across the various systems. Are all counselors prepared to address intersectionality with multiple traumas across all systems, for all clients, whether face to face or through telehealth sessions? How might the answer change our accreditation standards, licensure requirements, educational curriculum, supervisor training and professional development?

It’s true, there is a lot of work to be done, but I am hopeful. I am optimistic that 10 years from now, we will have answered these questions and proactively collaborated to meet the needs of an ever-changing society and done our part in contributing to global healing and overall wellness.

Sherry Cormier is professor emerita in the Department of Counseling, Rehabilitation Counseling and Counseling Psychology at West Virginia University and is currently affiliated with Full Circle Healing Arts and The Wellness House in Annapolis, Maryland.

The Chinese symbol for “crisis” also means opportunity. The issues that we are facing nationally and globally in terms of climate change, pandemics, food insecurity, social justice and interpersonal conflicts are not only challenges; they are also opportunities for change. We are evolving at a pace so rapid that it’s laced with tremendous uncertainty, grief, anxiety and aggression. Substance misuse and suicidality, as well as crisis calls, are steadily rising in response. I’ve lived long enough now though to not feel unduly alarmed over these issues. I’ve sat through enough deep loss and enormous social unrest to know that devastation is the opening for growth. Cynthia Occelli has captured this sentiment: “For a seed to achieve its greatest expression, it must come completely undone. The shell cracks, its insides come out, and everything changes. To someone who doesn’t understand growth, it would look like complete destruction.”

I believe this quote holds the key to the opportunities available to counselors and our profession in the next decade. We know from research that personal transitions are occurring at such a swift speed that nothing in our lives is linear anymore, and clients are unnerved and overwhelmed by constant upheaval (Bruce Feiler, Life Is in the Transitions, 2020). As important as self-care is for clients (and ourselves) now, this area of professional practice will grow exponentially in the next decade, especially for clients who feel their values eroded, their boundaries violated and their lives compromised in unthinkable ways. Since emotions like anxiety and grief settle deep in our cells, providing clients with ways to emphatically and consistently prioritize their own mental and physical health will be important future opportunities for counselors, including networking with complementary professionals whose practices supplement our roles.

Also, the search for self-knowledge and personal meaning will be even more relevant and necessary. The more intimately we know ourselves, the more resilient we tend to be from the waves of change in our external world. Those who stand poised to help clients discover more about who they are and about what they are connected to will be the leaders in the next decade.

At the same time, counselors who have a deep understanding of trauma, both personal and collective, will have expanded opportunities to provide services. Finding ways to work effectively with personal traumas will continue to be important, yet navigating cultural and societal traumas, including but not limited to racism and discrimination, will become more prevalent. If we fail to address collective trauma in our profession, we risk becoming irrelevant (at the very least).

As the incidence of posttraumatic distress grows, so does the opportunity for posttraumatic growth. For many years, we’ve considered counselors to be agents of change. That’s still true, but in the next decade, counselors will be known for being agents of growth and healing. The word healing means to “make whole.” Comprehensive self-care assessment and treatment modalities, facilitation of far-reaching self-knowledge and personal meaning, and sensitive and competent responses to individual and institutional traumatic distress will be significant opportunities for counselors to help clients develop wholeness and transformation in the face of anguish and desolation. As the mystic poet Rumi said, “Do not worry that your life is turning upside down. How do you know that the side you are used to is better than the one to come?”

Laura K. Jones is an assistant professor of health and wellness promotion and director of the Peak Performance Biofeedback Lab at the University of North Carolina Asheville.

“The gut trains the immune system to protect the brain,” proclaimed a November 2020 National Institutes of Health press release. The month prior, Brain, Behavior, and Immunity published a study detailing the inflammatory predictors of anxiety and depression in COVID-19 survivors. In 2020, nearly 17,000 journal articles noted interactions between the immune system and mental health, 4,000 linked mental health to the gut microbiome, and roughly 2,000 more described the role of sex steroids. Research substantiates that nearly every system of the body — the central and peripheral nervous systems, immune system, endocrine system and gastrointestinal system — influences mental well-being and how our environment influences that process. We now know there are likely multiple phenotypes of various mental health struggles, likely driven by differing physiological etiologies. We are on the verge of a watershed moment in how mental health — for centuries an enigmatic phenomenon — is conceptualized.

Although we have been championing this within our field for over a decade, I am more convinced than ever that to stay relevant and emerge as leaders in the broader mental health landscape, the field must recognize, embrace, and intentionally and ethically translate such findings through our unique therapeutic lens. However, this begets significant challenges, both within and external to counseling. A 2018 Journal of Humanistic Counseling article argued that neuroscience lends little substance to counseling and offers a reductionistic image of the human experience. Although ethical integration warrants caution, such perspectives are as shortsighted as the reductionistic viewpoints they argue against and problematic to the growth of the field.

Integration is not a binary argument. It is not a question of whether we stick to our humanistic ways or embrace what we know about physiology. We cannot pit one against the other and sit idly by while the rest of the mental health world changes. As such, the more appropriate question is how we will grow with the science, employing and building upon our humanistic traditions to best support physiological, interpersonal and social change.

This balanced perspective is vitally important external to counseling too as we begin to see the therapeutic implications of such burgeoning research. Such science will continue to inform how mental health struggles are diagnosed, prevented and treated. It is likely that our society — based in allopathic medicine and “quick fixes” — will begin to push for more pharmacotherapeutic and medical interventions. Although advances are important, this emphasis may have detrimental impacts on policy, insurance and perceptions of the therapeutic process.

Counselors have the obligation to remain advocates in the broader mental health and policy worlds for the importance and necessity of talk therapy and adjunctive interventions (e.g., neurofeedback, somatic therapies) facilitated by counselors. To support such efforts, we need to expand our research to explore the neurophysiological outcomes of counseling interventions, both traditional and those newly developed and informed by neuroscience.

Think about it. We know the importance of a strong therapeutic relationship and increased self-awareness, but how, physiologically, do these lead to an abatement of symptoms? How does engagement in counseling influence health disparities for Black, Indigenous and people of color? How can counseling ease the enduring health consequences of COVID-19? How does neuroscience-informed cognitive behavior therapy, originating from counseling, compare to traditional CBT in alleviating symptoms?

Answering such questions will require that we become more competitive within larger granting agencies, such as NIH and the National Science Foundation, and build cross-disciplinary partnerships. It will require more intentional, consistent and accurate training of counselors, which the American Mental Health Counselors Association Neuroscience Task Force is currently addressing. We are at a significant juncture in mental health care, and the counseling field has an opportunity, or rather obligation, to guide those changes and to be the voice for balancing the physiological perspective with that of the humanistic within policy, insurance and practice alike.

Matthew Fullen is a licensed professional clinical counselor in Ohio and a counselor educator at Virginia Tech, where his research focuses on Medicare reimbursement advocacy and supporting the mental health and wellness of older adults.

Medicare insures 60 million Americans, a figure estimated to approach 80 million by 2030. Exclusion from the Medicare program has far-reaching consequences for counselors, and the negative impact on Medicare recipients is even more alarming. For counselors, Medicare exclusion has resulted in untimely client referrals, loss of revenues and fewer job opportunities within certain segments of the mental health marketplace. Clients who rely on Medicare (i.e., older adults and younger people with long-term disabilities) experience long waitlists and financial challenges in accessing care and with issues such as hospitalization.

Medicare advocacy in the counseling profession has a long history, but recent developments suggest that the near future is bright. During the 2019-2020 congressional cycle, over 150 lawmakers became co-sponsors of two bills that aim to address counselor exclusion from Medicare. The Centers for Medicare & Medicaid Services will now reimburse services provided by counselors in opioid treatment programs, and a similar allowance was made, albeit temporarily, within rural health centers during COVID-19. In addition to these advances, awareness of the Medicare mental health coverage gap is reaching a wider audience through increased research and exposure in national press outlets such as Politico and the New York Times.

So, what comes next? How do we commit to advancing this advocacy over the next several years? And just as importantly, how do we ensure that the counseling profession is prepared to work with Medicare-insured individuals once current policy is changed? In the short term, there is an ongoing opportunity for counselors to increase their participation in the Medicare advocacy process. If you have never participated in an ACA advocacy campaign, we need you to start. If you have participated using only automated technology, we need you to make phone calls and write personal emails. If you have not yet met directly with your federal lawmakers about Medicare reimbursement, this is the time to do so. These steps will go a long way in advancing this cause. If you are busy serving your clients, we need you to share your stories about turning away Medicare-insured clients. If you are busy training counseling students, we need you to help them get involved in advocacy. If you are a student learning about the counseling profession, ask your instructors about how Medicare policy influences clients’ access to care. We need a wave of grassroots involvement that will show congressional lawmakers that the time for change is now.

As we advance toward Medicare inclusion, a new challenge awaits us. Will the counselor workforce, professional infrastructure and training programs be prepared to work with a vast influx of Medicare-insured clients, most of whom are over the age of 65? Just as the counseling profession has evolved to respond to the needs of other societal changes, so too must the profession ready itself for demographic shifts that are already underway. When we attain Medicare reimbursement, will our profession be ready to meet the needs of older clients? Counselors will need professional development opportunities to enhance the application of their practice to an aging population. Counselor educators will need to improve upon the very low rate of counseling research that currently exists. Counseling students will need greater exposure to training that addresses needs across the life span, which may require the reemergence of a specialization in gerocounseling, or at least the development of accreditation standards that address aging more directly.

The future of counseling is bright, and the profession’s ability to capitalize on current Medicare advocacy momentum and translate these successes into addressing the mental health needs of an aging population will shape our next five to 10 years. Advocates, pioneers, counselors wanted!

Sidney Shaw is core faculty in the School of Counseling and Human Services at Walden University.

In considering future challenges for the counseling profession, it is evident that artificial intelligence (AI) will influence the future of mental health services, and changes are already occurring. In broader society, human jobs have been altered by technology for generations. Switchboard operators, bowling alley pinsetters and cashiers are just a few of the jobs that are either no longer done by humans or have been at least partially replaced by technology. Even some journalists have recently been replaced with AI.

There can be benefits to technology supplementing human occupational roles, such as robots to inspect burning buildings for safety, but limitations include technological augmentation of jobs that are fundamentally rooted in human relationships. AI is accelerating at rates that were previously unimaginable, and this has unforeseen implications for our profession. In the month of January 2020 alone, there were 3.4 million downloads of the top 10 mental wellness apps in the U.S., and the monthly download number has increased since COVID-19 was declared a public health emergency by the World Health Organization on Jan. 30 of last year.

Mental health apps and AI bots are readily available, certain ones are free of charge, and some have research support. For example, a peer-reviewed study by Kathleen Fitzpatrick and colleagues found that people using Woebot, a chatbot that provides real-time CBT-based interventions, experienced significant decreases in depression symptoms. The increasing popularity of mental health bots is not separate from the broader societal and political environment. For example, the America’s Mental Health 2018 study found that access to care is a root cause for the mental health crisis in the U.S., and this is one factor that can make cheap or free mental health bots very appealing. With this in mind, it is important for the counseling profession to advocate for accessible health and mental health care for all members of society to promote well-being of the entire population.

People sometimes make vague decisions about the role of technology in their lives, and they may conduct informal cost-benefit analyses in this regard. Consider parents setting limits on screen time with their children, or how you might think about your own technology use and what limits should be set to maximize living a full life. Someone might argue that having a therapeutic relationship with AI bots is a good thing, so we should embrace it. On the one hand, they may have a point. However, more research evidence is needed in this regard, and a move toward therapeutic relationships with AI should prompt us to wrestle with some philosophical questions. Questions such as: How do we determine when technology is serving us versus when we are serving it? Even if AI can help decrease symptoms of depression, are we also sacrificing some important part of humanity or human connection in the process? The therapeutic alliance is the best predictor of counseling outcomes; how does this relate to mental health bots? How does increased reliance on AI for dealing with struggles affect broader society and human relationships? How do helping relationships with AI alter humanity over time?

Instead of sleepwalking into a future that is determined by the tech industry, the counseling profession needs to intentionally address these and other philosophical questions about the potential long-term impacts of AI so that we can thoughtfully influence the future of counseling for the benefit of clients and the profession. My essay is a call to look at the forward trajectory of AI and its potential effects on our field, mental health care and us as a species. In the words of Ilya Prigogine, “The way to cope with the future is to create it.”

Donna Gibson is a professor of counselor education, a licensed professional counselor and the
Association for Assessment and Research in Counseling’s representative on the ACA Governing Council.

It seems like our world has been experiencing “change” in warp speed. Constant changes that do not slow and seem to impact multiple aspects of our lives. The perception may seem a little skewed while living during the latter part of 2020, but there were fast-moving changes in politics, climate, economy, health care, immigration and other aspects of our society prior to this year. The year 2020 put an exclamation point on it, in some ways brought things to an abrupt halt, tested our ability to be flexible and try new things, and in many ways forced us to have a new perspective on the present and the future. Personally and professionally, I had to look at the opportunities that were given and what opportunities are there for us in the future.

Quarantine and social distancing measures highlighted individuals’ needs for connection and the importance of relationships. The need for connection to others and to be in relationship with others isn’t surprising to us counselors, and it’s the reason why we are needed. Yet we fulfilled this need in less often utilized ways in 2020 and demonstrated our flexibility in meeting the needs of clients and students. Instead of face-to-face meetings, individuals connected with friends and family more with texts, FaceTime or some form of web conferencing platform (e.g., Zoom). Counselors connected with clients more through phone calls, emails/texts and telemental health counseling platforms, and counselor educators had no choice but to go all in with web conferencing and online course delivery platforms (e.g., Canvas, Blackboard).

I note this change in service delivery because it provides insight into the future of counseling for the next five years. As a profession, we won’t go “back to normal” but rather to a “new normal.” Don’t be mistaken and think I am suggesting that we should not meet clients or students face to face, but utilizing technology creatively will allow for many more and different opportunities to meet with them. If we have a level of flexibility in meeting with clients that exceeds what we have done prior to 2020, then licensure portability is more important than ever before. Because the American Counseling Association is working diligently on a licensure compact among states, I do think we will see portability among states occurring in the next five years.

Writing my thoughts about our profession post-election, it is obvious that we have opportunities to help people examine relationships, practice self-reflection, and engage in conversations and work related to human rights. Protests related to human rights, and specifically Black Lives Matter, highlight the importance of counselors being leaders in anti-racism action. As a profession, we have opportunities and skills necessary to leading in this arena that respect the developmental aspects of self-awareness, empowerment and advocacy. In the next five years, we can lead in educating, training, listening and advocating for change. Change is here but rough around the edges, so our role is inevitable. Our society will continue to present more and more opportunities to lead in the years to come.

The year 2020 highlighted the creative ways that we do and do not attend to our wellness. Wellness is a foundation of our profession, yet many of us struggle with it. In the coming years, we will need to address wellness more intentionally as it impacts multiple aspects of our physical, spiritual, emotional, cultural and social sense of being. Wellness needs to be a priority instead of an afterthought for ourselves, as well as our clients, as we navigate changes in our society.

Brandon Ballantyne is a licensed professional counselor, national certified counselor and certified clinical mental health counselor who works at Tower Behavioral Health (Acadia Healthcare) in Reading, Pennsylvania.

I have been a licensed professional counselor for eight years, practicing in varying levels of care that include outpatient, inpatient and partial hospitalization. I believe strongly in the utilization of cognitive behavioral therapy to address symptoms of depression and anxiety that bring individuals into their respective treatment settings.

A silver lining is defined as a sign of hope or positive aspect in an otherwise negative situation. For most, whether in therapy or not, silver linings have been challenging to find in the midst of the COVID-19 pandemic. The pandemic has triggered an increased frequency of depressive thoughts and anxiety-driven behaviors that has culminated in significant psychosocial dysfunction for individuals across the board.

Based on my clinical experience, there has been an increase in suicidal ideation, substance dependence, avoidance, isolation, hopelessness, neglect of self-care, and an overall disengagement from healthy support systems. From a cognitive behavioral context, there has been a need to incorporate a larger emphasis on addressing cognitive distortions that exacerbate the distress-related patterns noted above. I anticipate an opportunity for psychoeducational services to serve a larger role in helping individuals understand the source of their symptoms.

Before symptoms are effectively resolved, it is critical to gain an understanding of where they come from. Symptoms are valid. Symptoms have an origin. The cognitive model can help individuals understand the relationship between stressful events, thoughts, emotions and reactions. Socialization to this model can provide individuals who may not currently be in treatment an opportunity to gain basic awareness of their emotions and basic cognitive restructuring skills presented through an introductory thought log workshop.

Based on my experience, when individuals gain a basic understanding that their emotional symptoms are directly related to their thoughts, and that their thoughts are essentially “sentences” that can be restructured to reduce distress, the result is an experience of validation and a greater sense of control over feeling better and doing better.

I would like to see psychoeducational workshops with an emphasis on basic cognitive behavioral therapy implemented inside of primary care physicians’ offices, community centers, libraries, recreational establishments and fitness centers. The next five years will bring greater opportunity for counselors to reach individuals in their respective communities who may have never had therapy or entered treatment.

Standardized psychoeducational services like the one I have described can assist in creating an easier entrance into therapy services, reduce stigma related to mental health, and reinforce maintenance of emotional well-being as part of routine medical care.

The COVID-19 pandemic has been a worldwide trauma that has led to significant hardship for most. My personal therapeutic philosophy emphasizes that even in the most difficult traumas or challenges, there is a productive lesson, important meaning or strengthening of resilience that can emerge. These constructive conclusions can be extremely difficult to find. They are not often found in our automatic thoughts. They are more likely to be discovered in the practice of cognitive restructuring, positive affirmations and coping thoughts.

Counselors need to take advantage of the upcoming need for standardized psychoeducational workshops in the community. It is our role to begin to offer a blueprint for those much-needed “silver linings.”

Dee Wagner, a licensed professional counselor and dance/movement therapist since 1993, is the originator of Chi for Two-The Energetic Dance of Healthy Relationship.

I predict that within the next 10 years, counselors will recognize all therapeutic work as bodywork — an energetic dance that facilitates self-regulation. Now that scientist Stephen Porges’ polyvagal theory has clarified trauma patterning, attachment styles and the role of oxytocin in social interaction, I predict a blossoming of appreciation for one key aspect of the work of child psychiatrist Judith Kestenberg and colleagues, especially dance/movement therapist Susan Loman. Kestenberg and colleagues identify infant rhythms that alternate between ones they call “indulging” and ones they call “fighting.” The indulging rhythms tend to match with parents’ movements, while the fighting rhythms mismatch.

How parents react to the mismatching rhythms plays a role in what Porges calls co-regulation, versus the relational “dances” that result in co-dysregulation. Co-regulation and co-dysregulation name the pinball-rapid passing of responsiveness back and forth between people, which can either facilitate the kind of calming that Shelley Taylor named “tend and befriend” or send us into a fight/flight response.

Fighting: The infant fighting rhythms and the mismatching dances help us individuate within relationship as long as these moves do not trigger fight/flight in our caregivers. Ideally,
as babies, we become aware of our bodies as we squirm in the arms of our parents.

I invite you to experiment with this “dance.” You might push your hands into a desk in front of you or go to a wall and push into it with one foot forward and one foot back. The harder we push into something outside of ourselves, the more we feel into our core. We gain core-to-hand and core-to-foot mindfulness. “When I push into what’s not me, I find me.” This me/not-me dance facilitates social justice.

Once we find ourselves, we have space for curiosity about others. In the me/not-me oppositional dance, we find our ability to support our heads and spines. We find core-to-limb strength that launches us into crawling, walking, running, galloping and skipping. We playfully engage with others. When we become adults and create businesses, we do not want to kill the competition. Who would we play with?

Porges’ polyvagal theory has revolutionized therapeutic practices. The way that polyvagal theory aligns with longtime trauma expert Peter Levine’s understanding of trauma patterning has allowed counselors to better understand human behavior.

I predict that in light of Levine’s studies, polyvagal theory will help counselors better sense the two different dances of activation and calming we have in our bodies — one for when we sense safety and the other for when we sense life-threatening danger. This idea of two activation/calming dances resonates with what attachment theorist Mary Ainsworth recognized as two main attachment styles: secure and insecure.

Results from the Adverse Childhood Experiences study are helping counselors recognize birth, infant and intergenerational trauma patterning. I see the studies of the neuropeptide oxytocin done by scientist Sue Carter helping counselors appreciate how developmental dances play out in our adult relationships. Before the work of Carter, oxytocin was mostly associated with birthing and nursing. Now we are seeing its role in all social interactions. With knowledge of the alternating matching and mismatching infant/parent dances, counselors can begin to see how appreciation of infant fighting rhythms facilitates the “dance” of productive debate in adulthood.

Recognizing the role that infant fighting rhythms play in healthy individuation will help counselors better “dance” within the therapeutic relationship. Clients will become more empowered and consciously use their counseling experiences to finish their unfinished infant/parent dances. A playful sense of self will emanate, facilitating living and working together more creatively.

Douglas Guiffrida is associate dean for graduate studies, a counseling professor and director of the mind-body healing and wellness advanced certificate program at the Warner Graduate School of Education and Human Development, University of Rochester, and has a private counseling practice focused exclusively on healing chronic pain.

According to a 2016 study by the Centers for Disease Control and Prevention, chronic pain affects more than 50 million Americans, which is over 20% of the adult population. The same study reports that a staggering 20 million Americans suffer with severe or debilitating chronic pain. In addition, chronic pain is estimated to cost Americans $635 billion a year in medical costs and lost productivity. People suffering with chronic pain are also likely to experience a host of comorbid psychological conditions such as depression, anxiety and sleeplessness, as well as being at high risk for opioid addiction. Chronic pain, therefore, is one of our country’s most pervasive and costly medical issues.

Unlike acute pain, which is short term and alerts people to an injury that needs treatment or rest, chronic pain is long term, often begins without an injury or, in the case of injuries, lasts beyond the normal time of healing. While acute and chronic pain have historically been conceptualized and treated the same way, research now indicates that they are actually two different conditions. In fact, a growing body of MRI research suggests that many forms of chronic pain are actually related to neuropathic processes in the brain rather than structural damage.

This awareness regarding the role of the brain in chronic pain has dramatically increased interest in mind-body counseling approaches and created significant opportunities for counselors to become leaders in the treatment of chronic pain. One psychological approach that has shown promise in the treatment of chronic pain is mindfulness. The practice of mindfulness, which has existed for over 2,500 years, was introduced to Western medicine in the 1970s by Jon Kabat-Zinn, who founded the Mindfulness Based Stress Reduction Clinic. While research indicates that mindfulness shows only moderate effects in curing chronic pain, it is highly effective in improving the psychological symptoms and physical limitations experienced by people in chronic pain.

A second psychological approach that has shown significant promise not just in improving psychological symptoms and physical limitations, but in actually curing many forms of chronic pain, comes from John Sarno, a physician and pioneer in mind-body medicine. Using the work of Sigmund Freud, Sarno theorized that many forms of chronic pain are actually created by the subconscious mind as a means to distract (or protect) us from experiencing painful emotions such as anger, rage and guilt, which we learned as children to be unacceptable and even dangerous emotions. His approach focused not only on helping his patients experience and express painful emotions, but also on psychoeducation about the psychological causes of pain and behavioral modifications to break the pain-fear cycle. Sarno’s theory has garnered a great deal of attention recently, and numerous studies by physicians and researchers such as Howard Schubiner, Mark Lumley and Allan Abbass support the efficacy of his approach.

Due to the counseling field’s emphasis on holistic and wellness-focused approaches, counselors are uniquely positioned to become leaders in the development and delivery of chronic pain counseling using mindfulness, psychoeducation, behavioral modification and emotion-focused approaches. In a Counseling Today article titled “A counselor’s journey to healing from chronic pain” (July 2020), I articulated how I implement these approaches in my private counseling practice to heal clients from a wide range of chronic pain conditions. Readers interested in learning more about this significant opportunity for counselors should consult this article. Readers may also consider learning about mind-body approaches by enrolling in the new online advanced certificate program in mind-body healing and wellness at the University of Rochester.

Susan Furr is a professor in the counseling program at the University of North Carolina at Charlotte whose areas of interest include professional competency in counselor education, college student development, and grief and loss issues, with particular emphasis on grief and substance use.

When considering the future of our field, it is difficult to separate my views of the future from the current challenges our country is facing. In just a few months, counseling made an abrupt shift in how we teach and how we offer services. I am both amazed by and appreciative of how quickly our field has adapted to the need for online learning and counseling. Technology has become essential to what we do, so our goals for the future need to focus on the research and development of effective online counseling services as well as examining the best practices for online teaching to prepare our future counselor educators to employ a variety of teaching methodologies.

The challenges of the pandemic have created a growing need for mental health resources and revealed cracks in service delivery. With increased issues with substance dependence, we need to make sure all counselors are prepared to assess for substance use disorder and provide appropriate treatment and referral if needed. Although training in addictions has been added to our professional standards, too many counselors do not feel adequately educated to address these issues. There is a tremendous opportunity for counselor training programs to expand educational opportunities in the area of addictions counseling.

The levels of depression and anxiety created by the pandemic have shown us that we need to broaden our concept of grief counseling to include losses beyond those associated with death. While many families and friends are mourning the deaths of those they love, many more are grieving the loss of the normalcy of daily life. The impact of these losses may emerge only over time because of our tendency to minimize the meaning of non-death losses. Missed family connections; lost life events such as weddings, graduations and proms; and disruption of daily routines of work and school need to be recognized as losses that impact our moods. We feel sad but don’t understand our need to grieve. Counselors need to be prepared to understand grief and create space for clients to explore the meaning and ways to cope with these “small” but ongoing losses.

We are increasingly a nation of traumatic events, but perhaps our growing knowledge of neuroscience is creating one of the most exciting times in our field. As we evolve a deeper understanding of neuro-informed counseling, we have the opportunity to improve our ability to train counselors in their capacity to assist clients dealing with the intersecting areas of trauma, crisis and grief. These are specialized skills that are needed by all counselors but often are not addressed in depth in counseling programs. Allen Ivey and colleagues have emphasized how our current theories and approaches are validated by neuroscience and how we can use this knowledge to improve our counseling approaches. Continued research needs to emerge in this area, particularly in examining any differences in online versus in-person counseling.

The emotional turmoil created by social inequities has highlighted the need for the counseling profession to continue to engage in social justice activities. We must address this concern on multiple fronts. First, increasing the diversity of students entering both master’s and doctoral programs is essential to providing counselors who match the diversity of our clients. Next, all counselors need to understand the impact of systemic racism on clients if we are to help clients address external issues that influence personal growth. In addition, we need to be politically informed and involved in helping change policies in ways that benefit mental health.

Peter Allen is the integrated care supervisor at Brightways Counseling Group in Madras, Oregon, and enjoys working with adolescents, adults and couples experiencing a wide variety of mental health challenges.

It is probably safe to say that the next 10 years in the counseling profession are certain to be both fraught with peril and bursting with possibility for new discovery and advancement in the field. If the global COVID-19 pandemic has taught me anything as a counselor, it is that everything we know and love is delicate in some way or another. This is not necessarily something to bemoan; some of the most priceless things on Earth are extremely delicate, and their value is in direct proportion to their fragility. I hold this lesson near every day as I consider my own relationships and what the future may hold for my colleagues and myself. If we acknowledge the tenuous nature of things in general, perhaps we can grow our appreciation of everything in real time.

Before the pandemic, who among us recognized that we had long taken for granted seeing clients in person and that we would ascertain the true value of these meetings just as the possibility of continuing them began to slip away? Certainly not me. It has been quite a change for me, and I suspect for all of my colleagues as well. We have had to rapidly pivot from seeing everyone in person and creating a healing physical space, to seeing everyone on a computer screen and doing our best to create a new healing space in the digital sphere. Telehealth is truly a wonderful option for us, as it allows us to continue providing therapy during this time, and it has most likely changed the way the profession will operate in perpetuity. I am grateful that we have an option for continuing to do our work, and one that allows us to provide for our families during this time of great uncertainty.

The biggest challenge in the next few years, in my humble opinion, will be taking care of ourselves in an honest and complete way. Clinicians are all taught to practice self-care, although it has been my observation that most of us are better at giving lip service to this than actually setting up our lives to include it in an effective and meaningful way. Being a therapist is difficult enough in “good times.” I add the quotation marks because our society is rightfully starting to reckon with the fact that people of color and other marginalized communities have not had a chance to share in those “good times.” So, we are challenged to take care of ourselves so that we can show up well for our clients, and continually try to expand our awareness of what those communities have faced for centuries. This will require us to examine long-held beliefs and practices and to evolve clear-eyed and willfully. Change is the only constant, and there is no victory over it to be had. One either makes peace with it or is defeated by it.

However, as always, moments of challenge and disruption create significant opportunities for growth in the long run. I believe the biggest opportunity for clinicians in the next 10 years will be in advancing social justice causes. We have a wonderful opportunity to include and listen to more voices in the conversation, acknowledge the validity of their experience, and serve as humble allies in the long march to equality. Victor Hugo once said, “Nothing is more powerful than an idea whose time has come.” Indeed, the social justice movement is a long-simmering idea whose time has come. We are ready to meet this moment with bravery, compassion, strength and humility.

Michelle Muratori, a senior counselor at the Johns Hopkins Center for Talented Youth and faculty associate in the master’s counseling program at Johns Hopkins University, has co-authored several ACA publications, including the third edition of Clinical Supervision in the Helping Professions: A Practical Guide, Coping Skills for a Stressful World: A Workbook for Counselors and Clients, and Counselor Self-Care.

As it is challenging to accurately forecast what will transpire over the next five to 10 days in these turbulent times, I find it even more difficult to predict the changes and challenges counselors can anticipate over the next five to 10 years. If the dysfunction and divisiveness in society persist at a heightened level, I fear counselors will be vulnerable to experiencing burnout, vicarious trauma and compassion fatigue at increased levels. The toxic political environment of the past four years has emboldened those harboring racial animus and xenophobic attitudes to display their hostility and hatred openly and proudly, sometimes with deadly consequences. Moreover, COVID-19 has killed hundreds of thousands of Americans, yet an alarming number of people still consider it a “hoax.” These disturbing developments have left people, including counselors and clients, feeling exhausted, stressed and traumatized.

I will speak for myself. During the weeks, days and hours leading up to the 2020 U.S. election, and after four excruciating years of witnessing democratic norms being eroded daily by our elected officials (and one in particular known for his rage tweets), I was consumed thinking about the fate of our democracy. I often wondered, will democracy win? Will social justice prevail? For that matter, will science prevail? Or will fascism replace democracy, will disinformation and conspiracy theories continue to spread and be embraced over facts, and will white supremacy, structural racism and tribalism continue to be actively promoted?

After the election, like millions of Americans, I was overjoyed and relieved that Joe Biden and Kamala Harris had prevailed. Ecstatic over the historic election of the first African American and South Asian American woman to serve as vice president, I felt like a ton of bricks had been lifted from my shoulders and that my hope for justice had been renewed. I remain optimistic that this new administration will restore dignity to the office of the presidency, repair America’s relationships with allies around the world that have been damaged, and provide us all with hope for a better and more stable future. Despite my optimism, insidious threats that jeopardize democracy continue to weigh heavily on me. It is of great concern, for instance, that the occupant of the White House at the time I am writing this, enabled by high-ranking officials who supported him, refused to concede the election and instead spread dangerous conspiracy theories about it being “rigged” or “stolen.” My heart sank when I saw yard signs that read “Stop the Steal” and “Voter fraud!!” The knot in my stomach reminds me of the painful reality that we still live in an extremely divided nation, one in which people cannot agree upon facts — a nation where a dislike of the “other tribe” is so powerful and runs so deep that it has created a context in which fake news has gained traction and attracted a massive audience.

This brings me back to my prediction about the future. My guess is that counselors will be on the front lines dealing with the emotional fallout of sociopolitical, public health and environmental crises for years to come — crises fueled by the rapid transmission of information (and disinformation) via electronic media. Counselors must be prepared to help clients process their reactions to and cope more effectively with these stressors and also advocate for social change. Counselors should closely monitor their countertransference triggers and be cognizant of how their own worldview may distort their perception of clients holding opposing worldviews. While this has always been important, counselors must be all the more vigilant in polarized times. Lastly, counselors must be committed to practicing self-care regularly to actively combat burnout, vicarious trauma and compassion fatigue. To end this on a positive note, I believe that counselors and the counseling profession will be more relevant and in greater demand than ever.

Kevin Doyle is a licensed professional counselor from Charlottesville, Virginia, and an associate professor and chair of the Department of Education and Counseling at Longwood University in Farmville, Virginia.

I think that the most significant development — with elements of change, challenge and opportunity — over the next five to 10 years will be the continuation of the widespread move to virtual service delivery. Delivery through virtual platforms is, of course, not new, but the COVID-19 pandemic forced counselors to adapt on the fly, and many who had not delivered services in this manner had to shift quickly to a new way of working with clients. I would like to comment on each of the three areas noted above: change, challenge and opportunity.

Change: Many of us counselors were trained to provide services only in the in-person environment. I think it is fair to say that some of us looked down our noses a bit at counseling provided through a computer, the internet, etc. Well, we have been shown to be mistaken, in many ways. In my own practice, clients have enthusiastically embraced online service delivery, both for individual and group sessions. They note that things like travel time, parking, weather issues, child care and family responsibilities are minimized when services are provided online. Many have indicated that they wish to remain online permanently.

Challenge: A major implication of the above is that counselor training programs need to include training counselors for online delivery in their curricula. The obvious challenge there is that a significant percentage of counselor educators were trained before online service delivery was common or even existed at all. Getting the educators up to speed on not just the use of online platforms but also how to teach students how to provide services in that manner is a major challenge facing the field. Likewise, accrediting bodies (such as CACREP), certification bodies (such as NBCC) and state licensing boards will all need to make sure that their regulations reflect the recent massive move to online delivery — and the training of those who will be providing it.

A related challenge will be how to accommodate those clients who truly desire in-person service delivery. I have heard reports already of counselors closing their physical offices because they were no longer cost-effective or needed. What will become of those clients who are not interested in online service delivery in such scenarios? Furthermore, there is an equity issue here. Not all clients have functional computers, smartphones or reliable internet access. Will marginalized populations become even more marginalized? The profession has an obligation to ensure that this does not happen.

Opportunity: This move to online or virtual services, of course, also provides a major opportunity. Even though this type of service is not new, it is infinitely more commonplace now. Clients have access to more services from more providers than ever before. State licensing laws, however, can still be barriers because, generally, counseling has been considered to occur where the client is physically located. The current environment presents a tremendous opportunity to enhance access to care for clients. Initiatives such as the current ACA-led interstate counseling compact may finally help to allow counselors to practice in more than one state without having to go through multiple onerous licensing processes. Whatever means are undertaken to address these barriers must prioritize client safety, emergency procedures and the reality that not all counselors practice ethically and safely, unfortunately. This may be a once-in-a-lifetime opportunity, driven by the global pandemic; it is up to the profession to take advantage of the current, albeit tragic, circumstance.

Christian D. Chan (he, him, his) is a national certified counselor and an assistant professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro.

The year 2020 represented a set of crossroads to allow our profession to do better and be better for ourselves and the communities we serve. Although 2020 culminated in explicit forms of white supremacy, anti-Blackness, health disparities and trauma, I have to remind myself and my colleagues that these issues have persistently shown up over and over again. Sadly, these forces date back several centuries, and many are not entirely external to our profession. In fact, they are conceivably within the auspices of our profession, and our profession is still navigating, resolving and reckoning with them during this time. They are here in our own home.

My hope, however, is that 2020 represents that radical shift for us to revisit our professional identity grounded in multiculturalism, advocacy and social justice. I ask myself again about the next era of counseling to revisit this identity as we practice, teach and advocate. One opportunity for us to consider as a profession is the impact driven by community partnerships and community-engaged initiatives.

Readers may think I am referring to a plunge, legislative advocacy or a cultural immersion project, but community engagement is so much deeper. It is an opportunity for each of us across several specialties (e.g., clinical mental health, school, couple and family, rehabilitation, college) to intentionally build partnerships with stakeholders and invite the cultural capital that already exists across culturally diverse and historically marginalized communities. It is our method of creating equitable partnerships with community stakeholders and community leaders. Many historically marginalized communities already sustain and own the tools, knowledge and wealth of cultural capital within their own communities. This valuable cultural knowledge has also been passed down generationally over centuries. Community partnerships become a way to signify that their lives and stories — often stories that counter oppression — ultimately do matter.

Community partnerships and engagement can be implemented across numerous sectors within the counseling profession. For instance, counselor educators can design a major class assignment that addresses counseling and mental health literacy among community members. Counselor educators and their students can collaborate with community leaders to angle their counseling literacy and mental health literacy initiatives in culturally responsive ways. Within community agencies and schools, community-engaged projects similar to these ideas can also identify pathways for community stakeholders and members to feel empowered to access their counseling services. Julia Bryan’s work in school-community-family partnerships is a serious testament to employing culturally responsive partnerships to further engage culturally diverse and historically marginalized students, especially students who are Black, Indigenous and people of color. I ask counselor educators and counselors, however, to intentionally build these partnerships and sustain them, so that they seek continuous input from community stakeholders and leaders rather than making them one-time events.

Professional associations are not removed from these possibilities. For instance, ACA divisions such as the Association for Specialists in Group Work and the Association for Multicultural Counseling and Development have enacted a Day of Service to coincide with contemporary issues of multiculturalism and social justice and to meet in partnership with local communities surrounding conference venues. Because professional associations hold a significant role of leadership within the profession, they can continue modeling and providing these opportunities for members to intentionally engage with their own communities.

When I ask myself again about the opportunity for the profession, we can be bolder, think critically and institute crucial community partnerships to further engage our communities. Although community-engaged initiatives and community partnerships have existed, I call our profession to further expand these opportunities in teaching, supervision, practice and service. These relationships can play a part of the healing in our society, and I have hope that we can still dream bigger and better together as a community and in solidarity.

Jude Austin is an assistant professor and clinical mental health counseling track coordinator at the University of Mary Hardin-Baylor, an American Counseling Association book author, and a private practitioner in Temple, Texas.

Change: Paradoxically, everything and nothing will change over the next five to 10 years for the counseling profession. What works in counseling — building a strong therapeutic relationship — will continue to work. Although, how counselors build that therapeutic relationship will change by varying degrees. The change is already happening as the global pandemic pushes counselors into virtual or some hybrid form of practicing counseling. To meet clients’ needs, counselors changed how they meet clients. Counseling no longer just happens in cushy offices. Counseling is on the go.

Portability is the future of counseling. Not only state-to-state clinical licensure portability, but counselors themselves are, and will continue to be, portable. Therapy will occur through multiple platforms: in-person, synchronous phone and video, asynchronous and synchronous messaging, a combination of those options, and more. Clients will come to counseling while driving to work, in a tractor during lunch breaks, while folding laundry, sitting on the porch or holding a sleeping baby. Counselors will need to meet clients where they are, wherever they are.

Challenge: That change will challenge how counselors meaningfully meet clients in the next five to 10 years. How do we ethically and morally provide care for a mom who is working through trauma, while her children are audibly making a ruckus in another room? This essay does not have the space to unpack all ethical concerns. However, the mandate of doing no harm will be expanded. While counselors will become more accessible, clients face greater risk of unintentional harm as counselors adjust to new therapeutic milieus.

While there may have recently been a collective competence growth in telecounseling, competence does not equal quality. Being with clients through multiple platform options may not be a natural way of doing counseling for some clinicians. Some counselors grew up developing virtual relationships. Others might scoff at digital communication. Regardless of the counselor’s era, all counselors will need to develop different communication skills and sharpen their perceptual senses to be effective over the next five to 10 years.

The common factors of effective counseling will look and feel differently through text compared with face-to-face sessions. Remaining present can be difficult while the trash truck decides to drive through the entire neighborhood in reverse during a session. Offering clients genuineness, unconditional positive regard and empathy in a message might feel both familiar and strange. Doing so will require developing a different therapeutic muscle.

Counselor educators will be challenged to prepare students for these new ways of being with a client. Some students are fair writers but shine when face to face, and vice versa. In the next five to 10 years, students will have to see all elements of communicating with clients as an opportunity to build a strong therapeutic relationship. Ways of assessing students’ abilities might change. Basic counseling skills might include a certain level of tech savviness. Professionalism might include emails or message response time. Professional attire might include lighting, pictures and other visible items during a virtual meeting.

Opportunity: Perhaps a silver lining throughout the changes and challenges counselors will face in the next five to 10 years is the demand for more highly skilled clinicians. If my caseload is any indicator, therapy has become “cool.” Finding a good therapist is like finding a good pair of jeans, and clients are shopping. Portability will give clients more options to find the best fit. This will be threatening for counselors who make their living based on clients’ limited service options. All counselors will have an opportunity to raise their game, which can only better serve clients.

Ann Ordway is both a lawyer and a counselor educator, serving as the college academic director of counseling for the University of Phoenix.

The year 2020 has presented so many challenges that I predict will have a lingering impact well into the next five to 10 years. Not only have we faced an international pandemic that has resulted in significant illness and death, but we have also become more isolated from one another, and the way we interact with others has been forever changed.

Individual experiences of grief and loss carry an unfamiliar complexity as mourners have been unable to sit with a dying loved one in the hospital and then been unable to engage in traditional mourning rituals due to restrictions on public gatherings. We have been challenged by a level of civil unrest largely influenced by a controversial election and a justified movement designed not only to bring attention to social injustice but also to increase multicultural awareness, competency, sensitivity, inclusion and respect. There is so much work ahead of all of us.

Of course, with these challenges, we have experienced drastic increases in depression, anxiety and overt manifestation of mental health issues. Moreover, with requirements for social distancing, more people have been working from home. Live conferences have essentially gone away — and the most social beings grieve the loss of personal contact. Families have been relegated to FaceTime. Children, during a stage in their development when socialization is critical, have been attending school online or are restricted from meaningful interactions with peers. I suspect we will see the continued emergence of nuances of posttraumatic stress disorder because the experiences of 2020 have clearly taken a toll. As counselors, we will need to be prepared to support an increase in the number of clients seeking services.

Self-care will become more essential as we navigate the uneasy waters that will continue to be present. We will need to be mindful of compassion fatigue, vicarious trauma and burnout, especially as we endeavor to be life preservers for our clients who are desperately trying to find a new normal. We have not been insulated. We have been personally and professionally impacted — and we need to rise to the challenge while also finding our own new normal, both in how we live and practice.

With challenges also come opportunities. Counselors are role models for patience, empathy and endurance. I suspect we will be called upon to model social interaction as clients start to relearn the art of interpersonal relationship and communication. We are well-trained, and with an increased need for services, I suspect counselors will be busier than ever before. Our focus on self-efficacy will serve us well in helping our clients build resiliency and coping skills and bounce back from the pervasive impact of the extensive societal trauma of 2020.

Counselors are flexible and adaptable professionals, and in an ever-changing world with old challenges persisting and new challenges emerging every day, we are uniquely situated to support the very many people who do not share our resiliency. We will be more involved and more highly regarded over the next five to 10 years in arenas where our previous presence has been scarce, including with Medicare, in Veterans Affairs locations, and in court proceedings as experts. I see us growing and emerging as a stronger collective group of professionals as we move through the next decade — and I, for one, am excited about the emerging opportunities as we move forward. It is not just about where we have been, it is where we are going.

Laura Shannonhouse is an associate professor at Georgia State University whose research centers on crisis intervention and disaster response.

The surreal reality of 2020 has emphasized one sad truth: Too many people are far too isolated. Our collective, individualized suffering is an ironic tragedy, and it literally costs lives. Struggling to belong cuts across the life span and widening class divides. From older persons who are homebound to bullied adolescents, and from those who agonize over how to best craft a social media post to those consumed by the drudgery of excessive working hours, all too many individuals are unacknowledged, are unconnected and feel unloved.

When we look at the history of our profession, one typically forgotten and ignored group has been older adults, which happens to be the fastest-growing demographic and the hardest hit by COVID-19. Millions of older adults have struggled with isolation, worthiness and mattering, yet gerontological counseling was dropped as a specialty area, and structural barriers (i.e., Medicare reimbursement) have made working with this population difficult. During COVID-19, physical distancing interventions needed to protect older adult health have been isolating, and medical ethical guidelines that prioritize the care of younger patients signal the expendability of older adults. As research has shown, chronic loneliness and social isolation foster thwarted belongingness and perceived burdensomeness, which interact to predict suicide desire. On average, an American over age 65 dies by suicide every hour. Many other suicides go unreported (i.e., voluntary stopping of eating and drinking, withholding of medical treatment, etc.) or are miscategorized as accidents. COVID-19 has exacerbated the psychological states which lead to suicide, and those deaths of despair punctuate the point that too many people, of all ages, have decreased quality of life because of their isolation.

Fortunately, suicidality is highly susceptible to intervention, and professional counselors are uniquely equipped not only to effectively intervene, but also to foster growth through adversity. Combating social isolation, fostering belongingness and buffering perceived burdensomeness interrupts the pathway to suicide. Because we are also researchers, we are well-positioned to collaborate with policymakers and federal entities that want to address social problems. Scholarship on outcomes from evidence-based approaches can drive policy. As a multiple recipient of Health and Human Services funding, I’ve had opportunities to dialogue across agencies (i.e., Administration for Community Living, SAMHSA, Veterans Affairs), which has been incredibly hopeful. When we come to the table with innovative solutions grounded in rigorous research at the systemic level, we can and do make a difference. One example of this is a prolonged campaign of lobbying that has almost made Medicare reimbursement for professional counselors a reality (kudos, ACA!).

At the individual level, when we connect with older adults, we have the opportunity to learn from their incredible wisdom, lived experience, resilience and insight. My lab (HOPE lab) at Georgia State University works with approximately 700 racially diverse older adults, and my students remind me, “If we are lucky, we will one day be future older adults.” The upcoming generation of future clinicians and educators is smart, hardworking, big-hearted and critically conscious.

They and you can be at the forefront of the solution to the social isolation problem. It is pervasive across populations and will undoubtedly be part of our clinical work, no matter who our clients are. Professional counselors have the tools to do this work, and we can be creative, strategic and persistent. I think that over the next decade, our greatest challenge will be engaging with systems to foster meaningful, reciprocal, prolonged connections for all persons. Humans are by nature social creatures, and professional counselors have the opportunity and responsibility to ensure that truth is validated, supported and realized.

Anabel Mifsud recently earned her doctorate in counselor education and supervision from the University of New Orleans, where she is currently teaching as an adjunct professor.

Our ability to predict the future has never been so sorely tested as in 2020. The unprecedented events of the past year were a sobering reminder that the inconceivable can happen, but they also illuminated a range of issues that have the potential to shape the future of the counseling profession in the next decade.

The COVID-19 pandemic not only has endangered people’s physical health, but also has put a strain on vital social connections that sustain our mental and social wellness. Advancements in technology, however, have enabled counselors to continue serving clients and communities in these trying times. The benefits of technology in counseling have never been in plain view until 2020, and the increased reliance on technology is here to stay.

As technology continues to proliferate and wield greater influence on the counseling profession, counselors need to be increasingly mindful of the clinical, ethical and social justice implications pertaining to the use of technology in counseling practice. Counselors are required to become savvier consumers by broadening their knowledge on the inner workings of these tools and their impact on client welfare and therapeutic success. We cannot afford to drag our heels on this front or relegate this responsibility to computer scientists. Additionally, counselors must advocate with technology developers for technologies that are tailored to meet the needs of diverse clients and promote equitable access to behavioral health services.

The disproportionate toll of the COVID-19 pandemic on people of color and the racial reckoning that ensued after the killing of George Floyd have laid bare the persisting social inequalities and systemic racism that threaten the lives and mental health of Black, Indigenous and people of color. As the counseling profession journeys forward, it must remain committed to its social, moral and ethical obligation to advocate for inclusive, just and safer healing spaces and societies. When one considers the highly charged and polarized sociopolitical landscape that we find ourselves in, the stakes have never been higher, nor have the opportunities for growth.

Counselors are uniquely positioned to help repair the rupture in our social fabric and redress social ills through healing and reconciliation efforts. Such a lofty pursuit, however, cannot be championed by any single profession. In these pivotal times, we must join with professionals in other disciplines to promote a culture of compassion, healing and respect for human dignity. Interdisciplinary cooperation is our best shot to address some of the macrosystemic challenges facing our human family. Additionally, the sheer magnitude of these problems highlights the need for more collective interventions, and thus the counseling profession may have to refashion how it pursues its goal to empower people to attain mental health and wellness.

Climate change is another looming crisis that has already wreaked destruction and mayhem across several communities in the U.S. It is another existential reckoning of sorts, and human survival hangs in the balance. It is a challenge that the counseling profession cannot sidestep. Counselors need to be fully equipped to help affected communities deal with the psychological and emotional costs of this existential threat and rebuild in the wake of disaster. As a profession that is grounded in the wellness model, counselors must go beyond remedial action and engage in preventive measures that can help communities develop climate resilience and advocate for sustainable lifestyles. It is an opportune time for the counseling profession to align its mission and efforts with some of the global goals endorsed by international organizations such as the United Nations and take a seat at the table with other experts to address global challenges that transcend national borders.

Sylvia Nassar is a scholar, leader, advocate, mentor and counselor educator at North Carolina State University.

I used to tell my kids, “Today is the first day of life as we know it!” They rolled their eyes then but are experiencing that phenomenon firsthand now. The present-day twin pandemics illuminate the priorities for which the counseling professional was already poised, as well as ones that may have been less obvious. Evolving service delivery models, social justice advocacy, workforce development and expanded counseling interventions represent foci for professional counselors in the upcoming decade.

I recall what a controversy was stirred up many years ago when the NBCC rolled out its ethical guidelines for distance counseling. I also remember serving my state’s LPC board some years later and grappling with the definition of “face-to-face” counseling. Counseling, and its service delivery, will likely never return to what it was before 2020. Regulatory, credentialing, educator and many other stakeholder groups have done admirable work trying to adapt to the COVID-19 pandemic in flexible and ethical ways. These efforts will continue to require creative and reflective professionals to redefine and update credentials accordingly.

The parallel pandemic of exposed structural racism illuminates the need for true multiculturalism and social justice competence and reform. Certainly, the recent unmasked cases of police brutality, particularly perpetrated against Black men, warrant alarm and immediate action. Restorative justice and other Black Lives Matter initiatives need to be mandated, not only in words, but through active advocacy. At the same time, we need to balance the growing knowledge base about intersectionality for all marginalized groups from a social justice lens. Hate crimes against so many marginalized groups hit all-time highs during the Trump administration. The tension between these concomitant yet seemingly conflicting goals creates tenuous balance. The counseling profession needs to learn how to use politicization as a tool rather than allowing it to become a distraction. The Multicultural and Social Justice Counseling Competencies (MSJCC) can provide a helpful framework to guide practice, research and policy. In turn, emergent research will inform the next iteration of the MSJCC.

These phenomena are readily apparent within the broad sphere of the labor market both domestically and globally. Workplace inequities across intersectional marginalizations run rampant in all levels of the workforce. These pandemics underscore not only the social justice imperatives of a more-inclusive workforce, but economic ones too. True change will require that current power brokers share their power — in other words, that commitment to multilayered equity occurs both from the top down and the ground up. This power shift will facilitate actual changes rather than superficial ones. The restructuring of the labor market to meet the rapidly evolving pandemic needs provides both challenge and opportunity to level out playing fields while responding to crisis — “building the plane as we fly it,” so to speak. The voices of marginalized individuals and stakeholder groups must be heard. Organizations unwilling to buy into this post-constructivist ideology will become obsolete.

As far as counseling interventions, the growing need for biopsychosocial perspectives is apparent. Counseling and allied health professions need to become better collaborators. As a breast cancer warrior currently undergoing chemotherapy, I am aware of the ways in which our traditional medical practices fall short in terms of supporting mental and holistic health. Counselors and researchers have increasingly recognized the value of broader approaches — for example, mindfulness and neurofeedback. We need to join our interdisciplinary colleagues in creating new evidence bases for these emergent interventions.

Moreover, we need to incorporate mental and other holistic health indicators in all systematic program evaluations of counseling and counseling-relevant program and service delivery. These efforts will facilitate accountability among stakeholders. More importantly, program evaluation should inform counseling practice, research and policy in a tripartite approach. This integration is the quintessential model of the 21st century.

Michele Kerulis is a licensed clinical professional counselor in Illinois and the Association for Multicultural Counseling and Development Midwest Region representative.

I think some of the most challenging things counselors have faced in our lifetime are related to the COVID-19 pandemic, and we will continue to navigate the difficulties of this time. I am pleased to see the community embrace technology as an asset to address many of these problems. While we have noticed the negative impacts of technology, like the fast dissemination of inaccurate information and cancel culture, we have also witnessed positive aspects, like teaching others how to conduct telehealth sessions, helping our older adult population learn how to use videoconferencing to connect with their families, and sharing free resources related to mental health with a wider audience. I have faith in my colleagues to be pioneers to advance the accessibility of counseling.

I am passionate about accessibility and about helping people learn about the positive impact of movement on mental health and wellness. One silver lining of the pandemic is that fitness studios offered free online fitness classes for all skill levels to help people feel a sense of control in an otherwise uncontrollable situation. One of the most significant opportunities for the future of counseling is for our field to recognize the impact of the mind-body connection and how movement and exercise can be a game changer for people on so many levels.

When people say they are intimidated to try exercise or movement to address wellness, I use encouragement from an Adlerian perspective, emphasizing effort over outcome and intrinsic motivation over external factors. I love using exercise and sports as analogies for how to create and live a successful life. Of course, the definition of success varies from person to person, and it is clear that people have unique circumstances, sometimes out of their control, that interfere with their life goals.

Examining these circumstances creates an opportunity for counselors to understand multiculturalism and marginalization in new ways. As counselors, we are responsible for understanding the barriers our clients face, for helping clients process these barriers and for advocating to have barriers removed.

A marginalized population within my specialty area of counseling includes people who have injuries or physical disabilities that limit their capacity to engage in activities. Physical disabilities, along with racial and socioeconomic discrimination, have resulted in exclusion and disrespect.

As a counselor who works with athletes and exercisers, it is not only my responsibility to understand human growth and development through the stages of life, it is also my responsibility to understand interruptions to stages of development, including injuries, illness and unexpected interference to people’s physical and cognitive states. This often-neglected population is provided with limited resources. Fortunately, there are several organizations dedicated to helping people who have experienced physical challenges engage or reengage in an active lifestyle. Organizations such as Dare2tri, Wounded Warrior Project, Special Olympics and Disabled Sports USA offer inclusive and supportive environments for adaptive athletes. In fact, many major sports, including marathons, cycling, basketball, snowboarding, surfing and weightlifting, have adaptive sports divisions.

My passion to help people of all physical abilities learn how to live balanced, active and healthy lives guided my career choices. I feel lucky to have the privilege to help clients understand how to navigate and process their own situations and to help them define and achieve their own ideas of personal success. I do believe that a major opportunity area for the counseling field is helping people of all abilities learn the joys of movement, enjoy more outdoor spaces and connect with one another through technology and group fitness.

Monica P. Band is a licensed counselor and owner at Mindful Healing Counseling Services in Washington, D.C., as well as an adjunct professor of counseling.

I want to preface this by saying that I do not believe this is a new challenge. Rather, it’s an ongoing challenge with a great opportunity for change. For many counselors, we were distinctly trained to do our best to distinguish between our personal selves and our professional selves — keeping boundaries clear. In this way, counselors continue to keep a veil of power and authority by distinguishing between client and counselor. However, COVID-19 and the increased use of telehealth has invited clients into our homes.

For some counselors, we do not have the privilege of having a separate or quiet home office. Rather, our clients begin to gain a deeper insight into our personal lives through the surroundings they see behind us. Additionally, COVID-19, globalization, social media and the sociopolitical climate of our nation blurred these boundary lines further. Counselors and clients are truly experiencing a global pandemic and existential crises together. For example, counselors are not unaffected by the racism within this country, and we should not pretend otherwise. This experience has me thinking about our profession and how we support our clients for the next five to 10 years.

For instance, I believe the psychological impacts of the pandemic will last for several years. Even in imagining a time in which we would transition in becoming more social through in-person engagement, we will need to begin to contend with anxiety, grief and complicated trauma. I anticipate that people will also be working on redefining their lives, as I have noticed some clients already doing. With experiencing an existential crisis often comes a confrontation of how one is living their life and the meaning they are making within the life they are given. I have worked with and witnessed clients struggling with and reconciling feelings of not living authentically and the grief that comes with missed opportunities when considering their mortality. The opportunity and gift I believe COVID-19 has given us is a chance to reconstruct rather than live in complacency. Both the challenge and the opportunity are for counselors to wake up and become activists.

I anticipate that counselors, if they are not already, will need to begin to become more competent and comfortable in thinking systemically and existentially on issues such as racism, climate crisis and COVID-19. Counselors have the challenge of no longer being natural or hiding behind a veil of power. I think the challenge and opportunity will be in the balance of making our stance on social justice issues known while being able to support both those who are like-minded and those who are not.

Victoria E. Kress is a licensed professional clinical counselor and supervisor, a national certified counselor, a distinguished professor, and the president of the Association for Humanistic Counseling.

Many evolving factors are sure to influence the counseling profession over the next decade. At this writing, America is wrestling with a global pandemic, a long-overdue reckoning with systemic racism and a politically polarized country. Climate change, exponential population growth and other factors will contribute to a further shortage of resources, and society will struggle with the conflicts that will ensue. However, as counselors, we know that all struggles hold opportunities for positive change. In fact, very often the most meaningful changes emerge out of conflict.

Many of the most important legislative decisions are made in times of crisis. It is important that counselors leverage the legislative and policy decisions that will be made over the next few years to help grow our influence and access to resources so that we can stay healthy and support our clients over the next decade.

Counselors are generally fierce advocates for vulnerable, disenfranchised populations, and client advocacy is foundational to who we are as counselors. That said, we are not always as good at advocating for ourselves as we are for others. While it is uncommon to speak of professional counselors as being discriminated against or oppressed, there are many examples of professional counselors not being accorded the respect and privilege associated with our training and credentials.

Some counselors may perceive that advocating for the profession is self-serving; however, we cannot do what we were trained to do — that is, help others — if we cannot practice in the way we were trained to practice or be reimbursed for providing services. As such, counselors must continue to grow as advocates not just for clients, but also for our profession.

Recent events have invited opportunities for all counselors to grow as advocates. Passion is the foundation of advocacy, and more than ever, we are seeing counselors express their passion. This passion can be used as an opportunity for counselors to learn about the legislative process and how to be effective in this arena. This past year, we also witnessed unprecedented numbers of Americans engage with the political process. This increased awareness of the legislative process and an understanding of how counselors can be effective legislative advocates is an additional opportunity we can use to support our profession as we move forward.

Many advances have been made around the growth of the profession. Most notably, we now have counselor licensure in each state, and we are able to be reimbursed by many third-party payers. We are, as a profession, enjoying a comfort we have not historically had, yet we have so much work left to do. The work never ends because daily, policymakers are making decisions that impact our ability to practice.

As we have seen in recent times and throughout history, when people are comfortable, they tend to not engage as much in the political process. Because counselors are not struggling mightily for recognition — as we have in the past — new and emerging generations of counselors may not understand the value and importance of sustained professional advocacy efforts, and this could be devastating to the health of our profession.

Recent events, while challenging and uncomfortable, have created opportunities that counselors can pull upon to support our profession, and thus the clients we serve. Moving away from spectatorship and toward active participation in political and legislative processes is critical to the sustained health of the counseling profession.

Sue Pressman is the president of the American Counseling Association, a private practitioner focusing on career development, a business owner, and an employer of counselor consultants for more than 30 years through Pressman Consulting LLC, with her largest client being the federal government.

What will the profession of counseling look like in the future? Often when people think about the future, they think of technological advancements such as hovercrafts, holograms and artificial intelligence. What about the importance of developing business skills that will help professional counselors become “business wise” ? All industries are going through a transformation to make services accessible to a multicultural and global society. There is intersectionality among peoples, services and currencies. Recognizing this, the business-wise professional counselor is poised to find increased and diverse opportunities to build their network in a domestic and global market and expand into what is being referred to as the gig economy.

The term gig economy has been around for decades and involves a temporary work arrangement with an individual being paid for a specific job, task or project. The latest U.S. Census Bureau nonemployer statistics report that self-employed individuals increased 19% from 2005 to 2015 and continue to grow. Gig workers can be service or goods providers such as musicians, entertainers, artists, retailers or trainers. They can be any worker not in a permanent position. The final component is the consumer. In the world of counseling, we may refer to ourselves as mental health, rehabilitation, career or employment counselors, just to name a few of our specialties. The final component or recipient of counseling services is the “client” or, in business terms, the consumer of our services.

How can counselors tap into this freelance “gig” workforce? The simple answer is for counselors to increase their business skills. To narrow the business skills gap, counselor education and supervision graduate programs might investigate weaving in basic business skill development into curriculums. This could include practice management, business development, accounting, finance, investing, marketing, strategic planning, delegation and negotiation. The pandemic has shown us that counselors are naturally resilient. When our in-person method of service delivery challenged us, we were quickly able to pivot and provide responsive services to those in need through new platforms such as telebehavioral health.

As we look to the future, counselors’ ability to adapt, create bridges and develop new skills is evident. The new world we live in has demonstrated, in the words of Sam Gladding, that “mental health is part of public health.” This is the beginning of our infusion into the mainstream public health arena and the gig economy where we will discover more opportunities for multiple income streams beyond a regular paycheck. The business-wise counselor will inevitably find new ways to innovate, influence and initiate systemic change on both micro and macro levels, resulting in counselors as consultants.

Counselors as consultants have existed in our profession for a long time. However, counselors thriving in a gig economy is something to consider for the future. Approximately 150 million people in North America and Western Europe now work as independent contractors. Gianpiero Petriglieri and colleagues conducted a study with 65 gig workers in 2018 and discovered that successful gig workers cultivated four types of connections: place, routines, purpose and people.

These four types of connections align with many aspects of counselors as consultants. Creating space, time, access and location are aspects when considering one’s place for conducting services. Those who had routines and schedules had enhanced focus and performance. As counselors, part of our purpose is to help others, and this purpose serves as a means to also earn a living. Finally, people such as our family, friends and colleagues can serve as supportive collaborators on our entrepreneurial journey.

“Success in the gig economy comes from a balance between viability and vitality.” — Gianpiero Petriglieri, Susan J. Ashford and Amy Wrzesniewski (2018)

Heather Trepal is the immediate past president of the American Counseling Association and a professor at the University of Texas at San Antonio.

The COVID-19 public health pandemic has changed our world. Although some say they can’t wait to get “back to normal,” the stark reality is that our world has forever changed, and we cannot go back to the way things were before. The pandemic has changed public health and shone a brighter light on health care disparities, and it will leave a trail of lingering physical, economic and psychological effects across the globe. The need for behavioral health care services will increase like never before.

Counselors must be prepared to meet this demand. There will be increased opportunities to develop integrated systems of care where physical and behavioral health care needs can be addressed together in new and innovative ways. In response, counselor training needs to be amplified to focus on preparing counselors to work as part of an interdisciplinary team. The counseling profession’s foundational focus on prevention and wellness will also become increasingly important.

Stigma and inequities in access to behavioral health care services will remain challenges. Counselors must be willing to be at the forefront of the battle. Stigma is a barrier to help-seeking. Others, such as professional athletes and celebrities, have become increasingly visible in their efforts to address stigma. However, counselors must also be prepared to do the difficult work of raising awareness about mental health. It is imperative that we increase our efforts to educate the public about who counselors are and what we do. Counselors need to break down barriers in service delivery and access and utilize upstream interventions to get ahead of the challenges in this area.

The increased focus on health care disparities will promote a much-needed awareness of their impact on access and care among professionals and the public. Racism is a determinant of physical and behavioral health care inequities. Anti-racism efforts will increase both in behavioral health care and in the counseling profession as a whole. Enhanced methods of counselor training, research and service delivery will be developed with an increasing eye toward social justice. Other inequities include language barriers. The profession must commit to recruiting and training bilingual counselors.

Finally, I believe the future will see a rise in counselors owning their role as advocates for our profession. We work hard to advocate for and with our clients to meet their needs. However, counselors also need to make certain that we have a seat at every proverbial table we can. We are a well-prepared profession. We need to be able to serve our clients, and we also need to be able to earn a living! Graduate programs will focus on enhancing advocacy skills and provide counselors the opportunity to both advance our profession and serve our clients and communities. Our new professionals will be role models as a workforce generation that takes the counseling profession to the next level.

Cirecie West-Olatunji is a professor of counseling and director of the Center for Traumatic Stress Research at Xavier University of Louisiana, a past president of the American Counseling Association and the Association for Multicultural Counseling and Development, and editor-in-chief of the Journal of Multicultural Counseling and Development.

When I think about the direction of the counseling profession over the next five to 10 years, I think about the most recent spotlights on social injustice in the U.S., and I also think about how established we are becoming as a profession. Along with that comes the possibility that we may be losing our edginess.

Without a doubt, the year 2020 was one of the most challenging of our lifetimes. For me, I saw it as a triple pandemic in which I, as a Black female counselor educator, was faced with the existential threat caused by COVID-19, coupled with graphic evidence of police brutality, and topped with climate change. Like many, I was personally aware of the day-to-day micro- and macro aggressions that Black people and other people of color experience in our society. So, when the first few news articles about the brutal killings of Black men at the hands of law enforcement officers were sweeping the media, I was not surprised. However, the additive effect of COVID-19 and the multiplicity of news articles that were so prevalent over the summer took my breath away. To make matters worse, as a New Orleanian, I dodged six of seven hurricanes in the fall, only to be hit by Hurricane Zeta that knocked out power and internet access for days on end.

Throughout this all, I participated in an ACA special task force looking at ways to mitigate the impact of structural racism on Black ACA members and the general public. While I was pleased to see how quickly the ACA leadership desired to create change, I was also disappointed by our seeming inability to move expeditiously as an organization. So, at that point, I realized that we, as an organization, have this challenge of actualizing our belief in social justice and equity. We write about it. We present on it. We may even teach about it, but we are having a hard time turning that lens inward to explore and assess what inequities exist within our counseling programs, for example. How can we use our knowledge of the Multicultural and Social Justice Counseling Competencies to transform the lives of the students we teach and the colleagues with whom we work? I think this is a huge challenge.

The other challenge is also an opportunity. When I began my master’s program many decades ago, we were still the new kid on the block. We’re still new, but I don’t think we’re that edgy anymore. In many ways, it feels like we are losing our groove, and someone should ask us, “How can Stella get her groove back?”

You may ask, “What are some of the exciting areas where the windows of opportunity may be closing?” Well, have we really begun to integrate neuroscience into counseling in the U.S.? Do we really value the partnerships that we created with our sister organizations abroad? Do we genuinely teach about culture-centered counseling theories so that our students can employ them in their internships and beyond? What do we know about infant mental health or pediatric counseling, and are our graduates in private practice specializing in working with children during early childhood?

I think we need to get our groove back. Now that we are established as a profession, we don’t need to be like the other guys. We’re different, and I’ve even heard some counselor educators say, we’re better!

Samuel T. Gladding is a past president of the American Counseling Association and a prolific author of books and articles on multiple aspects of counseling.

Counseling as a profession is ever-changing, as is the future. When I entered the field 50 years ago in 1971, counseling was not regulated. Anyone could hang out a shingle and claim to be a counselor. Then came what I call the “turf wars” where psychologists, psychiatrists and others tried to define counseling and argued against it becoming a profession. Ouch! However, because of the heroic fighting of individuals like Ted Remley, Tom Sweeney and others who saw the future, counseling emerged. The American Personnel and Guidance Association became the American Association of Counseling and Development in 1983 and, finally, the American Counseling Association in 1992. Certification from NBCC, accreditation of counseling programs from CACREP, and licensure from individual states, starting with Virginia in 1977, happened.

The point is, no one in 1971 could have predicted where counseling would be in 2021. Therefore, trying to predict how counseling will change in the future is close to impossible because of so many variables. Nevertheless, I will take a chance and focus on changes, challenges and opportunities for counseling in the next 10 years.

It is 2031! People in the United States still remember the coronavirus pandemic and its negative social and emotional impact. Therefore, they are continuing to talk about what constitutes good mental health. The opportunity is a challenge for counseling and counselors to be in the conversation about promoting wellness and well-being practices. While there are still counselors involved in treatment, many professionals are involved with individuals, community organizations and industries in finding ways to publicize and implement evidence-based research geared to having positive affective, behavioral and cognitive outcomes. Emphasis is on sharing meaningful experiences. Practices such as mindfulness, nature therapy, and “savoring” significant events and encounters are emphasized.

Technology has advanced and is used more by counselors. It promotes a change in the way counseling is conducted. It has not replaced person-to-person interactions in prevention or treatment. Rather, technology has become more of a tool in counseling than ever before. Counselors have been challenged to be more proactive and have developed realistic and individualized video games with names such as “Choice” and “Life.” These games are used by clients between sessions to help them see the outcomes and impact of what they do or plan to do more clearly. They are used with populations from 8 to 80.

Since counseling is now a worldwide profession, there are more international exchanges and novel ways of practicing as a counselor. A major change is that international accreditations are more prevalent and influencing counselors in positive multicultural ways more than ever. Worldwide learning about counseling practices is now an opportunity that is utilized.

Of course, neuroscience is lighting up more than regions of the brain in 2031. Specific applications from using neuroscience are prevalent. Counselor education and continuing education are filled with courses on the use of neuroscience, especially with people who are having difficulties coping because change is so fast. The term “change fatigue” is a term in the Diagnostic and Statistical Manual of Mental Disorders, with offshoots of anxiety and depression spinning off of it.

In addition, the American Counseling Association has changed. Its championing of interstate recognition of counselor licensure in the 2020s has made counseling stronger nationally. ACA is a major influence on counseling internationally too. One of its major foci is the producing of materials — films, books, pamphlets — for the well-being of the general population.

While the future is not ours to see, most likely many of the visions here will occur. Time will tell how they will be!

S. Kent Butler is president-elect of the American Counseling Association and has been appointed interim chief equity, inclusion and diversity officer at the University of Central Florida.

Change is on the horizon! History will show that the past few years have positioned the counseling profession to be the vehicle for this change, and we are proactively answering the call for transformation. Technology has evolved and will always carry us forward in very innovative ways. However, moving forward, contributions such as the Multicultural and Social Justice Counseling Competencies (MSJCC) will offer the muse that challenges the counseling community and affords us opportunities to grow both personally and professionally. The MSJCC proffer an empowering framework that encompasses meaningful advocacy. Exciting initiatives are imminent, similar to those provided by the Cultural Encounters Task Force — ACA members who are standing in the gap and extending to counselors evidence-based practices designed to help facilitate difficult dialogues pertaining to race and culture. ACA membership is being handed a road map and given insight that will help to mitigate and dismantle racism within our society.

As ACA’s 70th president, I look forward to future collaborations and leading ACA’s mission to promote the professional development of counselors, advocate for the profession, and ensure ethical, culturally inclusive practices that protect those utilizing counseling services. To date, ACA boasts 69 years of incredible leadership. However, only a limited number of underrepresented leaders have led the charge. Great strides must be made to mentor into governance aspiring leaders who represent ACA’s diverse membership. To this end, “The Giraffe and the Elephant — A Modern Fable” provides a real glimpse into our inner workings and efforts to embrace inclusion. It is a powerful narrative that showcases how insiders (giraffes) and outsiders (elephants) build inclusive environments together. This is ACA’s future!

To capitalize on leadership opportunities for counselors and the counseling profession over the next five to 10 years, I truly believe that we must learn and grow leadership exponentially and openly embrace a multitude of intersectionalities, allowing each person to intercede, touch and inform one another through myriad worldviews and life experiences. We benefit immensely when we are attuned to each other. I believe it is best practice to invest in these relationships. Investments empower leaders. They afford organizations opportunities to build a solid infrastructure that makes positive differences. A genuine acknowledgment of others also fosters a strong sense of belonging. Being inclusive successfully role models and empowers members to nurture collaboration and see value in embracing their colleagues for the gifts they bring to the table.

Leadership is not always easy. Ideally, leadership should be multidimensional and reflect myriad worldviews. By design, diverse governance provides role models and opportunities for mentorship and empowers aspiring leaders. As we move forward, these leaders must gain the trust of stakeholders, helping them to believe in their vision and to know that they can rely on it being carried out for the good of all. Furthermore, I believe that as good citizens, we must work collectively over the next decade to eliminate conditions that produce obstructions to the healthy professional development and wellness of individuals from all cultural and ethnic backgrounds. We must strategically take the time to build upon traditions that positively impact the lives of people across the globe. Ten years from now, we will have grown myriad diverse leaders who always take the high road and strive to provide us with a solid return on our investment.

Gerard Lawson is a professor in the counselor education program at Virginia Tech, a past president of the American Counseling Association, an ACA fellow and a licensed professional counselor in Virginia.

As we are reflecting on the future of the counseling profession, it may be the recency effect, but many of the things we have seen in the past year or so seem like they will be relevant areas of focus for some time to come. The roots of the counseling profession — in mental health and wellness, career counseling, and educational counseling — are as relevant to the challenges of today as they were 100-plus years ago, when the profession began. I’d like to focus on two challenges in particular, the first being the ongoing response to the COVID-19 pandemic and the second being the broad public exposure of injustices in the U.S.

There is no question that the impact of the COVID-19 pandemic on mental health, and on the vital services that counselors provide, has been profound. Many have observed a secondary pandemic of anxiety and social isolation as a direct result of the response to the coronavirus, and counselors who have traditionally worked only in face-to-face modalities had to adjust to an online counseling world to continue to support their clients. It seems unlikely that we will return to the way we used to practice, or that the nature of what clients bring to us will be the same, even after the pandemic has been brought under control.

Counselors who were skeptical of distance counseling are finding that it’s not as bad as they expected. Similarly, clients who have been relying on distance counseling to cope during the pandemic may actually need in-person counseling to thrive post-pandemic. And, unfortunately, we will probably see the mental health consequences of the pandemic for years, if not decades. For individuals who were vulnerable already, for students who were disconnected from their learning process and the normal support that they receive from talented and caring school counselors, and for those who were already stretched too thin and were asked to take on more, the recovery process may be protracted and complicated. Counselors may need to consider what progress and success will look like for those clients and for those for whom the “new normal” is still less than what they hoped for.

In 2020, we have seen the horrors of systemic racism more regularly, not because this is a new phenomenon, but because cameras have brought those experiences into the mainstream view. We have also seen the fear and insecurity that our neighbors who are members of the LGBTQ community feel who are afraid that their rights may be stripped away. We have seen neighbors who have lived in the U.S. for decades suddenly fearful that they could be sent to live in a country that they have never even visited. And we have seen neighbors suddenly find that their job no longer exists and unsure where their next meal may come from, much less what their career might look like.

Counselors can be agents of change in these areas. The Multicultural and Social Justice Counseling Competencies that ACA has promoted for years guide us to challenge our biases and assumptions, to practice in a way that is culturally competent, and to support clients who have been marginalized and harmed by unjust systems. We need to see and understand these experiences as part of an ongoing trauma that is embedded in the experiences of far too many individuals and families. As part of a system that values people based on what they contribute, not their inherent worth. We need to be out front, embracing everyone in our communities, affirming them and helping to change the systems that have led to oppression.

No small task. But counselors are accustomed to acting heroically.

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Share your thoughts on what might pose the most significant change, challenge or opportunity for counselors and the counseling profession over the next five to 10 years in the comment section, below.

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Jonathan Rollins is the editor-in-chief of Counseling Today. Contact him at jrollins@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.