Tag Archives: Technology

Crisis counseling via text

By Bethany Bray July 22, 2021

People in distress send messages to the Crisis Text Line 24/7 looking for help and support. The organization has responded to nearly six million chat conversations since the nonprofit was established in 2013. Some people find the text line more accessible and comfortable than in-person talk therapy, notes Ana Reyes, a licensed professional counselor and bilingual manager of clinical supervision at the Crisis Text Line.

In crisis counseling, clients need a safe and empathic environment to disclose deeply troubling thoughts and emotions. But how can crisis responders create this same environment using text messages, which don’t allow the clinician and client to see or hear each other?

Reyes acknowledges that crisis counseling through text feels much different than in-person counseling and demands a different approach from the responder. Words sent via text must be chosen very carefully, with the intent of validating the texter’s experience and building rapport.

“During in-person [counseling] services, my face responds to someone’s sadness. In text messaging, my words have to be that mirror, have to communicate that empathy,” says Reyes, who does group and individual counseling at a private practice in Denton, Texas.

Reyes is among Crisis Text Line’s staff of licensed mental health practitioners who oversee the organization’s volunteer crisis counselors, who are located across the United States and come from a wide variety of backgrounds. These volunteers undergo more than 30 hours of training, a large portion of which is focused on ways to ensure safety and build rapport through text messaging, Reyes notes.

Responders are encouraged to frequently use “feeling words,” Reyes says, because they reflect the emotions a texter is describing and help them feel heard, understood and validated. “Perhaps a texter describes that they’re feeling frustrated,” she explains. “We would name that [in a text response]: ‘It feels like you seem frustrated because your mom didn’t respond in the way you hoped she would’ or ‘It sounds like you’re feeling stuck, and it’s normal to feel stuck when things aren’t going the way you hoped or planned.’” These types of statements not only validate what the texter is saying but also act as a gentle way to de-escalate the crisis, she points out.

Many of the aspects of Crisis Text Line’s response model mirror the work a crisis counselor would do in a traditional session with a client, either face-to-face or via telebehavioral health. Crisis Text Line responders begin by introducing themselves and sending the texter a confidentiality disclosure, Reyes says. They use a warm tone throughout the conversation and use open-ended questions to fully understand the texter’s situation and allow them to talk through the issue and emotions that prompted them to contact the organization.

The responders also assess for abuse, homicidal and suicidal ideation as well as self-harm or nonsuicidal self-injury. However, they don’t begin to weave risk assessment questions into the conversation until after report and trust is established. Letting the texter know that Crisis Text Line asks everyone these questions also keeps them from feeling singled out, Reyes adds.

“We acknowledge their braveness,” Reyes says, and continue to use warm tones and statements that communicate care and validation when determining risk. For example, a responder may text, “Thank you for telling me about the stress you’re facing. I just want to make sure you’re safe, and to make sure I’d like to ask, Do you have thoughts about ending your life?” If they answer in the affirmative, the responder would follow-up with more assessment questions, including whether the person has a plan, time frame or means to carry out their thoughts of suicide.

Crisis Text Line responders do not know the location, name or phone number of the person with whom they are texting, although some texters do choose to disclose their name, Reyes says. However, a supervisor does have access to a texter’s phone number and can arrange for external intervention if the texter is deemed a danger to themselves or others, she adds.

Supervisors monitor anywhere from three to 20 conversations happening live on their computer screen, and they can step in anytime a crisis responder needs additional support. They also triage the incoming texts to immediately assign those with the greatest need and queue other less urgent conversations to wait for the next available responder.

In addition to risk assessment and validation, Crisis Text Line responders help texters identify goals and next steps that could improve their situation in the short or long term, Reyes says. Responders then work collaboratively with the texter to explore the resources they have in their life, from self-care to community and social supports. If needed, they may also suggest resources to help texters with a limited or inadequate support system. They share links to national organizations that can direct them to support in their local area because they do not know where the texter is located, Reyes explains.

At the end of the conversation, the responder checks in with the texter one final time to assess how they’re feeling and validate the work they’ve done. They also summarize the next steps and resource options they discussed during the chat. Most importantly, the responder honors the courage it took for the texter to reach out and reminds them that the Crisis Text Line is available 24/7 if they need to chat again, Reyes says.

Many of the people who reach out to the organization in distress are younger, simply because younger generations are usually more comfortable with text messaging. Reyes, who recently completed a doctorate in the counseling program at the University of North Texas, notes that common presenting issues include anxiety, stress, depression, and feelings of isolation and uncertainty — many of which have been heightened during the COVID-19 pandemic — as well as bullying or academic or school-related pressures. There is also a subset of texters who struggle with sexual or gender identity issues, such as the decision to come out to family or friends, she says.

The organization hopes to reach more people with its upcoming launch of Spanish-language services, which Reyes is helping to plan.

Crisis Text Line isn’t meant to be a substitution for long-term counseling, Reyes notes, but it can be a big help to people in moments of despair. The organization does see an increase in text volume in the evening hours, which is often when people are experiencing acute moments of despair, she says. It can also be a first step toward connecting with a local counselor for long-term care.

“It’s beautiful to see how our volunteers learn and blossom through training and experience. This work is meaningful, and it is heavy, but there is also this deep knowledge that you’re helping someone who hasn’t otherwise received any support that day,” Reyes says. “The need at the center of that is decreasing the stigma of mental health services and increasing access to services regardless of financial need or language.”

Tero Vesalainen/Shutterstock.com

Crisis texting in 2020

In 2020, the Crisis Text Line engaged in 1.4 million conversations with 843,982 texters.

The organization began receiving a higher-than-usual volume of texts in March 2020, as the COVID-19 pandemic began to affect Americans’ daily life. Perhaps unsurprisingly, the most common struggles these texters identified were stress and anxiety. However, the Crisis Text Line reports that the volume of conversations in which texters disclosed feelings of depression or sadness dropped by 10% between 2019 and 2020.

Additionally, conversations in which texters expressed thoughts of suicide dropped by 20% from 2019. The Crisis Text Line supported 26,629 conversations in 2020 during which the texter was deemed to be “at imminent risk of suicide because they mentioned that they had thought about ending their lives, they had a plan, the means, and wanted to make an attempt within 48 hours.”

The Crisis Text Line has made this data publicly available in a report, “Everybody hurts 2020: What 48 million messages say about the state of mental health in America.” View the report, including data breakdowns by issue, demographics and state-by-state, at crisistextline.org/everybody-hurts.

 

 

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Related reading

Look for Counseling Today’s August cover story, “Crisis counseling: A blend of safety and compassion.”

 

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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.

Pandemic telehealth: What have we learned?

By Bethany Bray April 27, 2021

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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The future of telehealth

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

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

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Action steps to learn more

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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 future of telehealth: Looking ahead

By Bethany Bray April 22, 2021

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

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

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

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

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

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

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

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

Language in the agreement ensures that any state that adopts the compact will allow counselors to use telebehavioral health permanently, Linde says. Launched in 2019, the compact project is a partnership between ACA and the Council of State Governments’ National Center for Interstate Compacts. Once a 10th state adopts the compact, it will become live and those 10 states will form its governing body.

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

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

Convenience and improved access

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

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

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

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

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

 

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

 

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

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

Helping clients develop a healthy relationship with social media

By Bethany Bray September 24, 2020

When a user opens Facebook, Twitter or many other social media platforms, there is a slight delay before an icon illuminates to indicate that the person has a notification, signaling that someone has liked or interacted with one of the user’s posts.

That moment of delay is purposely designed into social media apps to create an alluring cycle of anticipation and reward, according to Amanda L. Giordano, a licensed professional counselor (LPC) whose main area of research is behavioral addictions, including addictions to technology and social media. “Social media is made to be irresistible. It taps into the pleasure centers of the brain. It’s designed to keep you on it as long as it can,” says Giordano, an associate professor at the University of Georgia. “They operate from the variable ratio reinforcement scenario. That’s the most powerful reinforcement schedule there is. [Social media’s draw] is like gambling, knowing that there could be a big payout at any time, so you keep playing. Users know that they’re going to get some kind of reward, but they don’t know when it’s coming. There is a strong dopamine response [to that].”

That drive to seek the rewards that are triggered by social media can lead to compulsive and problematic use. But by providing psychoeducation about the ways that social media platforms are designed to affect neural pathways, counselors can help clients achieve a healthy balance with their social media use, says Giordano, a member of the American Counseling Association. This is especially true with child and adolescent clients, who are digital natives who have been exposed to technology all of their lives but may not yet possess the maturity to recognize the control that social media can exert over them, she adds.

Providing psychoeducation is just one of many ways that counselors can assist clients in flipping their perspectives and using social media to get what they want out of the experience rather than vice versa. Taking simple actions such as changing a smartphone’s color scheme to gray scale can render Facebook’s notification icon — a red bell — less powerful, Giordano notes.

“By becoming aware of all of that, and understanding how social media is tapping into some of these more primitive brain responses, clients can be empowered by the knowledge and take more control over their use,” she says.

Part of life

According to the Pew Research Center, 72% of American adults use at least one social media site “to connect with one another, engage with news content, share information and entertain themselves.” Pew found that those ages 18-29 had the highest usage at 90%, followed by 30- to 49-year-olds at 82%, 50- to 64-year-olds at 69%, and those 65 and older at 40%.

Pew’s data collection in early 2019 found that more than half of adults who used Instagram, YouTube or Snapchat visited those sites at least once per day. Facebook was pinpointed as the most popular social media site, with 69% of adults using the social networking platform. In addition, 74% of Facebook users visited the site daily.

These statistics point to a hard-to-ignore conclusion: Social media is a very real part of the fabric of people’s lives today. Regardless of counselors’ personal feelings about social media — whether they view its impact and influence as a net positive or a net negative — they must do their best to understand it and the role it plays in their clients’ lives.

Don’t discount the positives

Social media use can factor into any number of presenting issues and challenges that clients bring to counseling, from relationship friction discussed in couples counseling to self-esteem or body image issues in clients who struggle with perfectionism, eating disorders, social anxiety or other conditions. The COVID-19 pandemic has added another layer to this issue, as many people are quarantined or otherwise spending more time at home, feeling isolated and turning to social media to find connection or quell boredom.

As it relates to their clients’ lives, professional counselors may first think of the potential negative implications of social media use. However, the counselors interviewed for this article emphasize that there are both good and bad aspects of social media use. And for many people, the pluses can far outweigh the minuses.

“It’s an area that many counselors shy away from. … A lot of times, it feels like folks demonize social media. There are a lot of ways to keep from using it in an unhealthy way and to use it to your benefit,” says Kertesha B. Riley, a career coach at the University of Tennessee’s Center for Career Development and Academic Exploration, where she is working on a doctorate in counselor education. “There are hundreds and thousands of examples where social media is not a good thing at all, but I don’t let that outweigh the good that can come from it.”

Riley is active on Twitter, using the platform to stay up to date professionally, follow leaders in the field and forge connections. In the realm of career counseling, social media sites such as LinkedIn can play an integral role in clients’ job searches, Riley says, adding that she often talks with her clients about leveraging social media to enhance their career development. Creating posts with hashtags such as #jobs and #hireme can catch the attention of potential employers, while clients can follow hashtags within their own industries to stay abreast of trends or connect with colleagues.

“It can help [clients] to stay in the know and connect with people, but also further their career goals in a way that propels them a lot quicker than without [using social media],” says Riley, a member of ACA. “For networking, follow leaders and movers and shakers in your industry, and see who they follow. See what gets you noticed on this platform, and in your field.”

Social media can also serve as a tool to find and connect with professionals with whom clients relate, Riley notes. “Especially for those who are having feelings of doubt or mention that they’re not seeing people who look like them in the field, they can follow people they admire and identify with.”

As a Black doctoral student, this is the case for Riley. Although she doesn’t have many Black colleagues at her university, she follows and interacts with many Black doctoral students and professors via social media.

ACA member Jordan Elliott saw how social media could play a beneficial role in her work as a residential counselor at a treatment facility for women with substance use disorders. Many of the women at the facility had extensive trauma histories. Elliott, an LPC intern and licensed chemical dependency counselor in San Antonio, often worked with clients to create social media plans for after they were discharged. In many cases, this included joining social media groups and following pages with others in recovery.

These connections helped the women support each other and keep moving forward in their recovery after discharge, Elliott says. If a friend began to relapse, they would often recognize the signs in the person’s social media posts — or lack of posts — and reach out to check on one another.

“They often found intense connections with each other once in treatment. They were already drawn to connect with each other, and they wanted to continue that after they were discharged,” recalls Elliott, a doctoral student in counselor education at the University of Texas at San Antonio (UTSA). “This was huge for them, to stay in contact with one another through social media. … Social media has such a healing capability because it helps people connect and stay connected with each other.”

“When working with clients who have experienced extreme disconnection, via addiction, loss and grief, trauma or other ways, think of the power [social media] can have to bring people together and find connection,” Elliott continues. “In counseling, the relationship is key — we are relational creatures and drawn to connect. Think of how social media can be a connective intervention for clients.”

Getting up to speed

Counselors who aren’t familiar or comfortable with social media should think of it as “just one more way to connect with clients,” Elliott says.

“It’s our responsibility to keep up with it and how it is changing. It can be difficult to keep up with everything, but take that initiative to educate yourself on these platforms as much as you can,” Elliott urges. “For counselors who don’t feel as comfortable with technology, think of it as a creative intervention [to reach clients], and it might not be as intimidating.”

Giordano agrees, noting that counselors have a duty to bring themselves up to speed on social media to better help their clients. Having even a basic knowledge of the different platforms and their varying attributes will help practitioners ask the right questions to connect with clients,
she says.

“The best way is to ask clients, ‘What does it [a particular social media platform] do for you? Escape boredom? Find identity? Connect with peers?’ It’s really important to have a nonjudgmental view of it because, in large part, people have a good experience and find benefits,” Giordano says.

Counselors who want to learn more about social media can begin by doing an internet search on the different platforms and the terms they hear clients using in session. In some cases, counselors might want to consider creating a profile themselves so that they can log in and explore a platform further. Erin Mason, an LPC and assistant professor at Georgia State University, notes that some of the school counselors she knows have created TikTok accounts to better understand the video-sharing platform that is particularly popular among teens and young adults.

Mason, an ACA member, has maintained an active presence on Twitter, professionally, for nine years. She says it helps her stay up to date on trends and developments in the field of school counseling.

Riley recommends that counselors “stay open-minded and talk with someone in your personal or professional life who does use social media. Talk with your clients. Ask what draws them to it and what are some challenges that they’ve encountered. Hearing some firsthand perspective can help pull the wall down against social media,” she says. “[Social media] is a living, breathing, evolving entity, and because of that, there’s a place for everyone if you choose to look for it.

“If a client really loves TikTok, have them walk you through it: What do they like about it? What makes a good video [post]? What do they engage with the most? This helps open them up and tells you a lot about why and how they engage. … It gives you a better idea about their motivation, their mindset and their personality based on the type of platform and how they engage [with it].”

When it becomes a problem

There are no uniform diagnostic criteria for social media addiction, either in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or through the World Health Organization or other agencies, Giordano notes. However, she says, it is estimated that between 5% and 10% of adults have a “problematic relationship” with social media — a prevalence that is comparable with most other behavioral addictions.

“What we know is that it’s prevalent among adolescents, adults and young adults across the globe,” Giordano says. “In the United States, researchers have found that almost 10% of undergrads have social media dependence.”

With that in mind, Giordano urges counselor clinicians to complete thorough assessments of clients’ relationships with social media. The frequency and amount of time they spend on the platforms are good places to start, but there are many more nuanced indicators to consider. Giordano recommends that practitioners check in with all adolescent and adult clients about their motives for engaging with social media, their compulsivity levels, how social media use affects their moods and the emotions that they associate with it. For example, does it disrupt their sleep cycles? Do they experience envy, a lack of belonging or self-loathing?

“When the client is not on social media, do they have an urge to check it? Are they craving it? Do they have FOMO [fear of missing out]? Is it creating anxiety when they’re not on it?” asks Giordano, co-author of an upcoming article on cyberbullying and adolescent social media use that will appear in the Journal of Child and Adolescent Counseling.

Practitioners should note that using social media while driving is a red flag that can indicate social media addiction, Giordano adds. There is also a documented link between social media use and nonsuicidal self-injury — so much so that many of the major platforms have created guidelines for banning photos and posts that glorify self-injury, she says.

Overall, people with poor regulation skills are at higher risk for social media addiction, Giordano says, whereas those who have healthy regulation skills are better able to self-regulate their emotions rather than relying on social media to manage their moods. Counselors should listen for the hallmarks of addiction in the ways that clients describe their social media use, she says. Among the possible warning signs are:

  • When clients’ social media use becomes compulsive and they find themselves checking it when they didn’t plan to
  • When clients have a loss of control, staying on social media longer than they intended
  • When clients continue to engage in the behavior even after experiencing negative consequences such as cyberbullying, family or relational conflict over their social media use, or disruptive sleep patterns

Practitioners can use several assessment tools and questionnaires to screen clients for social media addiction, Giordano notes. More information on these tools can be found in “Investigating psychometric properties of social media addiction measures among adolescents,” an article that Giordano co-wrote with Joshua C. Watson and Elizabeth A. Prosek for the October issue of the Journal of Counseling & Development.

Elliott emphasizes the importance of assessing each client individually because what a healthy relationship with social media looks like will differ for each person. “One client could say that they only use social media six hours per day — but they used to use it for 12. Shift your perspective to meet them where they’re at with their social media use, and don’t pathologize it. … Don’t have a set idea of what it would or should look like, thinking you know what’s best for them. Let them be the judge of how they interact with these platforms instead of us placing our perceptions on them,” says Elliott, who co-presented a session with Stacy Speedlin titled “Healing the Brave New World: Resolving Trauma Issues for Millennials Using Social Media” (available at https://imis.counseling.org/store/detail.aspx?id=PEES19010) at the ACA 2019 Conference & Expo in New Orleans.

For Riley, a general indicator that a client has an unhealthy relationship with social media is when its use begins to interfere with the person’s daily life and functioning. If clients talk about choosing activities because they might result in posts or photos that will garner likes or attention on social media, that should prompt further questioning from the counselor, she says.

“It’s not as simple as the amount of time you spend on [social media]. That can be an indicator, but not necessarily. … Right now, with everyone at home [because of COVID-19], use will be higher,” Riley says. “If it’s impacting the time you [the client] are spending on self-care, or time with loved ones, being in nature or in your community, and you’re finding it’s taking time away from the things you want to do, then it might be approaching an unhealthy relationship. … Asking [clients] about their time spent on social media is a way to start the conversation. But from there, flesh out what is behind that. What is compelling them to spend so much time on social media?”

Cold turkey isn’t the answer

A recommendation that clients delete their social media accounts or discontinue their use altogether may be appropriate for the small percentage of individuals who truly struggle with social media addiction, Giordano says, but it might not be helpful — or even possible — for many other clients.

“There are a lot of benefits to social media, from building relationships and social connectivity to advocacy,” Giordano says. “The answer is not to stop using social media. The answer is for clients to take more control of their social media use so they’re not just going along with whatever impulses they have but [instead] being intentional.”

Counselor clinicians should also keep in mind that social media may be part of a client’s livelihood, adds Mason, so it would not be feasible for the person to quit the platforms entirely.

The same holds true in the realm of addictions recovery, notes Elliott, who counsels mostly adult clients at UTSA’s Sarabia Family Counseling Center, which offers free community services. Deleting one’s accounts would mean severing contact with those who support them during recovery. Social media “is often their lifeline to each other,” she says. “Say they relapse. It’s so important to have that network that they can plug back into. If they’ve deleted all their accounts, how are they going to do that?”

“I think the best way to help someone learn to have a healthy relationship with social media is [for them] to use it,” agrees Riley. “There can be instances where it can be helpful for clients to step back for a time, but for me it’s important to help them engage with it in a healthy way, and that’s not as easy if you go cold turkey.”

“I have a love-hate relationship with this idea, but social media is ingrained in our society,” Riley continues. “Not using it is lessening your engagement with the world, especially for those in rural or isolated areas. It’s a way to see the world without leaving your ZIP code and engage and learn from those who aren’t around you.”

Getting to the why

Researchers from Harvard University, in a November 2019 study published in Health Education & Behavior, found that routine use of social media could have positive health outcomes on social well-being, mental health and self-rated health. At the same time, researchers found that having an emotional connection to social media use could generate negative health outcomes, such as increased anxiety, depression, loneliness and FOMO.

Having a healthy relationship with social media involves understanding why one uses the platforms, and counselors can play a key role in helping clients explore that perspective. It’s most important for clients to decide on and create their own goals rather than counselors making suggestions, Giordano stresses.

“They probably already have people in their life telling them that they spend too much time on social media, so that’s not helpful to say. Instead, help them find their own motives for making change. From there, come from a nonjudgmental stance [and] use the client’s own motivation for making change rather than just imposing rules,” she says.

Giordano finds motivational interviewing and cognitive behavioral techniques helpful when engaging in this work with clients, but she says that counselors can adapt whatever framework they prefer to address this issue.

Practitioners can start by helping clients “give voice” to the pros and cons of their social media use. Giordano suggests asking clients in session why they use it, what they like about it and what they wish they could get out of it.

Giordano notes that research studies on the function of social media in people’s lives have pinpointed that people turn to it to meet three main needs:

  • The need to belong
  • The need for self-presentation
  • The need for emotion regulation or mood modification

She suggests that practitioners ask clients about their thoughts and beliefs prior to using social media, during social media use and after social media use. Then, listen for language that could indicate deeper issues or maladaptive core beliefs that might be motivating clients’ behavior. For example, a client who struggles with self-esteem may mention feeling inadequate or self-critical if they don’t post a witty response to a friend’s post.

Elliott emphasizes that the client should be the driver in this process. “I’m a huge advocate for meeting clients where they’re at. If they’re presenting with negative side effects of social media or an unhealthy relationship with it, ask them about their relationship, what is its role in their life and how is it affecting them. Enhance that conversation instead of challenging it head-on. [If you say], ‘It sounds like you’re addicted to social media,’ that’s not going to help. Fall back on motivational interviewing techniques to have them evaluate what it is giving to them versus taking from them.

“Social media is good because you get to choose who you’re connected to. There’s so much freedom. A counselor can help with flipping that perspective: [Clients] have control of who they’re friends with and what they might see in their feed.”

Perspective shift

Counselors can help clients move toward intentionality and control over their social media use. A good way to start this process is to prompt clients to talk about what social media gives them and what it takes from them — and how or whether they’d like to change those benchmarks, Elliott says.

Elliott recalls one client with whom she worked at the residential treatment center in San Antonio. Social media was a prevalent part of the woman’s life, and she had more than 1,000 “friends” on Facebook.

Clients were not allowed to have cellphones while they were in recovery treatment. As this particular client neared discharge, Elliott allowed her to turn on her phone — for the first time in two months — as part of creating a social media plan in a session.

Elliott sat with the client as she went through her social media contact lists, blocking, unfollowing and severing ties with people who had previously been part of her life of substance abuse. Many of them had sent her messages, knowing full well she was in a recovery program, to ask her to contact them once she was out.

“If she had looked at those messages at the beginning of her treatment, she might not have stayed. There were a lot of unhealthy people in her life,” Elliott says. “It was a really important exercise to do. In hindsight, I can’t imagine what would have happened if we didn’t address this together. Would she have left treatment, turned on her phone and been bombarded with all these messages?”

Instead, in session, Elliott and the client talked about setting boundaries with social media and processed each friend decision together. They talked about why she wanted to block some people and unfollow yet remain connected with others — those to whom she could be a help, Elliott recalls.

The client also was able to add women from the treatment program to her social media accounts. This greatly broadened her pool of friends, adding people of different ages and backgrounds. The process represented “a complete reframe” for the woman as she exerted control over her social media and decided what role she wanted it to play in her life and her healing moving forward, Elliott says.

This process was often part of creating social media plans with clients at the facility, Elliott says. She served as a support as clients deleted or began to follow accounts, set boundaries and rethought their social media use.

For example, if a client followed a page that glorified drug use, such as the account of an artist or musician, Elliott and the client would process that choice together. “I would talk it through with them: ‘How will it affect you to see that? If so, what are you going to do about it?’ We would evaluate which of these things [the people and pages the client followed] are worth it to them and which things aren’t, as well as knowing their triggers and making a plan for if they were triggered by social media. For example, ‘What if you go on to social media and find that someone has passed away [from an overdose]?’ I would talk all of that through with clients.”

Setting boundaries

Exerting control over one’s relationship with social media often involves setting boundaries and limits. Counselor clinicians can support clients in this process by helping them create a social media plan in counseling sessions. Giordano says this can be particularly helpful for adolescent clients, who may benefit from writing down parameters to which they can refer back outside of sessions.

Social media plans should delineate specific times that clients do not want to use social media, such as during mealtimes, while driving, right after waking up in the mornings or within two hours of going to bed at night, says Giordano, who is writing a book on behavioral addictions that is slated to be published next year. Part of a client’s social media plan might include deciding not to engage in phubbing, a term for when people are glued to their smartphones while gathered together with others — in essence, snubbing people in favor of their phone.

Offering psychoeducation about the triggering aspects of social media can also be helpful during this process, Giordano says. For example, discussing the brain’s dopamine response to a phone’s notification alerts might lead clients to deactivate the notifications for their social media apps. Similarly, explaining how the blue light emitted from digital screens can disrupt sleep cycles might prompt some clients to set a goal of putting their phones in another room when they sleep, thus removing the temptation to check it while in bed.

There are also numerous apps and programs available that limit the amount of time a user can spend on a particular website, including social media. Giordano recommends an app called Offtime, whereas Mason uses Freedom, which is available both as an app and a Chrome plugin. In both cases, the user selects the amount of time they’d like to allow themselves to use certain sites each day, or they have the option to block sites entirely.

“One of the things that makes social media so different from reading a book or watching a movie is that a book and a movie have a set end. With social media, you can scroll without end, so you have to be intentional,” Giordano says. “Clients and counselors can decide [as part of making a social media plan] to only use social media when the results are positive and to do emotional check-ins on how using social media is making them feel.”

 

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Social media and youth: Taking a proactive role as a counselor

For counselors who work with young clients or in school settings, part of staying up to date with social media includes becoming knowledgeable about cyberbullying, says Erin Mason, an assistant professor at Georgia State University.

Cyberbullying, or harassment via digital means, including through social media, is a complex topic. It can take place both during and outside of the school day and both on and outside of school property. In school settings, the responsibilities of counselors and administrators regarding cyberbullying can vary significantly from school to school, as can the consequences imposed on students, notes Mason, who was previously a school counselor.

Mason recommends that counselors visit Common Sense Media (commonsensemedia.org) to stay updated on the latest trends in social media and its use among children and adolescents. The site’s many resources include detailed descriptions and ratings of TV shows, movies, apps, video games and other media for parents and educators.

Mason emphasizes that counselors need to take a proactive role — rather than a punitive one — when it comes to cyberbullying. Efforts should go toward fostering a healthy school culture that includes a focus on positive social-emotional behavior, she says.

“Counselors need to be really vigilant about what’s trending at their schools. Sometimes the trends start in schools and then filter out and become problems in lots of places [in the community],” Mason says. “This is where partnerships are really important — partnering with other school staff, local police and families, and making sure everyone’s on the same page with what’s happening.”

In a trend that was brought to Mason’s attention by one of her graduate students, a problem arose at a school where students were exchanging and sharing messages via Google Docs. The students would type a message and change the font color to white so that any parent or school staff person who intercepted the document would just see a blank page. This method was a way to conceal cyberbullying among students, Mason says.

“Kids figure out the workarounds, ways to trick the system or at least trick the adults,” Mason says. “It’s a lot for educators to stay on top of, and it’s a lot for families to stay on top of.”

On the flip side of the coin, Mason says she has seen social media used as a positive tool in schools. One of her colleagues was running a small group for female students in high school that was focused on empowerment, confidence and positive body image. She created a Pinterest board, and the teens were able to “pin” inspiring quotes and positive messages to share with one another. This activity bolstered the group’s cohesion, Mason says. The young women would add to the board outside of sessions, and the group would discuss the posts when they met in person.

“Some of this comes down to generational differences, and I wonder if over time we will see more of a shift in understanding how social media and these kinds of tools can be helpful, because they are so integrated in people’s lives,” Mason says. “Over time, the negatives won’t diminish, but the advantages will begin to outweigh the negatives, and counselors have a role to play in that — with families and in school settings. We need to be thinking about how social media can contribute positively to school environments.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

ACA Code of Ethics (counseling.org/resources/aca-code-of-ethics)

  • Section H: Distance Counseling, Technology and Social Media

Continuing education

 

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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.

Voice of Experience: The miracle of 28 days

By Gregory K. Moffatt September 17, 2020

When I began my life as a mental health worker well over 30 years ago, the words “managed care” weren’t even a blip on the radar. Almost everyone had personal insurance. People who had an HMO were mostly factory workers, and to have an HMO or a PPO was generally not regarded as a good thing. Otherwise, you could go to whatever doctor you wanted, there were no “referrals,” and both physicians and counselors had immense latitude in the first few weeks of treatment.

In those days, there was a joke in our profession that went something like this: “How long does it take to treat [fill in the blank with any issue]?”

The answer: “Twenty-eight days.”

The reason for 28 days is that insurance companies would reimburse for up to 28 days of treatment — even in-patient care — without question. After that, lots of other documentation was required. So, miraculously, in-patient care was often — you guessed it — 28 days.

Of course, no responsible therapist planned their treatments based on that 28-day ceiling, but we had tons of latitude on treatment plans. But the late 1980s brought us major changes in health care. Managed care (HMOs and PPOs) changed the way we did business. I was too new in the field to have an opinion at that time, but I remember the outrage among my supervisors and other veteran counselors.

In retrospect, the change in how insurance worked actually helped us (forced us?) to become better in how we provided services. For example, brief solution-focused therapy, which was something that didn’t exist when I was a graduate student, is a result of this change.

You may be asking yourself whether there is a point to this interesting trip down memory lane. Well, I think we may be seeing something just like I described above happening right now.

Americans are innovative. I am confident that the coronavirus pandemic has created a scenario that will permanently change much of our culture. In the 1980s, therapists didn’t have to think about being “brief” or efficient, but the rise of managed care forced our hands, and we got better because of it.

This virus has forced us into telemental health and other ways of offering services that, prior to March of this year, we didn’t have to think about unless we wanted to. I have encouraged all of my supervisees to pursue the telemental health credential in our state, and I have done so myself, both as a clinician and supervisor, but I suspect that lots of veteran therapists just didn’t want to mess with a new modality.

Imagine that. Once again, here is something that we were forced to do that we should have been doing already because it provides options and helps our clients. In my early years, I learned to be efficient — to do in one session what my teachers might have had the luxury of doing in five or 10 sessions. I did things efficiently because managed care forced me to do so. But shouldn’t we have been doing that anyway?

I’m not belittling my predecessors. My teachers and supervisors didn’t have to do something they weren’t accustomed to doing, so they only did it if they felt like it. Now I’m realizing that this current pandemic is changing the way we do business, and that change isn’t going away when the virus eventually fades away. I predict that some of our clients will never choose to go back to the way it was. And maybe they shouldn’t. Young therapists will probably look back on this time in history and say, “Why did my teachers need a virus to get them to routinely offer services that benefited their clients? Crazy!”

This will also affect me as a college professor. My students undoubtedly will be asking, “Why do I have to come to the classroom?” long after the pandemic is history.

My clients will be asking something similar: “Why do I have to drive all the way across Atlanta and deal with traffic every week when I can see you from the quiet of my home office (in my slippers and jammies) if I wish?”

So, in our very near future, I suspect that graduate programs will not offer telemental health as an optional certification. Instead, programs will be adjusted to provide telemental health as an expected option for clients who fit well with this modality.

If any of you reading this are holding your breath until things “get back to normal,” don’t hold your breath any longer. We have a new normal, and this will almost certainly, in some ways, be very good for us, good for the counseling profession and, most importantly, good for our clients.

 

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Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

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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.