The COVID-19 pandemic has disrupted nearly every aspect of life, from parenting and family relationships to personal finances and career trajectories. Self-care and coping mechanisms that people previously relied on were often set aside or became harder to access because conditions related to the coronavirus were (and to a certain degree still are) in a constant state of flux. Answers to worries such as “Is it safe to go to the dentist?” or “Will I put my grandmother at risk if I visit her in person?” continue to change with each new phase of the pandemic — the initial uncertainty, the availability of vaccines, the rise of multiple variants, the reopening of schools and workplaces, and so on.
It has all made client wellness a moving target over the past two years. As a result, counselors might consider rethinking how they approach wellness — and all its dimensions — and foster collaboration with other professionals to help clients maintain their mental and physical health even as they are repeatedly thrown curveballs that interrupt their life patterns.
The domino effect
Wellness counseling looks beyond a client’s diagnosis or presenting concern, using a strengths-based approach to view clients holistically. The approach focuses not only on an individual’s mental and physical health but also on their spirituality, social connections, work life, financial situation, home environment and numerous other factors that vary slightly depending on the wellness model the practitioner uses.
And all of that — from clients’ social-emotional health to their financial stability and sexual wellness — has been affected by the COVID-19 pandemic over the past two years, says Christine Ellis, a licensed professional counselor (LPC) who is the founder and clinical director of a counseling practice in Wisconsin.
Ellis’ practice uses the National Wellness Institute model, which concentrates on six dimensions of wellness: emotional, occupational, physical, social, intellectual and spiritual. Because all the dimensions of wellness are interconnected, distress in one area has a domino effect on the others, Ellis says. For example, a client who feels heightened anxiety over the safety of their children returning to in-person school might also experience weight gain and other physical manifestations of stress or increase their intake of alcohol or other substances.
These circumstances have also resulted in Ellis receiving additional referrals and seeing more new clients at her practice. That has been something of a silver lining to the pandemic’s storm cloud, she says: “People have looked at their own wellness … [and] felt, finally, for the first time, ‘OK, now I have an excuse to ask for help.’”
Ellis says she and the other counselors at her practice have been intentional about maintaining a nonjudgmental atmosphere as clients talk through their pandemic-related stressors, which often include frustrations that stem from feeling limited or disrupted in their goals or life plans.
“We have been using a ton of distress tolerance techniques during the last couple of years,” says Ellis, a member of the American Counseling Association. “It’s been hard during COVID. How do you change when everyone is stuck? … When we hear clients say, ‘that’s not possible,’ our job is to validate that and recognize it as suffering. Then, we focus on small changes.”
Equipping clients with new and different coping mechanisms and talking through what they can and cannot change has been extremely important over the past two years, Ellis says. It has all been done with an eye toward empowering clients and giving them a sense of ownership over their own wellness. For some, this also included working on identity-related issues, such as no longer being a soccer mom and taking the kids to sports activities regularly or not being as productive or successful in their career while working from home.
Ellis has found that pandemic-related stress has been acute for clients who struggle with focus or attention challenges such as attention-deficit/hyperactivity disorder. She believes anxiety and distraction have heightened for these clients because routines have been upset and there have been so many unknowns over the past two years, such as “Will I get COVID-19?” or “Will my child be able to wear their mask at school?” Young and adult clients alike have needed to go back to the drawing board to find new coping mechanisms, Ellis says, because many of the tried-and-true tools they had been using no longer worked under such extenuating circumstances.
Clients’ mental well-being also took a hit when the pandemic disrupted or canceled activities that previously boosted their wellness, such as fitness or art classes, community parenting groups and church coffee groups, Ellis notes. Helping clients identify substitutions and replacements for these activities was vital in the early days of the pandemic and continues to be important now because routines are still in flux.
Perhaps a client previously maintained their physical and social wellness by attending a favorite fitness class, but the class got canceled or they no longer feel safe attending. Under that scenario, Ellis would validate the client’s feelings of loss and ask questions to spark ideas of alternative ways to attain those same benefits. She may ask, for instance, “How can you replace your water Zumba class? What about it do you like, and how can you find that elsewhere? How can you achieve the same things that you know you value, just differently?” Perhaps the client could call or video chat with a friend from the class or set up an area in their home to exercise on their own, she suggests.
A big part of this work, Ellis notes, is helping clients make the shift from an external source of motivation (relying on a class to boost their wellness) to an internal one (finding ways to boost wellness on their own).
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Christie Kelley, an LPC who uses a wellness approach at her solo private practice in Bristol, Connecticut, says her clients have been experiencing many of the same feelings and challenges that Ellis describes. Kelley has also seen an increase in new clients recently because, she says, many people are evaluating aspects of their lives and wellness and finding areas they feel are lacking or that need changing.
Many of Kelley’s clients felt they had more options — and more motivation — to tend to their wellness at the start of the pandemic, she says. It was easier to schedule breaks to get outside and engage in physical activity with their children while they were all home together or to do exercise classes at home via Zoom. But as more schools and workplaces began to reopen, the novelty of incorporating wellness into daily life faded for many people.
More of Kelley’s clients now view wellness as separate from or less intertwined with their daily routines, she notes. This includes approaching physical activity as one more thing to add to their to-do list rather than weaving it into the workday, such as by walking a few flights of stairs during their lunch break.
Kelley has found she needs to emphasize to clients that wellness remains an interconnected part of life. “In my area, I’m really noticing more of an impact with the pandemic now. Many of the people I’m working with are experiencing more problems and hardships now,” says Kelley, an ACA member. “Where I have seen people struggle is getting back to this ‘new normal.’ They developed some ways of being healthy in their homes during the pandemic, but now many are going back to work and struggling with balance.”
Getting creative
Many clients have needed support and guidance from a counselor to manage their wellness because so many aspects of daily life have been disrupted during the pandemic. Ellis has found it helpful for counselors and clients alike to consistently seek fresh ways of looking at challenges and stressors.
If clients are feeling stuck or unmotivated, Ellis suggests asking them to name one thing they could do within the hour or that day to boost their wellness. It might be as simple as drinking some water, planning a healthy meal or finding a book to read that gives them more information and ideas on a wellness topic.
“We’re still going through this wave. … Things are not how we want them to be every day. How do we deal with that [through] a compassion-focused lens?” Ellis asks. “Have a beginner’s mind every day. Promoting how to look at something [as if it’s] the first time brings a freshness. That big picture view keeps us from being stuck and getting stuck. … Get away from the entrenched perspective.”
“We [counselors] can help clients see things that way: They can simply put their shoes on and walk around the block. You don’t have to run a mile, but take one step toward wellness,” Ellis says. “Wellness is also about allowing ourselves to sit with the discomfort of an emotion or feeling and simply working to observe it, asking it what it has to teach us — as [Buddhist teacher] Pema Chödrön’s work models — and then it can be used as fuel to motivate a new wellness behavior, activity, attitude or belief.”
Kristin Bruns, an associate professor and college counseling and student affairs program coordinator at Youngstown State University in Ohio, stresses that counselors not only need to get creative with their approach to client wellness but also ensure that the work is client driven and culturally sensitive. Counselors shouldn’t make assumptions about what wellness activities might or might not work for a client, Bruns says.
For example, a client may not feel comfortable or safe going back to the gym even if it has reopened. Or they may have lost their job during the pandemic and no longer have the financial means for a gym membership. A counselor’s role is to explore that with the client and prompt conversations to find other avenues that will work for them, Bruns says. An important aspect of this work is for counselors to be aware of resources within their communities — especially free and low-cost offerings — such as programs and groups at libraries, community centers and local nonprofits, she adds.
“Also, ask clients what their self-care looked like before the pandemic, what it looks like now and what would they like to change. That can help us work with them to figure out what they want to reengage in and what they might want to look different,” says Bruns, a licensed professional clinical counselor who sees clients part time and uses a wellness approach at a private practice outside of Akron, Ohio. “Use those basic counseling skills — really listen to what the client is telling us, and help [them] think of things that might fill that need. It’s easy to want to throw out suggestions, but it’s more powerful when clients come up with [solutions] themselves. It’s really powerful when we let the client be creative.”
Kelley agrees that it’s helpful to ask clients about their self-care prior to the pandemic and to work on “translating” it for the current environment. Sometimes there is a need to expand clients’ understanding of self-care, she notes.
In the past two years, Kelley has noticed that her clients’ view of self-care has oscillated between basic tasks such as showering and getting dressed to more cliché ideas such as doing yoga — endeavors, she says, that are helpful but not the be-all, end-all.
Kelley begins conversations about self-care by asking clients about their hobbies and interests and the things that bring them joy. Then, she uses one of their answers to apply a clinical focus. For example, a client who loves tea or coffee can use their time spent with a warm mug to pause and do a mindfulness exercise.
“I’ve needed to challenge people’s understanding of self-care and wanting it to fit into a mold. My challenge is to try and help them expand their thinking process, their idea of what self-care is,” Kelley says. “Self-care is anything that you do for yourself; it doesn’t have to be this one thing. I try and help them have a broader idea of it.”
The use of telebehavioral health during the pandemic has helped in this realm, Kelley notes. Doing sessions via video has given her insights into clients’ environments, including elements that have sparked ideas to boost wellness and self-care. In one case, a client had set a goal to incorporate more mindfulness into his life, and during one of their video sessions, Kelley and the client started discussing a seating area in his house, visible in the camera, that he could use for that purpose.
“I never even [asked], ‘Could you use that spot [for mindfulness]?’ … [The conversation] just naturally went there. One of his goals for that week was to prepare it and use it for wellness,” Kelley recalls. “I’ve really been trying to work with people in a very organic and personal fashion, as opposed to a generalized idea of wellness. … It’s one thing to ask if they have a pet at intake [during in-person counseling] but another to see a pet on screen during video therapy. You can incorporate it into conversation or therapy goals. It’s something that they already [got] enjoyment [from], but now they can think of it as self-care.”
The use of telebehavioral health has also prompted Kelley to get creative and modify the wellness-focused activities she previously used with clients during in-person sessions. When teaching breathing techniques, she encourages clients to lie down or otherwise get comfortable off screen, if space allows, while she talks them through the exercise.
“It has been helpful for clients because they’re in their own space and are comfortable, but it also shows that they can do it in their home,” Kelley says. “It’s not as disconnected as sitting in therapy and having the thought that they’ll do it at home, but then they get busy and don’t. They’re more likely to do it outside of therapy [sessions] when they’ve already done it
at home.”
Addressing all aspects of wellness
As the pandemic drags on, clients are processing its effects more and more. Wendy Thorup-Pavlick, an ACA member with a wellness coaching practice in the western suburbs of Chicago, says many of her clients have become more aware of their own wellness. As a whole, they are also more open to a mind-body focus to help them make changes and find solutions for symptoms related to physical and mental stress, sleep problems, mental health challenges and other issues that have spiked during the pandemic.
“For many clients, the pandemic was the catalyst toward embracing a healthier, more balanced lifestyle,” says Thorup-Pavlick, an LPC and adjunct faculty counselor at the College of DuPage in Illinois. “Good health and wellness are more than the absence of disease or illness; it is multidimensional and interconnected. Wellness is a conscious, self-directed pathway to optimal living, and integrating a wellness approach allows clients to use wellness principles to build resilience and thrive amidst life’s challenges. Adopting wellness practices provides additional support to clients who may be feeling abnormal and continuous levels of stress caused by the pandemic.”
This unprecedented time affords counselors an opportunity to dig into wellness-focused techniques with clients to help them cope with stress, manage their emotions and attend to the whole self. One such tool involves keeping a food-mood diary, says Thorup-Pavlick, a certified health and wellness coach. Her clients have benefited from recording their food intake and sleep habits, emotions, moods and other mental and physical symptoms to observe patterns and connections during the pandemic.
Thorup-Pavlick says clients have particularly needed support related to sleep hygiene during the past two years. Adequate sleep is tied to wellness in numerous ways, including supporting a healthy immune system and cardiovascular health, improving cognitive function and emotion regulation, and managing weight gain, she notes. Counselors can provide psychoeducation that it is not only important to prioritize sleep and maintain a consistent sleep schedule but also helpful to limit caffeine intake before bedtime, engage in physical activity during the day, keep naps short, and foster a relaxing environment in their sleeping area, including turning off computer and smartphone screens.
Motivational interviewing can be a helpful technique for asking clients about their sleep habits and finding out what they already know about sleep hygiene. If the client is open to it, the counselor can offer more information, Thorup-Pavlick says. If clients wear a fitness-tracking device, such as a Fitbit, asking about the sleep data it has collected can also be a way to introduce the topic, she notes.
In addition, Thorup-Pavlick often asks clients the following questions:
- What does your sleep schedule look like?
- Tell me about your sleep environment.
- How rested do you feel on a scale of 1-10?
- What’s working well for you at the moment?
- What isn’t working well at the moment?
- On a scale of 1-10, how motivated are you to improve your sleep habits?
- What do you think you should do first?
- Whatever your first step is, is there anything that might stop you from doing it?
“The idea is not to become a sleep expert but to know when the client may need to seek additional medical attention for sleep-related issues and how those issues may impact the client’s emotional well-being,” Thorup-Pavlick says.
Those interviewed for this article agreed that counselors need to be proactive and ask clients about aspects of their wellness — including use of alcohol and other substances — both at intake and regularly throughout therapy.
Counselors can also prompt discussions about wellness with clients by creating a wellness wheel in sessions, Thorup-Pavlick adds. During this exercise, the practitioner guides the client to create or fill in a circle diagram based on the health of the different dimensions of wellness in their life, including occupational, physical, social, intellectual, spiritual, emotional and other realms.
“When life is in balance, the wellness wheel will be round; when out of balance, the wellness wheel may look and feel a little more like a flat tire,” she explains. “It can inform the mental health practitioner how ‘in balance’ each wellness dimension is for the client. … The wellness wheel is a tool that will help identify how clients view themselves and how satisfied they are in each dimension of wellness.”
From there, Thorup-Pavlick often prompts clients to create a “wellness vision” for themselves that connects to their core values. This involves talking through not only a client’s desired wellness outcomes but also the challenges and knowledge gaps they might face and the strengths, motivators and supports they can rely on as they work toward their goals. Creating a personalized plan helps clients make sustainable progress toward wellness, she notes.
“The focus should be on what the client wants to achieve and not what they want to eliminate,” says Thorup-Pavlick, a member of the Illinois Counseling Association and a board member of the Illinois College Counseling Association. “As clients begin to get excited about their desired wellness outcomes, they can incorporate behavioral changes that will move them toward achieving these wellness goals.”
Forging connections with the medical community
In addition to the physical health concerns related to the coronavirus itself, the pandemic has caused a wave of negative outcomes that might have been prevented or caught earlier if people hadn’t postponed or skipped routine health appointments and screenings, such as mammograms and colonoscopies, during the past two years. These distressing outcomes are higher among people of color and those of lower socioeconomic status.
Professional counselors have a role to play in ensuring that clients are tending to all aspects of their wellness, including physical health, as the pandemic continues to disrupt life patterns, says Deanna Bridge Najera, an ACA member who works as a physician assistant (PA) in emergency medicine at a hospital in Maryland.
People have been canceling or delaying medical care for a wide variety of reasons, including resistance or discomfort with telemedicine or the inability to pay for services or prescriptions, Najera says. At the same time, medical offices have been overwhelmed, so it can be hard to get an appointment, and some have stopped accepting new patients, she adds.
This unprecedented time presents the counseling profession with an opportunity and a responsibility to forge connections with the medical community and do more interdisciplinary work, Najera asserts.
Not only do counselors have a responsibility to ask clients if they have a primary care provider and other questions about their medical care, but they should also be proactive and advocate to help them overcome barriers when there are gaps in that care, says Najera, who has a master’s in clinical mental health counseling as well as a master’s degree and licensure as a PA.
The first piece of this work is for counselors to become familiar with and connect with medical providers and other support services in their community. It also can involve advocacy with individual clients, such as helping them find health care services or supporting them while they call a pharmacist or a provider who prescribes psychiatric medicines.
In addition to her work as a PA, Najera provides psychiatric medication management services part time at a community mental health agency and is a backup psychiatric provider for Shippensburg University and Gettysburg College. She is also employed part time in the Carroll County Health Department in Maryland, working with clients in the reproductive health program. “We [professional counselors and medical providers] have to both play in the same sandbox,” Najera says. “It’s about meeting [clients] where they’re at and best supporting them on their journey. It has to be a team taking care of the whole person. We have to play well together … [and] it works a lot better when we all have open communication with each other.”
Ellis says that part of working as a wellness-focused counselor is serving as a catalyst to connect clients with medical care and other essential services. “We [counselors] are active listeners, so we are often the first people to hear about problems they’re experiencing,” she notes. “We are ethically bound to connect with other practitioners, help make connections and referrals, and have good relationships with [interdisciplinary professionals] in the community.”
For instance, if a client were to mention during a counseling session that they are suffering from back pain, Ellis says she would first provide empathy and prompt the client to talk about how the physical pain has been interfering with their everyday life and affecting their moods, sleep and other aspects of wellness. Then, she would shift the conversation to focus on how the client can advocate to find solutions to move toward how they want to feel. This may include making phone calls together during session to schedule appointments or ask questions of medical providers, she says.
“When people are not taking care of themselves, sometimes they need that little piece of support and the message that ‘I’m worth it,’” Ellis emphasizes.
Najera believes counselors should build connections with clients’ primary care providers, and if they don’t have one, explore why that is and support them in finding one. Ensuring a client’s medical provider is aware of their counseling goals also affords counselors the chance to consult or hand off care if things go beyond their scope of practice, she adds.
“As mental health professionals, we [counselors] cannot prescribe medical things,” Najera continues. “It makes sense to tell clients to go take a walk, but if they go out and have a heart attack, you may be at risk for being accused of giving medical advice.”
“It’s a gray zone,” Najera admits. “Talking about a sleep schedule or healthy diet is fine [as a counselor], but making recommendations about specific things to eat isn’t OK. You don’t know if they might have blood pressure issues or diabetes” or other diagnoses that require a specific diet.
Counselors can still work from a wellness perspective without advising clients beyond their scope of practice — it just takes a little creativity, Najera says. For example, suggesting breathing exercises to a client who struggles with lung function may go beyond a counselor’s scope. However, studies show that singing can help with improving lung function after illness or injury, diaphragmatic breathing, and one’s mental wellness and ability to cope with stress. Using music therapy or encouraging clients to sing to a favorite song to boost their mood would be a creative way to reap those benefits without overstepping professional boundaries, she says.
Listening for client statements such as “My doctor told me to walk every day, but it’s been too hard” can also give counselors an avenue to talk about the reasons why it’s been a challenge and support the client in reaching their walking goals without making medical recommendations, Najera says. She recommends counselors ask clients about their goals and any potential barriers by saying, “It sounds like this is important to you. How do we work on that goal and support you? What would keep you from doing it?”
Najera also suggests counselors ask permission to contact a client’s medical provider(s) on intake forms. Once permission is granted, the counselor has a “permission slip” to make phone calls or send emails or faxes to connect with other providers. However, Najera reminds counselors that doctors and other specialists are often busy and “off limits” for direct contact. Instead, they can work with nurses and other support staff. Many medical offices’ automated phone systems have an option for other providers (e.g., “Press two if calling from another provider’s office”); counselors shouldn’t hesitate to use that option, she says, because they are part of the client’s care team.
Najera also recommends that counselors write a standard letter or email for collaborative care: “Dear Dr. so-and-so, I am now meeting with your client, so-and-so. What recommendations do you have to benefit their overall health and wellness?” Even if that initial communication doesn’t result in a reply, “it creates an avenue for conversation and opens the door,” she says.
When looking to consult on a client’s wellness goals, counselors should make it easy for the provider to respond, Najera advises. “It may be as simple as [sending] a fax or email saying, ‘I’m seeing Jane Doe, and we’re talking about exercise. Is it OK to recommend walking X times per week?’ That way, the provider is able to answer with a simple no or yes and sign off that they are OK with the recommendation,” she says.
Counselors could also prepare letters outlining their contact information, services and areas of specialty and drop them off at local medical offices. This serves not only to spread awareness of their availability for referrals and other patient care but also to offer counseling services to medical staff themselves, many of whom are burned out right now, Najera notes.
“What would be amazing is to say [to medical staff], ‘We recognize that this is a really crappy time for you, and I’d be happy to see you for counseling sessions.’ Being flexible and willing to offer sliding scale and/or evening appointments makes the point that we’re all on the same side,” she says.
Extending counselors’ reach
Interdisciplinary work extends beyond just medical providers, Najera says. Counselors could partner with school-based and community mental health providers, hospital case managers or local law enforcement to help with issues such as crisis management and evaluation.
If a counselor runs a therapeutic group for teenagers who struggle with eating disorders, for example, they could reach out to other local providers and agencies that serve youth to see if they have any clients who might benefit, she says. Or a counselor who specializes in trauma could forge a connection with a wound care center in their area to counsel patients and help them work through the range of emotions associated with losing a limb.
“There’s a lot of ways counselors can stretch and grow and expand their services,” Najera points out. “We [counselors] don’t need to stay in our offices. Integrated care is meeting people where they’re at.”
Bruns is co-directing a federally funded grant to foster wellness on the Youngstown State University campus. She says one of the project’s biggest takeaways so far has been the importance and power of interdisciplinary partnerships. Sharing resources and working across specialties enriches and strengthens services on both sides.
“Don’t take for granted what we [counselors] know about wellness. We have a lot to share. Don’t underplay the value of wellness and self-care, both in our own lives and for our clients. The impact of small changes in self-care and wellness can shift a person’s life, and there’s so much power in that,” Bruns says. “On an individual basis, you can create a culture of wellness wherever you are. We have a part to play, to create a culture of wellness one person at a time. We all have a space where we can make that difference.”
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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.
To me, making those elusive connections between events, experiences and symptoms in our clients’ lives is one of the most exciting parts of counseling. There may be no clearer connection between the mind and body than sleep.
