Tag Archives: Rehabilitation & Disability

Wanted: Inclusive licensure process for clinicians with difficult life situations

By Kevin Wreghitt September 11, 2015

Licensure is a “rite of passage” for most mental health professionals. When new professionals graduate with either a master’s or doctorate in counseling, they usually have great expectations of taking the world by storm. There is one pesky reality standing in the way, however.

I am of course referring to going through the multiyear licensure process, which involves taking a board exam and practicing under supervision for several thousand hours. In my case, this process Disabled parkinghas been more burdensome than I ever imagined because I am in a difficult life situation.

My birth was difficult, and I sustained significant brain injury because of a lack of oxygen. As a result, I have quadriplegic cerebral palsy and am confined to a wheelchair. I have random motion and a speech impediment. The use of my hands is poor to nonexistent, and because of this I can do few things for myself, relying on others for all my daily needs.

Nothing has come easily for me, but I have experienced many successes and surprises in my life. This is due to the hard work and perseverance of many people who have worked tirelessly with me and to my own determination to prevail despite the odds. I also demonstrated a few abilities from a young age. For example, I had an interest in helping others who were going through difficulties by listening to them and being present with them. My thought in early adolescence was that I should go into a field where I could help people with disabilities. Through the years, beginning in high school, I had a number of mentors in the counseling field, including some who were disabled themselves, who encouraged me to join the profession.

I always did well in school, attaining high marks and honors in high school and beyond. When I graduated from high school, I went on to college and then graduate school. Because of my disability, it took me about twice the time as other students to complete my undergraduate and graduate degrees. By the time I finally was done, I was in my mid-30s. My major in graduate school was mental health counseling. Upon finishing, I had planned to go through the state licensure process. This is when some of the toughest obstacles in my life began.

 

Hitting a brick wall

There were multiple considerations I had to think about to make my “dream” a reality. For the sake of simplicity, I will boil it down to two general factors. The first was my disability and how I would be successful in gaining employment with my type of challenges. The second factor was going through a licensure process. Both of these factors interact.

I worked with two rehabilitation counselors and other community career counselors plus my own therapist. I went on some interviews, but many of my inquiries simply went unanswered. After six months to a year of being rejected, I became frustrated. I continued looking for another year, at which point I had to quit because I found the whole process soul destroying. From talking to people, I gathered I could not third-party bill because I did not have a license, and this was a major obstacle to obtaining employment in the field.

I was tired at that point of looking around for other placements. So, in 2009, I found a volunteer job as a mental health clinician counseling people with intellectual disabilities. I had to hire my own supervisor because there were no counseling professionals on staff, but I began trying to accrue hours for licensure. I wanted to clear the “examination hump,” so I took that in 2011 and passed.

All this time, I was seeing very few clients because the population served by the day habilitation facility was considered too severe to be counseled. At the same time, I knew I had a total of 3,360 hours to fulfill for state licensure in Massachusetts. With so few clients available, I had difficulty gaining enough hours, even on a six-year part-time basis. During the past six years, I have looked periodically for other volunteer opportunities, but for whatever reason, other places never materialized.

 

The psychological toll

As with any disappointment or heartache in life, this experience has been a daily rollercoaster. It has really caught up with me in the past couple years, and this year has been the hardest so far. I guess that is because I am nearing 50 and it looks doubtful that I will achieve the type of career I dreamed of so long ago. I feel like I am still back in my 20s and no further along in my career aspirations. I still feel like a student or an intern who is just learning when I should be capable of practicing on my own with expertise, specializations and much experience.

I keep wondering how I got into this mess. What didn’t I see or plan for? Where was the point where I went wrong, and should I have known it? Was I ever meant to be a counselor, or was it all just a pipe dream gone terribly wrong? Was all that effort, all these years, all for nothing? Who am I anyway? These are the questions that haunt me daily.

I do not want people to feel pity for me. That is not the purpose of this article. Most of us in the counseling profession know that we respond with empathy not pity. To correct or manage a problem, we first have to understand it and how it impacts people. This is a core principle in our profession, and I hope by briefly explaining how deeply disappointed I am about this whole situation, perhaps counselors can begin to understand this problem — not only for me but for others who find themselves in similar situations, dealing with a disability or other difficult circumstances, who try to obtain a start in the counseling profession.

 

What the literature says

Despite claims that counseling is a scientific field, the profession (and related others that practice psychotherapy) has failed to validate what it takes to be an effective counselor. All the states seem to have differences in the total number of supervised hours needed to qualify for a counseling license, although it seems to be 3,000 on average. I once posed the following question on the ACA Connect forum: “Where did the number 3,000 or more hours and all the subtotals come from and why?” Nobody could or would answer this question.

Paul Lowinger published a study in the Journal of the National Medical Association in 1979 saying that nonprofessionals could diagnose 70 percent of psychiatric outpatients and that an even larger proportion (80 percent) of 36 patients evaluated could be treated by nonprofessionals. In 1967 in the American Journal of Public Health, Truax reported therapeutic mastery with five novice counselors who took a 100-hour training course.

In a 2005 study that appeared in the Journal of Consulting and Clinical Psychology, Wampold and Brown found factors such as the therapist’s age, gender, education and experience had little effect on client outcome. Nyman, Nafziger and Smith, writing in the Journal of Counseling & Development in spring 2010, pointed out the possibility that supervised paraprofessionals might be as beneficial as licensed and advanced clinicians. In the March 2014 issue of Counseling Today, R. Tyler Wilkinson commented about the inequities of the licensure process (“The Affordable Care Act and counselor licensure”). It is as if the profession and the states have said to candidates who struggle, “You’re good but not good enough” when some of those candidates could be effective therapists.

It appears to me from this brief analysis that the high bar of total clinical hours is arbitrary and not based on real objective proof. In fact, some research would suggest that one could make due with fewer post-degree clinical hours and still perform just as well as those with the thousands of hours now required. In my view, the licensure laws around the country seem created mostly out of subjective cognitive constructionist criteria rather than being based on objective standardized measures designed to benefit society.

 

Achieving licensure inclusion

The American Counseling Association (along with its divisions and branches), outside organizations such as the National Board for Certified Counselors and the states need to work toward inclusion for licensure. If a person wants a license, he or she should be given every chance to achieve that status. Here are a few ideas:

  • Counselor education programs could have two-year residency periods so that universities would be responsible for placements and assist with supervision after graduation, similar to what medical schools do.
  • All students should be educated about the licensure process as part of their course work or by attending extra seminars. They should also be made aware of alternative career paths within the mental health field in case counselor licensure is not a practical pathway for them.
  • Students with disabilities should be encouraged early on to seek counseling about licensure from faculty.
  • State boards should be consulted early about unique circumstances that may require special accommodations.
  • Achieving licensure should not be the only way to be paid in the mental health field. There should be another certification that is recognized by insurance plans, the government and the profession when an individual obtains a degree and is working toward licensure.
  • The licensure process might be able to be streamlined if a new national standard were adopted, with all states and professional organizations agreeing on a uniform number of hours and other requirements needed for licensure.
  • Some states may need to modify rigid licensure laws to allow licensure boards more flexibility in dealing with special circumstances while still complying with competency standards.
  • A robust and active disability interest network needs to be established within ACA to, in part, advocate for counselors with disabilities.
  • Employers in counseling centers need to be educated about the unique opportunities inherent in employing a counselor with a disability, no matter the severity of the limitation. People striving through adverse situations may make some of the best therapists.

The road toward licensure inclusion will be long, but we have to take on this challenge. The counseling profession preaches cultural diversity, but when a person with a different set of life circumstances comes along, I find there is little consideration given to that person. The profession may drive away capable people by promoting high standards without providing a way for those professionals to succeed.

I understand that the counseling profession has to protect the public, but we can do this while providing extra support in becoming credentialed. For the profession to achieve the ideals ACA has set forth, we need to be more inclusive — not exclusive — in licensure and employment practices.

 

Conclusion

This article asks what the soul of the counseling profession really is. Are we content to exclude potential licensed professionals because they have difficult life situations, or do we welcome them into the practice of counseling? Disability, financial concerns and difficult family situations, among other circumstances, may be keeping some people from achieving licensure.

I do not know if I will ever become licensed, but I hope this article might change the way licensure is handled and give new professionals in difficult life situations a chance at this wonderful achievement. There has to be a way!

 

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Kevin Wreghitt is a mental health clinician counseling people with disabilities in day habilitation and college settings in Massachusetts. Contact him at kevinwreghitt@verizon.net.

 

Bio/neuroethics and counseling: A novel partnership

Kevin Wreghitt May 1, 2012

Bioethics is the multidisciplinary field that applies knowledge of health care policy, law, philosophy, sociology and dispute mediation/resolution to solve moral dilemmas in clinical practice and research in medicine and allied professions. Human cloning and stem cell research, which are hotly debated in society, are examples of bioethical issues. Beginning roughly in 2002, neuroethics emerged as a subdiscipline of bioethics that seeks to solve moral dilemmas arising from neuroscientific research and clinical cases of brain trauma and mental illness.

Daniel Buchman of the National Core for Neuroethics at the University of British Columbia said this about his field: “Neuroethics has deep roots in ancient philosophical discussions of mind and brain and has joined this history with contemporary thinking in biomedical ethics and neuroscience devoted to elucidating ethical challenges prior to and during the transfer of new research capabilities to the bedside.” The use of psychiatric drugs and other treatments for patients who are mentally ill, issues related to neuroscience and national security (such as brainwashing) and the use of “designer drugs” to change one’s personality or enhance cognitive function are examples of neuroethical issues.

In clinical or consultative ethics cases, which revolve around an identified patient/client and his or her cognitive status, counselors can play an important role by uncovering the psychological issues belonging to that person and the people around him or her and explaining how those characteristics might influence bioethics or neuroethics decisions. Therapists could assist bio/neuroethicists, the courts and others in keeping those psychological variables “in check” and preventing irrational behavior from being destructive to the ethical decision-making process.

What often receives less consideration, however, are the psychological factors of the participants trying to reach bio/neuroethical decisions. For instance, what types of psychosocial interactions occur between the individuals involved in clinical bio/neuroethical discussions? It is reasonable to suspect that issues such as personal values and cultural issues are presented, but is that enough? Are there situations that go beyond the capabilities of bio/neuroethicists and require more of a mental health approach?

Case of persistent vegetative state

According to a 1991 Multi-Society Task Force on PVS (persistent vegetative state) as cited in The New England Journal of Medicine, individuals are considered to be in PVS when they have been unconscious for longer than 12 months due to brain trauma and also have a poor prognosis. Higher cognitive processes are nonfunctional, with awareness of self and the environment being absent. These patients cannot communicate or follow commands in any way. Sensory experiences may occur but have no conscious meaning.

One of the most famous cases concerning PVS centered around Terri Schindler Schiavo, who died on March 31, 2005, almost two weeks after her feeding tube was removed and her hydration cut off under court order. Terri’s death was preceded by a lengthy court battle between her family and her husband, Michael. The psychosocial questions and issues surrounding the Schiavo case are numerous. What was the state of the marriage between Michael and Terri before she suffered massive brain damage and was put on life support in 1990? What did life and death mean to each participant in the conflict?

Perhaps psychometric testing (for example, the Minnesota Multiphasic Personality Inventory, or MMPI-2) could have assisted in identifying who was best mentally fit to make decisions on Terri’s behalf. Was Michael Schiavo violent toward Terri as some claimed? More questions could be added as possible psychological influences. None of these issues came out in the bioethics proceedings.

Clearly, PVS cases are complex, and the mental health of each participant and the family as a whole has to be taken into account. Mental health and ethics professionals need to ensure that a careful psychological examination takes place, and the courts should require such assessments. The people involved in PVS cases are dealing with heart-wrenching experiences, and psychological assistance is needed.

Health care system implications

On March 23, 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act, and a few days later, he signed the Health Care and Education Reconciliation Act. Among other major reforms, these two laws allow for 32 million Americans to obtain health insurance who do not currently have coverage. The future of health care delivery is in question, not only because of new governmental regulations and bureaucracy, but because our wavering economy might influence any outcome as well.

New moral and legal questions will challenge the fields of bio/neuroethics in the United States because of health care reform. For example, will new regulations interfere with best practices in medical and mental health services? Will vulnerable populations have difficulties accessing needed specialized treatments and services? Perhaps treatments that are offered now will be excluded or reduced because of cost or rationing. If some of these negative consequences take place, there might be emotional fallout. Everybody hopes the new policies will benefit our health care system, but counselors should remain cognizant of the potential pitfalls of this new system — especially because no one really knows yet how or if it will work.

The field of neuroplasticity has offered discoveries on how patients can rebuild neural networks, even after brain damage, through certain therapeutic experiences and targeted exercises. There are neuroethical concerns, however, that some systematic difficulties might impede clinical practice. In the fall 2009 Focus newsletter of the Center for Health Care Policy and Ethics at Creighton University in Nebraska, Caroline Gaudet and Trisha Cochran said, “Given the limited length of stay and reimbursement for in- and outpatient rehabilitation services, clinicians have a sense of urgency to get their patients as functional and independent as possible as quickly as possible, often having to teach compensatory behaviors instead of fostering neural recovery.”

Counselors need to be sensitive to ethical and societal questions that might affect their clients who have various types of illnesses. Sociological changes such as health care reform can usher in much hope and, simultaneously, significant concern. Such opposing outcomes probably depend on what people expect medical or mental health care to do for them. As another example, professionals who work with psychiatric clients know that any change in their environment might cause these individuals anxiety and perhaps trigger a total relapse of their conditions. Changes in the U.S. health care system might become a direct or indirect trigger for such challenges.

Other bioethical issues

Beyond the neurological areas, there are other bioethical issues that may require mental health attention. For example, should medical providers assist in ending the life of terminally ill patients? With biotechnological advances and societal changes, the bioethical, psychological and medical issues of death and dying have become more complicated than they once were for persons with terminal illness and their families. Recommending that patients have feeding tubes implanted or making decisions concerning who should receive an organ transplant presents both bioethical and mental health implications.

These represent only a couple of examples of the bioethical issues that health care clinicians face daily. We should ask ourselves whether counseling and therapy might help to improve the prevalence of healthy and ethical outcomes in these scenarios. Counselors must bear in mind that there are often competing values between the patient, the health care team, the family and society in many such situations.

Counseling initiatives and strategies

Organizations such as the American Counseling Association have the opportunity to promote clinical practice, research, legislative advocacy and education in this specialized area. People vying for guardianship in court (for example, in the Schiavo case) should be psychologically screened so the party that is most mentally fit for the task can be identified.

It might be beneficial for ACA to partner with other organizations such as the American Society for Bioethics and Humanities; the American Society of Law, Medicine & Ethics; the Neuroethics Society; and the National Bioethics Advisory Commission to create initiatives that would foster integration between our respective fields. We could partner with these organizations to devise new protocols for cooperation between bio/neuroethicists and counselors. More training opportunities on bioethical issues for the counseling profession would also be beneficial. Perhaps some counselors might want to earn another degree in bio/neuroethics and develop a subspecialty in clinical or research areas.

Health care workers who come into contact with these types of cases supposedly receive ongoing bio/neuroethics training. This does not mean, however, that such staff could not use additional emotional support as well. This could involve values clarification classes as well as individual or group psychotherapy. A mental health clinician, independent of the case being considered, could be included in bio/neuroethical discussions to identify and assist with the psychological issues that may arise.

Offering a grief model might be helpful. Part of the difficulty might be that each person is at a different place along the grief journey. The father may have accepted the reality, while the mother might be in denial and a nurse could be bargaining. Counselors have to help identify and reconcile the psychosocial variables in any health care dilemma.

The patients who can participate in the decision-making process should be in counseling/therapy to help them cope with what is happening to them. The counselor might have to assist these patients in reshaping their expectations to bring about a resolution. Bear in mind, “incompetence,” if imposed, is a legal term — not a medical or psychiatric diagnosis. Even though the legal profession pronounces some people to be incompetent, it doesn’t necessarily mean the person cannot think for himself or herself. However, he or she may need added support in making decisions. The person should not be dehumanized by the label of incompetence or by the bio/neuroethical process, and counselors can play a role in ensuring that does not occur.

It will be important in the coming years for counselors to monitor changes in the U.S health care system, not only as these changes pertain to the counseling profession but to medical professions as well. Starting in 2014, when health care reform goes into full effect, some clients might experience confusion and distress. Counselors will be needed to help individuals navigate both expected and unforeseen challenges. If systematic difficulties become acute or long term — necessitating rationing of services, for example — this could lead not only to a medical crisis but to a mental health crisis as well. If so, strategies and changes to the counseling profession might need to be developed.

In the beginning of the bio/neuroethics process, the individuals involved should be made aware that they have biases that will come out. People should be encouraged to pinpoint their own motives and the meaning of the actions they take. For those who want to hide behind the objective professional cloak, they should be reminded of their humanity and that their motives will ultimately escape from the mental iron curtain. Finally, the legal profession might need to be educated about the influence of psychological factors in these dilemmas. The Schiavo case illustrates what can happen when such psychic forces are overlooked.

Conclusion

I’m writing this article not as a bio/neuroethical expert but rather as a casual observer of the process and a newcomer to the counseling profession. I am also a quadriplegic due to cerebral palsy from birth, so I can empathize with people with disabilities who might feel that others are in control of the quality of their lives. It is frustrating to know others are in charge of making choices on one’s behalf, even though some patients/clients might not be as aware of this due to their inability to comprehend. Counselors can play a significant role in assisting patients/clients, families and professionals to cope with bio/neuroethical issues. I think it would be worth the effort.

Kevin Wreghitt is a mental health clinician and a Massachusetts mental health counselor licensure candidate at Coastal Connections Inc., an adult developmental disability day program. He has an interest in counseling clients with neurological injuries. Contact him at kevinwreghitt@verizon.net.

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