Tag Archives: Technology

Embracing fandom in counseling

By Samantha Cooper November 7, 2022

Fan communities, or fandoms, are often misunderstood by the public. Fandoms refers to people who share a common interest in an aspect of popular culture. Whether they are huge fans of the Marvel Cinematic Universe or enjoy dressing as anthropomorphic animal characters, also known as “furries,” people who dedicate their free time to a specific piece of media are often seen as “odd” or childish to others.

For example, according to a 2017 article published in Psychology Today, some people consider furries’ desire to dress as animals as a form of sexual gratification, rather than a form of self-expression. In the case of fans of fictional franchises, such as the British science-fiction TV series Doctor Who, the negativity seems to come from a long-established idea that these fans are social misfits and outcasts and that they place more importance on their fictional world rather than reality.

Being a fan of a certain sport or sports team, however, is seen as more socially acceptable and often isn’t considered to be a “fandom” in the same way pop culture fiction is. But even as science fiction, fantasy and superhero franchises become more mainstream in pop culture, those who are deeply enmeshed in fandom culture may still feel as though their passions won’t be properly understood by mental health professionals because of these stigmas.

“Speaking as a science fiction geek myself — I even have a Star Trek tattoo — this subject is really close to my heart. Empathy is important when supporting any therapy client, but because there can be some stigma around fandom communities, empathy is important when supporting fandom clients. If the therapist is coming from a perspective that perpetuates stigma, such as looking down on furry cosplay artists or fanfiction authors, it’s important for the therapist to do the inner work, to grow as a person, to learn how to see the joy in others’ joy,” says Lindsay Meagher, a licensed mental health counselor at Protea Wellness in Seattle. “It’s important to internally approach fandom clients from an open-hearted, open-minded, empathic perspective.”

Using fandom to build rapport

Some counselors embrace “geek therapy,” which integrates aspects of so-called “nerd culture” such as video games, comic books and science fiction media to build rapport with clients.

Geek therapy operates on the principle of affinity, which is using common interests or background to establish a repertoire with a client. If a counselor mentions they share an interest in a particular piece of media or a love of going to fan conventions, the client can feel more comfortable expressing this part of their identity.

Ashley Myhre, a licensed marriage and family therapist at POW! Psychotherapy in Minneapolis, says it’s important for clinicians who are working with this population to create spaces where the clients can feel safe to express themselves.

Myhre has created her practice around the idea of fandom therapy. The logo for her private practice resembles a sound-effect bubble from comic books: It’s a light blue bubble with the word “pow” written in orange, capital letters. She says this design choice helps communicate that her practice is one where clients can bring their whole self to sessions.

“If that’s the kind of client you want to cater to, you need to make your space welcoming,” she explains. Her office space is decorated with rainbow flags, pop culture figurines and stuffed animals, which are images that signal to her clients that her practice is a safe space for people in LGBTQ+ and fandom communities. Her website also contains a statement saying, “Mental health for nerds, geeks, misfits and others outside of the mainstream.”

Counselors who aren’t a part of fan communities can still show their support in small ways, Myhre notes. For instance, she says that little things such as office decorations can make or break a client’s trust. “Do you have any kind of fan art in your spaces? Is your mug from your favorite TV show? What are [some] visual cues you can be sending to clients that it’s a safe space?” she asks.

Counselors can also find ways to learn about fandom and use this knowledge to build rapport with clients. It’s much easier to make your space welcoming to those in fandoms when you understand the basics, Myhre says. And part of that can be done simply by listening to and respecting clients’ passions.

Myhre advises counselors to listen for cues where the client is talking super passionately about some aspect of fandom such as a particular character or object. When she hears this, she will ask the client questions such as “How has this mirrored some of your own experiences?” “How have you come to better understand yourself through being a fan of this media?” “What are the strengths you see in these characters that you want to bring into your own life?” or “How does this align with your values?”

Doc Davis, a licensed professional counselor and owner of Side Quest Therapy in Austin, Texas, takes this a step further by incorporating games, such as video games or online chess, into counseling sessions. This is the approach he takes with one of his clients; he always begins their virtual counseling session by playing a video game together.

“We start our sessions literally online together playing a game,” Davis explains. “We’re not talking about therapy just yet; we’re just playing a game, … having fun, and then the therapy starts to slip in.” When the conversation starts to be less about the game and starts becoming more about the client’s life, Davis puts the game on pause, and they continue the conversation and move into the therapeutic part of the session.

Kashawn Hernandez/Unsplash.com

Finding a sense of community

Fandom can also provide a sense of community. Those who struggle to connect with others in real-life communities may find their companions online or in person through a shared love of a piece of media. For people who struggle to make friends, outwardly expressing their fandom makes for an easy icebreaker. Two people wearing the same shirt, for example, can strike up a conversation and form a friendship based on their mutual interest.

Meagher says that while anybody can potentially be drawn to fandom cultures, people on the autism spectrum are often drawn to fandoms. “A lot of fandoms and a lot of passions are autistic special interests,” says Meagher, who is autistic. “Many of us in the autistic community lean into our passions in really beautiful ways that are part of the community’s norms, but that can be jarring for a lot of people outside of the autistic community who maybe don’t engage with the world in that way.”

People in fandom often use social media platforms to connect with each other. Both Facebook and Reddit allow people to join different groups devoted to fandoms, and there are several hashtags that make it easy to find people who share similar fandom interests.

“I know that social media has helped people who are isolated, often as a result of physical disabilities like fibromyalgia, or as a result of being in grad school. … Often people in fandoms are seeking friendship with people that they have something in common with, and it can be a little hard sometimes to make local friends quickly who share in one’s passions, so this makes online social spaces, such as Archive of Our Own, Discord, Instagram, Tumblr, and even Facebook and Twitter, really lifesaving for a lot of us,” Meagher says.

Therefore, it’s important for counselors to recognize the role that fandoms play in people’s lives, and the different aspect and nuances that come along with it, including the prevalence of parasocial relationships, which are one-sided relationships that someone forms with a media persona. (For more on parasocial relationships, see the sidebar below.)

People involved in fandom often consider themselves to be their own community — one with a shared interest. So having a therapist who is also familiar with the concept and importance of fandoms will make a client more comfortable in the therapeutic environment.

“I think if you’re in fandom, you get it. We have this shared experience. … It just makes things so much easier,” Myhre says.

Just knowing that fandoms are valid communities and becoming curious about a client’s passion is a good start and helps counselors connect with this population. Counselors can also consider where their own “geeky” interests lie and make those interests known to their clients, Myhre adds.

Davis agrees that counselors should be open to exploring aspects of fandom that interest them. The name of his private practice, Side Quest Therapy, is a reference that is instantly recognizable to people who play video or tabletop games. It shows that he’s more than a therapist who just happens to play games, he says. It shows that he integrates it into his clinical work.

Counselors, of course, can’t be a fan of everything, so they will encounter clients with different interests. When Myhre has a client who has an interest she isn’t familiar with — such as a particular anime — she’ll watch a few episodes so she can learn a little bit about it and be able to connect better with the client. For example, she may ask, “What are you getting from anime? Is this particular story connecting with you? Are you bringing some of the lessons into your own life?”

Myhre, Davis and Meagher agree that the most important thing is for counselors to be themselves.

If counselors do not specialize in geek therapy or do not find that it fits well with their clinical approach, then they should refer clients to someone who does have knowledge working with this population, Davis says. If a counselor’s first reaction to somebody whose main hobby is cosplay is “What is that?” then it might not be a good match. But counselors who aren’t into fandom, Davis adds, can still put in the work and educate themselves on what fandom means to their clients.

However, in general, a client whose identity is centered on fandoms often works better with a counselor who also has a passion for them. “Can you imagine what it would be like to go to your therapist and [have] them express to you from that same place because they have that same love, same passion and you can recognize them?” Davis says. “If you don’t have knowledge of fandoms, you could seriously consider creating a referral list for people like me who will look at that and be like, ‘Cool, let’s make that happen.’”

 

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Parasocial relationships

Parasocial relationships (i.e., a one-sided relationship between a viewer and a media figure) and fandoms are closely intertwined. Not every person involved in a fandom has a parasocial relationship, but the relationships with fictional characters or actors is often an important part of many people’s fandoms.

As with any kind of relationship, a parasocial relationship can become toxic, but they can also be beneficial. People who are isolated in their real life may find community and friendship online with their peers and with fictional characters, says Lindsay Meagher, a licensed mental health counselor at Protea Wellness in Seattle. Having parasocial relationships can be a way to make real friendships with people online and/or in person by bonding over a shared love of fandoms, they explain.

These parasocial relationships can be a way of exploring aspects of one’s identity, such as gender or sexuality, that they may not be able to do with the people in their lives. Parasocial relationships provide a sense of community and healing that the person may not otherwise have, Meagher notes.

Ashley Myhre, a licensed marriage and family therapist in Minneapolis, says that parasocial relationships can often be handled in a lot of the same ways as real-life relationships. There isn’t a different technique needed to coach somebody struggling with a parasocial relationship.

Myhre sometimes incorporates the parasocial relationships in session. She may ask a client to imagine what the person or character they are in a parasocial relationship with would say to encourage them when they’re in a depressive state, or she may ask the client to find a positive attribute they share with this person/character. If a client’s favorite character is physically fit, for example, then that client may be more inspired to make healthier lifestyle changes because they want to emulate the character or because seeing this character’s lifestyle motivated them to make changes they were already wanting to make in their lives. In addition, seeing a fictional character go to counseling or talk about their mental health can help destigmatize the idea for potential clients.

But at the end of the day, parasocial relationships with fictional entities often come down to people seeing similarities in experiences that are like their own. Someone who is neurodivergent, for example, may not feel accepted in their real-life social circles, so having a parasocial relationship with a fictional character or celebrity who is also neurodivergent can help them figure out their own identity and accept their differences.

“I think so much of it [parasocial relationships] comes down to a feeling of being seen, a feeling of being understood, validation [and] representation,” Myhre says.

 

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Related reading, from Counseling Today:

 

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Samantha Cooper is a staff writer for Counseling Today. Contact her at scooper@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.

Are counselors ready for the metaverse?

By Staci Hayes November 4, 2022

I am  going to be completely honest with you. I have never had Facebook or any social media for that matter. I’m aware that may hurt my credibility, but I never really got into any of it. I wanted to avoid having that conversation with students and clients about why we couldn’t or shouldn’t be friends online. I just never got on board. 

But when I saw that Facebook was changing its name to Meta, the Macy’s Thanksgiving Day parade was selling non-fungible tokens (i.e., a digital asset that links ownership to unique physical or digital items such as art or music), cryptocurrency was on Saturday Night Live, and my husband walked into our house with pricey Oculus goggles, I started to pay attention. Some influential, smart and wealthy people started to express a really big buy-in for this metaverse thing, and I was seeing more and more evidence for its relevance. But I still wondered: What is it and why should I care?

Embracing technology

Before the pandemic, I was a relatively staunch and rigid believer that counseling could not really occur in virtual spaces and counselor education could not be as effective online as it could be in person. It is never really a comfortable place to operate from when you must readily admit that what held you back were your own personal biases about technology, ones that you later learned are inaccurate. From a completely anecdotal perspective, many clients and students have both benefited and grown from relationships that have been created and maintained over Zoom. 

Born completely out of necessity, this shift to online counseling, supervision and education in response to the COVID-19 crisis has been met with a healthy dose of suspicion and apprehension. Appropriately so. With so many of us continuing to use virtual platforms with clients, work from home and teach completely online, it’s the perfect time for counselors and other mental health professionals to discuss the potential benefits and dangers of virtual counseling. 

Will we be able to help, empower and counsel clients virtually anywhere as the world around us becomes more and more technological? Will we be ready for what the winds of change bring our way? And how well will we be able to adapt and calibrate without losing a sense of who we are and what we are personally driven and ethically bound to do? In short, how can we be counselors in this rapidly changing world?

The metaverse of today and tomorrow 

As I began to explore and dabble more with technology-centric disciplines — ones I never thought I would find myself in — I unearthed a growing curiosity in myself about technology. So, like the character Neo from the 1999 science fiction film The Matrix, I decided to take the red pill — the one that offers a glimpse into a world with an uncertain future — and head down the rabbit hole. Please believe that my innate pragmatism, low stress tolerance for cutting-edge technology and counselor professional identity have all acted as a carabiner, hooking me to the safe rock of reason and practicality. 

Along this journey, I discovered the metaverse, which is the next iteration of the internet and is referred to as Web 3.0. This term is often conflated or confused with virtual reality (VR). Although VR provides an opportunity to best experience the metaverse, these terms are not synonymous. The metaverse is the swimming pool, and VR is the floaties (yes, I have multiple children) or life vest that you choose to wear or not. The vest (VR) can undoubtedly improve the quality of your experience but is not necessary for you to enjoy the pool (metaverse) or for the pool to exist. VR may be something that many could avoid entirely, but the metaverse will be harder to ignore because it will impact how we live our everyday lives and represents all the technological advances that will undoubtedly permeate our day to day. For example, it is hard for anyone to even apply for a job without accessing the internet; smartphones are easy to find; and most of us use two-factor authentication and are often asked to use CAPTCHA to prove that we are not robots.

Most people know of the metaverse through movies and television shows such as Wreck-It Ralph, Westworld, Ready Player One and Black Mirror. These shows often depict the metaverse as a dystopian reality, with robots taking over the world, a dispersion of wealth that has devastated some and elevated others to extravagant riches, and everything else in between. And although these Hollywood imaginings are a while — potentially years — away from becoming a reality, people do use VR goggles to maximize their enjoyment of the digital world from a 3D perspective through avatars. 

There is not one specific metaverse yet, but many large companies are currently working to create one. You do not need a search engine or “middleman” to log on to the metaverse, and it can be assessed from a computer, smartphone or smartwatch. Voice recognition, hands-free operation and artificial intelligence are hallmarks of the metaverse. So anyone who has ever told Siri or Alexa to play their favorite song or received a social media ad for products after talking about that product near their listening device can attest to many aspects of the metaverse that are already available.

The potential benefits 

As technology races to catch up to the vision and imagined concept of the metaverse that represents the collision of a physical world and augmented reality, we are given a precious opportunity as counselors to gain our bearings and come up with a frame of reference. What can the confluence of VR and the metaverse do for our clients, our supervision and our education? For me, it is less about a personal love of technology and more about recognizing the changing landscape that is altering how we are collectively interacting.

Regardless of whether counselors choose to engage in this modality or they choose not to pursue it, we as helpers need to be prepared and equipped to handle any of the issues or concerns that will undoubtedly emerge because of its existence. Having difficult conversations and exploring what psychopathologies could potentially be exacerbated by this cultural shift could give us an opportunity to instill a preventive and strengths-based approach. If we as a helping profession had known how access to and popularity of social media would impact our society and how the prevalence of cyberbullying would ravage schools, could we have prevented some of the carnage instead of reacting to it? 

VR opens up creative possibilities in technology and counseling, and there is some research to support that it can be helpful to a wide array of clients. In particular, VR has shown effectiveness in the following clinical areas: 

  • Fear of heights and flying
  • Posttraumatic stress disorder
  • Eating disorders 
  • Substance use disorders 
  • Trauma 
  • Grief and loss

In addition, counselors can use VR to do the following:

  • Engage in role play for social skills interventions with clients 
  • Help clients improve empathy and increase understanding of complex societal issues 
  • Reduce unfamiliarity and mitigate discomfort of mental health treatment  
  • Create spaces for people with disabilities 

A few words of hope and caution

As we enter this technological space and begin to have these conversations, I want to offer an opportunity for reflection.

What we have been doing is not good enough long term. It is important that as licensed professionals, supervisors and counselor educators, we are aware that many of the practices and policies that have been used during the COVID-19 crisis are not rigid and evidence based enough to be enacted for long-term care. As the internet expands and we realize that there is no computer system or program that is not at least somewhat susceptible to penetration, we must be continually focused on preserving client information and confidentiality. We have learned so much from our telehealth experiences that may be applied to our journey with VR and into the metaverse. It is our responsibility to cultivate and encourage ourselves, colleagues, counselors-in-training and newly licensed professionals to not get too comfortable in the current state of operation and embrace the ambiguity that comes from striving for better. It is time to establish best practices that are informed by the protocols and suggestions from the Health Insurance Portability and Accountability Act, the Health Information Technology for Economics and Clinical Heath Act, and Section H (Distance Counseling, Technology, and Social Media) of the 2014 ACA Code of Ethics. 

We must not be willing to compromise the safety of our clients or their information because we are excited about or see the applicability of these technological advances. Issues surrounding confidentiality, affordability, accessibility, equity, emergency situations and credentialing all need to be addressed. And because no legal precedent regarding telebehavioral health has been set yet, we must continue to execute due diligence. This includes detailed and appropriate documentation about clinical services and clear rationale for decision-making. 

Some of the top concerns for counseling in the metaverse include:  

  • Confidentiality and storage of client information: Can we protect clients’ personal information? Can we ensure that what is said in these virtual spaces will remain protected and be heard and shared only with the intended parties? 
  • Affordability and accessibility: Can we ensure that all who would benefit from services and resources in the metaverse will be able to use it, especially marginalized and oppressed populations? (See Daniel Pimentel and colleagues’ article “Virtually real, but not quite there: Social and economic barriers to meeting virtual reality’s true potential for mental health,” published in Frontiers in Virtual Reality in 2021, for a more in-depth explanation of potential barriers.)
  • Client and counselor identification: Can we always verify the identity and location of people within the metaverse?
  • Emergency situations: If a client shares suicidal or homicidal ideations while in the metaverse, will we be able to intervene effectively, keep the client safe and notify the proper authorities? 
  • Evaluation for appropriateness: Can we effectively screen, evaluate and identify those who would most benefit from incorporating the metaverse into counseling and those who might potentially be harmed?
  • Competency: Can we properly train and educate counselors who want to use the metaverse for counseling? (For more on this topic, see Rodney Goodyear and Tony Rousmaniere’s 2019 article, “Introduction: Computer and internet-based technologies for psychotherapy, supervision, and supervision-of-supervision,” published in the Journal of Clinical Psychology.)
  • Unforeseen consequences: Can we provide preventive care for those whose existing emotional and mental health disorders may be exacerbated by the use and installation of the metaverse? 

Preventive care equates to a pluralistic acceptance of technology. Do all counselors need to “goggle up” and dive headfirst into the metaverse? There is no simple, straightforward answer to this question. Deciding whether we should or shouldn’t embrace the metaverse really comes down to our unique interests, skills, passion and ultimately our scope of competency. Self-awareness should guide each of us to choose whether this is something we would enjoy and, most importantly, effectively execute. Adequate and appropriate clinical training in contemporary topics is difficult to find, so we must create specialized training, continuing education, and thorough research on technology and mental health, as well as develop a decision-making model for determining how to appropriately use technology with clients.

We could use a humanistic/anti-reductionist lens to guide our ability to optimize human growth and development with our clients by offering more education, support and meaning attribution. Viewing our clients and counseling students as holistic, purpose-driven and capable human beings could provide context for our students and clients and help them make sense of this technological world and their desired role in it. Only by leaning into technology can we better understand the connection between the metaverse and mental health and predict if an extended and universal misuse of the metaverse could result in mental health issues such as lower stress tolerance, poor emotional regulations, anxiety disorders, porn addiction, phone addiction, narcissism and psychosis. And then we can work to develop appropriate responses before it becomes a cultural crisis.

We must meet this change with a healthy skepticism. It is my hope that as professional helpers and caring human beings, we keep an open but very guarded heart as we consider new technologies. Change is hard no matter who you are, and we need to be kind and patient with ourselves as much as we are with others. As we hear more and more about avatars, non-fungible tokens, blockchain technology, the Internet of Things (i.e., devices and other physical objects that are connected to the internet) and more other-worldly seeming terms, we must stand fast to our counselor identity and not resent the overtechnological existence we find ourselves in. An overall aversion to and resentment of cellphones being glued to people’s hands, and now wrists, are not the best ways to advocate for our clients, especially those who Marc Prensky in 2001 dubbed “digital natives” — people who were born or grew up during the age of digital technology and therefore do not know a world without the internet and technology. Instead, we need to be practical, passionate and curious. 

Accepting this new technological world does not mean that we cannot fight like hell to make it better. We need to have a pluralistic acceptance of technology, accepting the positives that can come from it without losing sight of the inherent dangers. We must be able to disagree, bring alternative viewpoints and find creative solutions to complex problems. As much as the metaverse represents a convergence of a multitude of disciplines, our articulated response needs to represent the art and science of what we do as counselors.

Here are some tips on how to best dip your toes in the metaverse: 

  • Have fun. Try VR yourself and explore the current metaverse.
  • Be practical, passionate and curious.
  • Consider multidisciplinary approaches by incorporating and growing the work you are already doing with a technological spin (e.g., using VR goggles with clients for role-plays or mediations). Counseling has always been a creative process, as Samuel Gladding’s book The Creative Arts in Counseling illustrates.
  • Educate yourself on current trends. Although some clients may not want to get into the “pool” of the metaverse, we must be ready to see any potential danger and protect our clients who are already swimming in it.
  • Have difficult conversations about what this means for us as counselors.
  • Advocate for marginalized populations and make technology accessible for all.

Final thoughts

How well we can embrace cultural shifts while upholding the values and core professional beliefs outlined by the ACA Code of Ethics to benefit clients and continue to grow as professionals will dictate our longevity and significance in the coming decade. As counselors, we adamantly believe and live our personal and professional lives to promote growth and continued development in both ourselves and our clients. So how can we not embrace, with a reflective and introspective heart, all cultural and technological shifts? We do not have to view technology as the enemy of meaningful and sustainable relationships if we are able to collectively work together to instill preventive care. We can take a strengths-based approach that is focused on constantly improving accessibility to our services and removing obstacles for all. 

We have an opportunity to consider how these technological changes will affect both mental health professionals and clients and calibrate how we as a profession are going to respond. Given the chance to rebuild spaces in which people are going to interact, let us advocate for them to focus on diversity, equity and inclusion. Creating a culture that fosters engagement, collaboration and belonging is important because we value individual perspectives and understand that people do not experience the world the same way. We have a chance to help people approach this virtual world with kindness and acceptance and learn to create meaningful and productive lives within it. The metaverse is coming whether we are ready or not, so let’s start the conversation.

Athitat Shinagowin/Shutterstock.com

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Staci Hayes is a licensed professional clinical counselor and was in higher education for five years. She has recently started a nonprofit organization focused on mental health and wellness in the metaverse with a focus on diversity, equity and inclusion. Contact her at shayes@metavoicefoundation.io. 

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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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.

Taking a clinical selfie

By Bethany Bray October 25, 2022

“But first, let me take a selfie.”

This phrase, which was first popularized in The Chainsmokers’ 2014 breakout hit song “#Selfie,” has become a common saying in today’s culture — and one that is sometimes used to satirize younger generations who can’t seem to experience something without documenting it with a self-portrait.

On the surface, the act of taking a selfie can seem shallow or self-promotional. But Amanda Winburn and Amy King, both counselor educators who have a background as a school counselor, say that when used intentionally and in a structured way, selfies can become a therapeutic tool and a way to spark self-reflection, engagement and connection with younger clients.

“We know that children are engaged in” taking selfies, says Winburn, a licensed school counselor, licensed professional counselor and registered play therapist. “So why not take the positive attributes of this practice and expand upon it” in counseling?

Selfies in session

Winburn and King, who have presented on the therapeutic power of selfies at conferences of the American Counseling Association and the American School Counselor Association, have used selfie activities as a therapeutic intervention in individual and group counseling settings.

“This is just one more way we could give children and adolescents an opportunity to express themselves and narrate their story,” says Winburn, an associate professor of counselor education at the University of Mississippi. “We try and incorporate [clients’] worlds in our work, and selfies are an everyday part of our world and everyday part of expression for children, adolescents and adults. It really is the new self-portrait.”

However, Winburn and King stress two important caveats to this work:

  1. Practitioners should take care to ensure that any selfies captured in sessions are not taken with a device that is connected to the internet (i.e., not the client’s personal cellphone) so the images cannot be shared or used in a nontherapeutic context.
  2. Practitioners must obtain consent from a parent or guardian to capture the image of any client under the age of 18.

King, a certified school counselor and provisionally licensed professional counselor in private practice in Mississippi, uses a tablet computer that does not have internet access to allow students and clients to take selfies. She prints the selfie images and keeps them in a client’s file to refer to during sessions and deletes the images from the device. The tablet and client files are kept in a locked cabinet in her office when not in use, she explains.

Tapping into self-expression and boosting empathy

Having young clients take selfies during counseling sessions can serve as a visual and relatable way for them to track their progress in therapy, Winburn and King suggest.

Selfies can document physical aspects of improvement and growth in ways that a client may not notice without a visual record, such as smiling or holding their head up more, sitting tall and appearing more confident, Winburn explains.

When she was a school counselor, King once used selfies to help a student who was struggling with self-confidence. The student kept the printed selfies that she took in counseling sessions in a journal, to which she added notes and drawings. When King and the client talked about her therapeutic progress and looked through the selfies together, the young client was able to recognize that she looked happier and more confident in her progression of photos throughout the year.

She was able to note that she had gotten taller and that her smile was brighter. “She was glowing because she was looking at herself in a really positive way and reflecting about that,” King recalls.

King, a lecturer in counselor education and supervision at Boise State University, finds that students love to look back at their progress in counseling, and by using selfies, young clients can visualize that progression of moving away from having a tough time to having a better outlook on their situation or life.

In addition to strengthening expression and self-confidence, using selfies in this way also provides an opportunity for counselors to explore and process clients’ feelings of self-doubt or self-criticism, Winburn says. In therapy, selfies can be a visual portrait of a client’s narrative and a discussion starter for work that increases self-awareness and emotion recognition.

Winburn advises counselors to ask clients questions to understand the motivations behind their self-expressions and explore if they are trying to portray themselves differently than they really are. For example, she says clinicians can ask, “How does seeing that image make you feel?” or “What makes you feel that way?”

Winburn asks her counseling students at the University of Mississippi to take a selfie at the beginning and end of their day for an entire week. She tells her students, “It’s a way to step out of your comfort zone and process how you were feeling [that week] and how you portray yourself.” Then they reflect together in class on the story their selfies tell, which can be quite eye-opening, Winburn says.

King also used selfies in group counseling with second grade girls during her time as a school counselor. The group’s focus was on building confidence, communication, friend making and social skills. Learning to give and receive positive affirmations — to oneself and others — was an important component of this group work, King notes.

King, assisted by graduate counseling interns, had each group participant take a selfie with a school-issued tablet computer. The student would first look at the selfie themselves and then share it with the group. This activity allowed participants to open up and talk about the feelings their selfie elicited and, in turn, prompt group members to offer positive feedback.

It was a powerful experience that boosted the second graders’ empathy, reflection and listening skills and their ability to consider others’ perspectives, King says. The students would listen, connect and make comments such as “your eyes are really sparkling in that one,” she recalls.

After the group had been meeting for a little while, teachers and recess monitors at King’s school began to report that the students who were in her counseling group started to have more positive interactions during recess, she says.

Using selfies in counseling can help children actively learn and foster positive feelings about themselves as well as learn about individual and cultural differences in group settings, King notes.

“There’s no right or wrong way to make a selfie,” she adds.

Keeping an open mind

King and Winburn acknowledge that counselors can sometimes be skeptical of using technology in sessions, especially mediums such as selfies that can have negative connotations. However, they feel that when used in an ethical and appropriate way, selfies can strengthen trust and the therapeutic alliance with young clients.

It can also be a way to model that technology can be used in a positive way, to build each other up, King adds.

“Make sure you’re using safeguards to keeps clients safe, but try it [using selfies], embrace it and be open to it,” Winburn urges. “Especially with adolescents, counselors need to be playfully engaged and aware of where they are. This is an active way of embracing the world that they live in and meeting them where they are.”

wavebreakmedia/Shutterstock.com

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 Related reading, from Counseling Today:

 

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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.

Rethinking the accessibility of digital mental health

By Chris Gamble July 11, 2022

If your social media algorithm is anything like mine, you’ve probably seen an increasing number of ads for companies offering teletherapy through an app-based platform. Maybe you’ve seen Olympians Michael Phelps and Simone Biles sharing their own mental health stories in TV commercials for a couple of these companies. Regardless of how you come across your information, one thing is clear: the digital mental health (DMH) era is here. 

A 2020 report by the World Innovation Summit for Health defined DMH as “the use of internet-connected devices and software for the promotion, prevention, assessment, treatment and management of mental health, either as stand-alone tools or integrated with traditional services.” This can include platforms that offer varying combinations of therapy, medication management and coaching and those that don’t provide therapy but instead rely more on self-guided, therapist-created content. There are even artificial intelligence chatbots and virtual reality-based mental health interventions, which are likely to expand with the buzz surrounding the metaverse (a digital world where people can interact with others in a computer-generated environment). Throw in meditation apps, guided journals and mood trackers and the crowded bucket of DMH is surely overflowing. 

Although many of these platforms existed before 2020, the onset of the COVID-19 pandemic contributed to their expansion, as many poised themselves as solutions for filling the access gap made wider by the global health crisis.

I have worked as a licensed professional counselor in Washington, D.C., for six years, mostly with low-income, Black youth and families in schools, community-based agencies and currently a children’s advocacy center. So, the constraints of a fragmented public mental health system, long waitlists and a lack of culturally relevant services have been at the forefront of my mind for quite some time now. I regularly see how inadequate availability of quality mental health services can compound trauma and further complicate the healing process. As a Black counselor, I am protective of the populations I serve and vigilant toward any sweeping claims of answers to long-standing problems. Thus, I keep my clients and other marginalized groups in mind when approaching the larger question of how access can be improved through the medium of digital technology. In this article, my aim is not to endorse or dissuade from any specific DMH company but to examine the field of DMH and its shortcomings in improving access for marginalized populations.

Accessible for whom?

In the public discourse around mental health, access is often limited to definitions of ease and convenience. People often assume that removing the burden of internet searches and transportation needs and increasing privacy protection by being in one’s home are key to making mental health care more accessible. In this sense, app-based therapy seems to be a good fit. At least for some. 

The COVID-19 pandemic and the need for schools to switch to remote learning exposed the digital divide in the United States. I personally witnessed similar issues in my community mental health work at the time. For many low-income, Black households, a parent’s smartphone may be the only internet-accessible device they have, or their internet service may not be adequate to sustain full therapy sessions. Add to that the higher likelihood of multigenerational households within certain racial groups, and suddenly one’s home is not so private. Even more barriers exist for disabled people and those with no or limited English proficiency. Considering the amount of work it takes to develop an app, it is concerning that these issues are so often overlooked. If the innovations spurred by DMH continue to ignore cultural differences and structural disparities, the contradictions with goals of increased access will only become more noticeable.

For apps offering self-guided content and therapist-created videos or live discussions, we have to wonder about the cultural relevance of this material. A quick look at popular media and creative content-based platforms supports the suspicion that certain groups could be catered to over others. This is an inherent vulnerability in the “attention economy.” In the battle for our eyes and ears between social media, podcasts, TV and movie streaming, music streaming, and video games, DMH platforms are poised to join the arena. Adding self-guided and therapist-produced content to attract users may seem antithetical to attending to their mental health needs, but when subscriptions and engagement drive a company’s value, what safeguards keep this from happening? 

Given these market-driven incentives, it is imperative that marginalized communities are able to find content that reflects their lived experiences. And DMH companies will need to demonstrate a responsibility to these communities and not stray from public accountability. Suppose a company signs a contract with a popular therapist with a large social media following to produce informational and educational videos for their app. Over time, perhaps users begin to notice cultural bias in this therapist’s mental health tips, or the therapist becomes the subject of a scandal involving discriminatory behavior or public commentary. Would users again be left to trust a tech company to make moral decisions over monetary ones? And how a company responds to such an issue could illustrate whether the well-being of marginalized groups is a priority. Counselors would be wise to take notice of this intersection between the mental health field and broader societal trends in order to understand the varying effects on different groups.

Impacts on the mental health workforce

DMH is also positioned as a solution to fill the gaps in the mental health workforce shortage by using technology to bring clinicians to underserved areas. Let’s first look at what might draw counselors to working for DMH companies. One potential benefit is that therapy apps could handle the business aspects of independent practice, such as insurance paneling, client referrals, scheduling and billing. Taking these responsibilities off the counselor’s plate can make the increased use of these platforms attractive to the field, especially for those who prefer working from home or other remote locations. 

Before looking at how this affects access, we can’t disregard possible downsides for DMH workers. Because many DMH companies are startups, they tend to rely on contract work to facilitate business growth. There have even been instances of changing salaried, benefit-receiving employees into contractors, leaving therapists in precarious financial positions. Other practices such as being paid per the number of words texted to clients call into question whether a counselor would be incentivized to provide care for clinical reasons or personal financial ones. Everyone’s finances and living conditions are different, but these parallels to the gig economy should draw caution. On a broader scale, accepting pay that doesn’t match the labor, along with following business practices that are possibly out of line with the ACA Code of Ethics, can influence how the counseling profession is perceived.

GaudiLab/Shutterstock.com

In the presence of a DMH industry looking for more workers, the previously mentioned problem of the digital divide becomes heightened. As more mental health professionals transition to DMH platforms, fewer are left to work with those who can’t access them. This trend could accelerate even further if we consider the recent progress with establishing the Counseling Compact. I and many others have been eagerly awaiting this development, but I also wonder: Could expanding our reach through the Counseling Compact amid increased DMH options end up siphoning the counseling workforce away from those most in need within our proximity? For instance, if I took advantage of licensure portability in the future and was able to practice in several different states, my caseload would likely be easier to fill and maintain, but marginalized D.C. residents would suddenly find my services to be less available. If licensure portability were implemented on a larger scale, counselors may cast a net so wide that those closest to them end up falling through the holes. 

What to do?

Now that the possible effects of DMH on marginalized groups and the counseling profession have been laid out, the question remains: What can we do about it? Here are some ideas to consider.

1) Get to know the research. With billions of dollars being invested into DMH, the industry does not seem to be going anywhere anytime soon. Counselors need to pay attention to the research and marketing around these products in order to understand what is being prioritized. Determining whether apps are equally or more effective than in-person therapy will be an ongoing project, with outcome-based studies being conducted both internally by DMH companies and by independent parties. It is important for counselors to know what constitutes a quality study design and how companies represent their evidence-based claims. Sample size, outcome measures and the time range of studies are all things to keep in mind. A glaring omission I’ve noticed within much of the DMH research is the lack of racially diverse participants and the fact that sometimes racial demographics are not collected at all. To position DMH as improving access without even looking into possible differential outcomes for people of various identities could actually result in deepening preexisting health inequities. I encourage counselors to take the time to browse the websites of different DMH companies to see if the research studies they reference collect comprehensive demographic data, and then ask themselves what this means in the context of who the app is marketed to.

2) Find the problem-solvers. There are growing pockets of research focused on these problems and their potential solutions. In a 2021 article published in JMIR Mental Health, Elsa Friis-Healy and colleagues developed five recommendations for how the DMH industry can design products that increase utility for racially and ethnically minoritized groups. There are also implementation studies such as Samantha Connolly and colleagues’ 2020 narrative review, published in the Journal of Technology in Behavioral Science, which examined factors for successful implementation of mental health apps, from their design to their uptake and sustained usage. Counselors can use research such as this to understand what elements make for a quality app, thereby empowering us to make informed decisions around their use. Additionally, we can get involved in developing ways to advocate for these solutions or propose our own, whether through national organizations already doing this work or by creating local networks attuned to local needs.

3) Know your clients. Most importantly, counselors who work with marginalized populations need to recognize all the ways their clients can be left behind by an increasingly tech-focused field. By leveraging what we know about the social contexts we work in, we can become better equipped to dismantle barriers to DMH or identify more appropriate solutions to access needs.

Conclusion

The necessary uptake of teletherapy onset by the pandemic lockdowns seemed to open a door to solving the long-recognized problems associated with accessing mental health services. If the heads of DMH companies are the main force behind this change, however, there may end up being more hurdles than expected. This article explores some of the mismatches between DMH’s promises and the needs of communities most affected by the inaccessibility of mental health services. By incorporating the conversation of technology and access into the counseling profession’s efforts to practice with cultural intentionality, we can ensure the best interests of all clients are maintained amid the rapid changes occurring in our society.

 

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Chris Gamble is a licensed professional counselor, national certified counselor and certified clinical mental health counselor based in Washington, D.C. He is committed to showcasing the power within marginalized communities. Contact him at cmgamble92@gmail.com and follow him on Instagram @chris_thecounselor.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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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.

Behind the book: Distance Counseling and Supervision: A Guide for Mental Health Clinicians

Compiled by Bethany Bray January 11, 2022

The COVID-19 pandemic exponentially increased counselors’ use of distance counseling and moved telebehavioral health from a lesser-used, avant-garde approach to a mainstream practice within the counseling profession, say Daniel G. Williamson and Jennifer Nivin Williamson, co-editors of the ACA-published book Distance Counseling and Supervision: A Guide for Mental Health Clinicians. There are both pros and cons that come with this development, but, most of all it affords an opportunity to refine and implement best practices for distance counseling.

“The COVID-19 pandemic quarantine will serve as a watershed event that ushered in the use of telehealth … It is remarkable how our profession rose to the occasion during this crisis,” say the Williamsons, who are both core faculty with Capella University and co-founders of PAX Consulting and Counseling in Texas. “It is an exciting new frontier for the field. The challenge in the ethical and legal aspect is that the technology and oversight are a moving target, and it is challenging for counselors to keep pace with the changing rules and regulations.”

 

Q+A: Distance Counseling and Supervision: A Guide for Mental Health Clinicians

Responses co-written by book co-authors Daniel G. Williamson, Jennifer Nivin Williamson, Marty Jencius, Susan Belangee, Stephanie Marder, Jeff Parsons, Angela McDonald, Jason Martin and Mykia Griffith.

 

From your perspective, what are some “pros” and “cons” that have come from counselor’s increased use of telebehavioral health?

Jason Martin: The clearest and greatest “pro” is definitely the increased availability of counseling that telebehavioral health brings. If someone has access to the internet, they can now access counseling services. People who live in more remote areas, have transportation issues, or health issues can now access counseling. Because of the hesitance some clients have about seeing a counselor within the community where they live and work, they now may access counseling services in other communities, thereby providing an additional layer of privacy within their home community. Above all else, these “pros” provide unprecedented access to care, and that impact cannot be overstated.

The “cons” are a bit more complicated. First, while the technology used for telebehavioral health continues to become more user-friendly, there are still many people who may struggle with the technology necessary to make it work. Some may not even have the devices needed to access telebehavioral health. Second, it also may bring insecurity to the counseling environment. No longer may the counselor be able to restrict who may enter the therapeutic setting because the client’s environment may not be secure or even private. Third, some clients and counselors may experience interacting through a computer screen to be less intimate and personal than meeting face-to-face, thereby affecting therapeutic rapport, and increasing possible distractions.

 

The circumstances of the COVID-19 pandemic have led to some clients never meeting their counselor in person. What are the nuances that counselors should be aware of and mindful of when treating a client 100% virtually?

Marty Jencius and Stephanie Marder: Counselors should be aware that a virtual presence is possible even when meeting with clients using telebehavioral health. Like many tools available for use by counselors, how a client’s outcome is impacted depends on how the counselor wields the tool. Clients can form a solid therapeutic relationship with a counselor online or over the phone. It may not be a counselor’s preferred way of working, but in response to the pandemic, counselors have had to embrace a change leading to a new way to provide client service.

Some insights gained from practicing online throughout the pandemic:

  • Invest in a good microphone and earbuds so your client can hear you clearly and you can hear your client without distraction from outside noise.
  • Consider your space and have good lighting when conducting video sessions. It is just as vital for the client to see you as for you to see the client.
  • Have a plan for when technology is not operating properly.
  • Pay attention to observable cues the client could potentially misinterpret or misread when meeting virtually (e.g., thinking the counselor is tearing up when they are scratching their eye).
  • Create specific guidelines to prevent clients from being distracted or multitasking during appointments (running errands, driving, etc.)
  • Try to wait an additional one or two seconds after you think a client has stopped speaking to avoid talking over one another due to lag.
  • Working with younger children can still be a challenge; however, adolescents can often adapt to telehealth quickly.
  • Do not automatically think older clients would be averse to using technology for distance counseling. Like many of us, they have developed a new comfort with video chat.

We encourage practicing counselors to seek continuing education opportunities as telebehavioral health counseling evolves.

 

What would you want counselors to know about navigating virtual sessions with a client who is not alone or in a private area (i.e. children are in the background, a spouse or parent is in the next room, or a client is at their workplace on lunch break, etc.)?

Daniel and Jennifer Williamson: Confidentiality is an ongoing concern in any counseling relationship, and one of the largest changes in the shift to telehealth is that the counselor has lost the ability to control many aspects of the clinical space. Educating clients about what constitutes an appropriate clinical space and how to be creative in finding appropriate meeting places is an important and ongoing conversation. We define being in a clinical space as being alone in a room with a door, the door is closed, and a “sound machine” is on. Clients can be creative in finding ways to create their own “clinical spaces.” Many have met in walk-in closets, parked cars, offices, bathrooms, and garages.

It is helpful when counselors remain aware of nonverbal shifts in attentions that indicate someone has entered the clinical space. It is important for the counselor to continue to explore informed consent surrounding the importance of clients protecting their own privacy. The ability to create a clinical space should be considered during the initial evaluation to identify if the client is suitable for this modality.

It might be prudent to establish a “signal” between client and counselor in the case that someone enters the client’s clinical space. A client might touch their nose or ear to indicate that someone has entered the private space and it is no longer safe to talk. Virtual services that constantly monitor for voice commands such as Siri, Alexa, Google, bluetooth connected devices, or gaming programs including Discord should also be considered, and clients should be informed about these potential breaches.

 

In the book, you mention that distance counseling will not be a best fit for some clients and that counselors must assess clients to determine whether it’s an appropriate medium. What are some “red flags” counselors should listen for that might indicate telebehavioral health is not a good fit for a client?

Daniel and Jennifer Williamson: While each client should be assessed individually, several considerations seem to signal “red flags” for the use of telehealth. Safety is a number one priority, and counselors must assess if the client is connecting from a place that is physically and emotionally safe. Clients in domestic violence situations or who are a harm to self or others might not be a good fit for the telehealth option. Emotional stability, trauma history, impulsivity, level of care, and ability to self-regulate are also considerations when evaluating clients for suitability.

It is equally important to explore the client’s comfort and skill using this type of technology. Many clients report enjoying the convenience and access that telehealth counseling provides while others miss the in-person human contact. Some clients have reported feeling stuck once the session had ended because they can’t leave the place where they explored difficult topics.

Counselors must assess the clients’ access and ability to navigate the hardware and software involved in telebehavioral health systems. Clients may not have stable internet access or updated technology for interfacing with the telehealth platform. Amber Hord-Helme created an assessment for evaluating clients for telehealth that is included in the book.

 

With vaccines widely available in many areas, some practitioners are opting to offer both virtual and in-person counseling. What would you want practitioners to know about managing this hybrid model?

Susan Belangee and Mykia Griffith: We are both currently doing the hybrid model, returning to the office one or more days a week and working virtually from the home office during the other time. One idea to manage this is to schedule clients who want to come in person on one day and any clients who wish to do sessions virtually can schedule on a different day. This can help to foster a rhythm to work depending on the day.

Is it best to have a client stick to one or the other (virtual or in-person)?
Allowing room for change allows for flexibility as well as opportunity for growth within the therapeutic relationship/alliance. Clients report that they appreciate the flexibility even if they tend to choose one option most of the time. Knowing that they don’t have to miss a session if they are unable to come into the office as planned seems to reduce stress. Life happens for everyone, and having the ability to maintain appointments through telebehavioral health will allow for continued work and continued progress.

 

During the pandemic, state regulatory boards and insurance companies broadened their acceptance of distance counseling (and telehealth as a whole). Where do things stand now – what would you want counselors to know? And/or where should they be looking for the latest updates and changes regarding insurance coverage and regulation of telebehavioral health?

Jeff Parsons and Angela McDonald: Prior to the pandemic, many state boards and insurance companies were ambivalent towards distance counseling. While some states had clear regulations around the practice of distance counseling, others did not. The pandemic spurred change in several areas. In an immediate sense, it allowed for the provision of distance counseling in most states; including registries that allowed for services across state lines. It also loosened restrictions, allowing for the use of technologies that would not traditionally be acceptable (e.g., phone, non-HIPAA software). In many cases, it opened up billing opportunities for distance counseling in states where this may not have been an option in the past. Finally, it encouraged states to actively engage distance counseling as a legitimate delivery model for counselors.

The long-term impact of COVID-19 on distance counseling will vary by state. Some provisions, such as interstate registries and loosened restrictions around phone/non-HIPAA compliant software, will likely be retracted once the state of emergency is lifted. However, it is likely that many states will (if they haven’t already) enact regulation around the provision of distance counseling, formalizing its place in our profession.

Counselors should continue to closely monitor their state(s) regulations and board activities for updates about distance counseling and supervision. Many states issued temporary changes that impacted healthcare practice during COVID-19 state of emergency declarations. As the emergency declarations expire and are lifted, boards will need to issue updated guidance to the public so that counselors can be certain that they are acting in accordance with the regulations. In some cases, boards may issue new interpretations of regulations that protect the public and attend to the expanded capabilities of safe practice in telehealth, and, in other cases states may pass legislative changes that make more permanent changes such as adopting the interstate compact for counselors or adopting broad telehealth regulations that apply in a state to many different regulated professions, all healthcare professions, or all behavioral health professions.

 

From your perspective, where does telebehavioral health fit in the future of professional counseling?

Jeff Parsons: Distance counseling is here to stay. It opens opportunities for services to a wider range of clients, including those who may have transportation or health issues. It also holds a convenience factor that may be appealing to counselors looking for flexibility in their schedules. However, its insertion into the everyday lives of counselors and clients has limitations. Confidentiality issues and video conference burnout are common complaints from counselors who have focused their practices around distance counseling during the pandemic. Likewise, distance counseling may not be ideal for all clients.

Long-term I think we are going to see significant growth in the creation of counseling agencies that focus on distance counseling. However, for most agencies, I think it’s more likely that distance counseling will be used as a tool that adds flexibility to the provision of face-to-face services. For example, counselors might use distance counseling with clients that are on vacation or have transportation issues. However, as this future unfolds, I believe states will be in a much better position to support the provision of distance counseling, as they develop much needed regulatory processes.

Angela McDonald: I am really excited to see telebehavioral health expand access to care, support continuity of care for mobile counselors and clients, and for communication skills in the tele-space to be strongly incorporated into standards for counselor education and supervision.

Susan Belangee: I think telebehavioral health is here to stay as a valid and effective treatment delivery option. The pandemic forced the profession to utilize virtual counseling options and this likely changed professionals’ opinions about how effective they could be using this method of treatment delivery. It will necessitate the development and revision of best practice guidelines as technology continues to evolve.

Mykia Griffith: Although telebehavioral health will never be able to replace the experience that comes with in-person treatment/therapy, telebehavioral health is essential for the future of professional counseling. The virtual method was previously just an option that left room for uncertainty. At this point in time, telebehavioral health has had an incredibly quick shift into our everyday reality and may prove to be fundamental moving forward.

Marty Jencius and Stephanie Marder: Telebehavioral health fits into the future of counseling by extending a counselor’s ability to reach clients when certain barriers exist (e.g., health, distance, inclement weather, global pandemic) which may have previously prevented a client from obtaining services. COVID-19 forced the counseling profession to use telebehavioral health tools more widely than ever before.

We may not need to use telebehavioral health tools as profusely as during the pandemic. However, the benefits of these tools have been demonstrated and their usefulness to the profession has promoted a willingness among counselors to explore these tools as viable options for providing counseling services.

 

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Distance Counseling and Supervision: A Guide for Mental Health Clinicians is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/store or by calling 800-298-2276.

Watch ACA President S. Kent Butler’s conversation with Jennifer Nivin Williamson and Daniel G. Williamson in a recent episode of the “Voice of Counseling” video podcast: https://youtu.be/jtIk5jJjv-0

 

Proceeds from book sales will benefit Uganda Counseling and Support Services, a nongovernmental organization that brings counseling and mental health services, education, clean water, farming and medical services to rural Uganda. The organization was established by one of the Williamson’s former graduate students, Ronald Kaluya.

 

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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.