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Counseling’s evolution under COVID-19

By Bethany Bray May 20, 2020

Under a shelter-in-place order, are professional counselors considered essential workers?

What if a client’s insurance covers in-person therapy but doesn’t cover video or telephone sessions?

Are Skype, WhatsApp or Zoom compliant with health privacy laws?

My employer expects me to continue seeing clients in person, but I’m not comfortable with the health risk that entails. What can I do?

This spring, worried practitioners flooded the American Counseling Association’s on-staff ethics specialists with these and many, many other questions as the new coronavirus that causes COVID-19 gradually became a concern and then — very rapidly — upended the landscape of daily living across the United States. The past three-plus months have presented a steep learning curve for professional counselors, especially with the pandemic causing disruptions and difficulties with something at the heart of their work: connecting with people.

Many counselors in clinical settings responded to these new realities by ceasing in-person interactions and quickly getting up to speed to offer client sessions via telebehavioral health. Most school counselors and counselor educators found themselves negotiating unplanned extended breaks or even abrupt halts to their school years in early spring. Many of these professionals navigated a similar scramble to that of their clinical counseling colleagues, having to adopt and use new technologies so they could continue supporting and teaching students online.

In addition to those challenges, the economy took a dramatic downturn, causing many counselors to wrestle with financial worries and even job uncertainty. Despite the widely reported rise in mental health concerns connected to or exacerbated by the COVID-19 pandemic, some counselors are facing income loss because of a decrease in clients. That’s due in part to many clients experiencing financial struggles of their own, including loss of insurance.

Under the strain of adjusting to this new normal, counselors say they have experienced a flood of emotions, from stress, worry and fear to vulnerability and frustration. At the same time, professional counselors are finding silver linings, such as learning the heights of their own strength and flexibility.

“It’s exhausting,” acknowledges Andrea Morganstein, a licensed professional counselor (LPC) and owner of a solo private practice in West Chester, Pennsylvania. When interviewed in mid-April, she had shifted her entire client caseload to sessions via telebehavioral health. “It’s been a constant evolution,” she says.

Morganstein says she has been relying on the support of her professional peer consulting group, which has been meeting virtually more frequently throughout the spring. In addition, she says her new self-care routine of taking a walk every morning at 7 helps her to anchor her day and maintain a stable schedule, including observing regular mealtimes and bedtime.

“I’m not scared of the virus. I try to take the approach that if there’s nothing to worry about right now, there’s no productive reason to take on extra worry. [But] at times, I’m not feeling good about myself and getting down on myself about not being able to manage everything and get enough work done,” she says. “I’ve learned about how much I was taking for granted in terms of the day-to-day social contact that I had [before the pandemic] and that it’s so important that it’s worth putting in the extra energy that is needed now to maintain those relationships and feelings of connection.”

As this article was being written in April, there were still many questions about how COVID-19 might affect the counseling profession over the long run. Will counselors rush back to offer in-person sessions as soon as possible — and will clients rush back to schedule them — after becoming more comfortable with online therapy? Will some of the emergency measures that offered flexibility regarding regulation of telebehavioral health spur change for the future? Will a mental health pandemic follow the COVID-19 pandemic as some experts predict?

Only time will tell. In the meantime, professional counselors will continue to do what they do best: supporting their clients and students, regardless of setting or circumstance.

Navigating the learning curve

Morganstein had set up the office at her practice so that she and the client sat perpendicular to each other during sessions. The comfort of that arrangement went missing when Morganstein shifted to offering sessions exclusively via video and phone in mid-March.

In addition to learning and adjusting to the technical piece of telebehavioral health, including a new web camera that initially caused extreme frustration, the medium forced Morganstein  and her clients to be “eyeball to eyeball” for video sessions. Some of her clients who struggle with self-esteem also expressed discomfort at seeing themselves for the duration of their sessions in the little video box in the corner of the screen.

When sitting with clients in her office, Morganstein often uses her own body language and positioning to help clients feel more comfortable during moments of silence or when struggling with difficult emotions. That subtle strategy is harder to deploy with telebehavioral health sessions. Although, as time has gone on, Morganstein has adjusted to sit farther away from the camera to bring more emphasis to her upper-body language and less to her face, she says.

“The biggest thing for me has been the use of silence. I have been finding that sitting in silence in telehealth feels different — more anxious and less comfortable for me,” says Morganstein, a member of ACA. “In exploring that, I realized when there’s silence on a video or phone call in the social realm, it’s a cue to say goodbye; we’ve said all we need to. But in therapy, I will often use silence to give the client space to think or process [a question or topic] or think through a new idea that’s coming to them. You can see it in their body language, that they’re ‘getting it’ and seeing a concept. It’s much harder, in my experience anyway, to do that in telehealth.”

“I’m finding instead that in my own internal experience with telehealth, my brain is telling me that I should be doing something — I should be keeping this conversation going and doing something to fill this space. It shifts the role that I typically inhabit in counseling,” Morganstein continues. “At some point, I do think it would be helpful to put it on the table and say [to the client], ‘Gosh, this feels different. Here’s a time that I would [normally] sit here quietly and let you think. What is this feeling like for you?’”

Morganstein says she is trying to stay mindful that as different as this new normal feels for her, it feels just as different for her clients. As the weeks pass, she continues to look for ways to shift her approach and re-create the warmth and openness she strives for during in-person sessions.

She lives in a townhouse with her spouse and children, so she has set up a section of her bedroom to conduct video therapy sessions. She has staged a section of wall to mimic an office setting, complete with a plant, a lamp and a canvas print. “I refer to it as ‘my home office’ to my clients. But it’s my bedroom, and I can’t leave confidential files lying around. That’s the part I’m finding very stressful,” Morganstein says.

Morganstein says the shift to telebehavioral health has also caused her to adjust the methods she uses with clients. In person, she often writes on a whiteboard in her office during sessions to illustrate a topic. “I find that [now] I am encouraging my clients to do a little bit of [in-session] journaling themselves, when normally I wouldn’t have slowed down to have them do it,” Morganstein says. “I’m finding it to be powerful and will bring it more into my in-person work. … I’ve learned that I should have clients write things down more on their own, in their [own] words. At the end of the session, they’re more likely to internalize what we just talked about when their brain had to do the work to construct it and put it on paper.”

On the minus side of the ledger, Morganstein says the exposure component of the social skills work she does with clients with attention-deficit/hyperactivity disorder has “ground to a halt” because clients aren’t leaving their homes. She is also finding that in-depth counseling work such as processing trauma is being put on hold because clients need to focus on more immediate needs such as dealing with the stress of going to the grocery store or, for school-age clients, mourning the loss of school activities and graduation celebrations.

“Doing trauma work temporarily leaves clients more vulnerable,” Morganstein points out. “Now is not the time to leave people feeling more vulnerable or emotionally exhausted.”

Morganstein also believes some clients have taken her off of a pedestal after watching her operate outside of her typical office environment — and she is comfortable with that. Seeing her struggle with technology at times or hearing her dog bark occasionally during sessions has allowed more opportunities for her clients to see her in a new light. “It’s OK to be human with your clients,” she stresses.

Morganstein recalls one session — or rather, an attempted session — scheduled with a middle school-age client in the early weeks after switching to telebehavioral health. Morganstein had sent the client’s mother a link to connect on the video platform she uses. When it came time for the session, Morganstein couldn’t get either the microphone or camera on her computer to work. She knew she needed help from her husband — “my IT guy,” she jokes — but counseling ethics regarding confidentiality dictated that her husband should not see the client, who was visible on the video feed. The client’s mother offered suggestions, staying online with Morganstein as she tried to problem-solve, but after 25 minutes, Morganstein gave up and ended up rescheduling the session.

What could have been a frustrating or angering situation for both parties actually ended up improving Morganstein’s relationship with her young client’s mother. The client was relatively new to Morganstein’s practice, and before this incident, the mother had been a little nervous and somewhat guarded around Morganstein. After witnessing Morganstein in a vulnerable situation, the mother seemed to feel much more comfortable around her, even making the occasional joke, and their relationship has grown since that time, Morganstein reports.

Practicing what you preach

Licensed mental health counselor Stacey Brown closed her Fort Myers, Florida, group counseling practice and began offering client sessions via phone and video on March 13, well before many practitioners in her area were doing so. It was becoming clear to Brown how easily the COVID-19 virus could spread, and knowing the number of clients who came through her office in an average week, she followed her gut instincts that Friday and made an impromptu decision to cease in-person sessions. “It just felt like the right thing to do,” Brown recalls.

Since then, Brown has been able to keep a full schedule of client sessions while working from home. She has found that a majority of her clients prefer telephone sessions. To retain focus during sessions and maintain some privacy from family members or others with whom they live, Brown’s clients have talked to her while sitting in a parked car, taking a walk or even floating on a raft in a backyard pool.

“All of my clients’ [presenting] issues are still happening, so they need support — or need even more. When people are forced to be by themselves, they have to deal with themselves. A lot of our talk [in sessions] has been on how to deal with ourselves,” Brown says. “For me, when you’re with somebody [a client in session], you need to really be with somebody. You need to be 100 percent present. You can’t go into a session with preconceived notions. That really messes you up. You can’t go into a session and think, ‘Today we’re going to talk about her mother.’ … Over the phone, it’s the same — sitting and really listening and concentrating. I really feel like I can be right there with them, and it’s turning out OK.”

Client struggles with anxiety, trauma and grief have intensified since the outbreak of the new coronavirus, says Brown, a clinical supervisor and ACA member. In addition to using cognitive behavior therapy and other methods, Brown has found it helpful to emphasize calming techniques such as breath work and meditation with clients. She has also ramped up conversations and check-ins about how well clients are sleeping, engaging in self-care, staying hydrated and eating — some of the foundations of Maslow’s hierarchy of human needs.

Wellness practices can help counselors and clients alike process and digest emotions, just as the body digests food, Brown says. “Now is not the time to do just counseling or just therapy,” she says. “Ask your clients if they’re having neck and shoulder pain, or how are they sleeping and what are they eating. Everyone is ramped up right now, and we need to take care of our bodies. Talk about stretches and relieving tension and the difference between shallow breathing and deep breathing. Remember the mind-body connection.”

As the pandemic continues to affect counselors’ work, Brown emphasizes that practitioners — now more than ever — need to heed the guidance they give their own clients: Don’t forget the importance of self-care, and find ways to move away from rigid and one-dimensional thinking.

“If we’re upset because things aren’t the way they are supposed to be, we will only get madder and more closed off. See this change as an opportunity, a chance to be creative and flexible,” she says. “You have to nurture yourself and find balance. This includes turning off the news, if needed. Take the same advice you give your clients [to] be aware when your anxiety is rising.”

Likewise, counselors often encourage clients to be intentional about their life choices and the goals they set. The same guidance applies to practitioners themselves, especially during times of crisis, Brown asserts. Brown, who is certified to teach yoga and meditation, has found ways to diversify her work and supplement her income from counseling. In addition to offering meditation and yoga instruction, she paints and sells her artwork, writes, and supervises counselors-in-training.

From Brown’s perspective, the business side of counseling is a lot like a tennis match. When your opponent is about to serve you the ball in tennis, she explains, you don’t know where it will go, so you have to be agile and “springy” in order to run and meet the ball. So too with running a business: You have to think ahead and be both prepared and flexible when challenges arise.

“Counselors can’t just sit in their office and see people anymore; they need to diversify and have multiple income streams. We can’t just be awesome clinicians; we have to be awesome business people as well,” she says. “We have to practice what we preach — and this is the challenge, always. If you’re constantly in the box, then that’s where you’re going to stay. … If you’re always reactive, then you’re going to have some trouble with your business. If you’re intentional and manifest what you want, then you’ll be fine.”

Professionally, Brown says these past few months have presented her with lessons in creativity, patience, gratitude and self-trust. Even though she loves her office setting, she is thinking of continuing to offer telebehavioral health from home one day per week after the COVID-19 pandemic subsides.

“This has given me time for self-examination and time to reflect and confer with others on how they’re running their businesses,” Brown says. “Aside from the health fears, it has been a rejuvenating time for me because of the creativity element. When I was in the office, I was all zoomed in on day-to-day activities. Now I have been able to zoom out and see things from the big[ger] picture. It’s different somehow. … It’s helping me to refresh my perspective and stay curious on how to do this and how to grow my business to be sustainable to attain my ultimate goal: to help people.”

Emphasizing safety

Linda Diaz-Murphy has been doing play therapy with young clients via telebehavioral health ever since New Jersey enacted a shelter-in-place order in March. Parents and youngsters alike have easily adapted to the medium, she says. A parent or caregiver is always present during the session, and young clients use a combination of their own toys and play therapy items such as sand trays that Diaz-Murphy previously sent home with families.

Even when delivered via telebehavioral health, Diaz-Murphy says, the focus of play therapy remains the same: building clients’ sense of safety and developing their coping skills and strategies. This includes talking about and processing emotions as young clients draw or create scenes with figurines.

“We use whatever resources they have,” says Diaz-Murphy, an LPC and registered play therapist whose private practice in Leonia, New Jersey, is 15 minutes away from the George Washington Bridge leading into and out of New York City. “One child likes to cook [using a play kitchen] and feed everyone in his family. We used to do that in the office, and now we’re doing that in teletherapy. We’re continuing to do the same things in the home as we do in the office, which is really amazing. Nothing has really changed except the location.”

Diaz-Murphy has also been emphasizing safety with her adult clients in the form of extra outreach. As soon as she switched to telebehavioral health, Diaz-Murphy increased her communication with clients, checking in regularly (once or twice per week) via phone or text message. She has let her entire caseload know that she is available for extra sessions or even “just to talk,” although she limits client phone calls outside of sessions to 30 minutes.

“It’s more than I would usually do, but this is important,” Diaz-Murphy says. “Years ago we called it proximity control, but it is just being there for [clients], helping them feel safe and know that you’re there to help.” It also involves staying close with and being available for clients without being too intrusive, she explains.

One of Diaz-Murphy’s clients, an adult man who lives alone and is geographically separated from his family, had a relative die of COVID-19 in April. Initially, he was hesitant to use telebehavioral health, but Diaz-Murphy continued to stay in touch with him via text message. Eventually, he agreed to participate in a counseling session over the telephone. Now they are in contact roughly twice per week, and the client is reaching out to her instead of the other way around, which Diaz-Murphy views as a very positive development.

“What is important for me, especially during this coronavirus crisis, is to always be honest [with clients], share my limitations, discuss options, think of safety first, be patient, offer reassurance, speak in hopeful tones and use hopeful language, remain in the present and think of the future, make myself available, and remember [that] my presence is important,” Diaz-Murphy says.

Diaz-Murphy has completed extensive training in disaster mental health and is a crisis response counselor. She has drawn on that knowledge this spring, she says, adjusting her approach to meet her clients’ needs as anxieties swelled and so much was unknown. Part of her own coping strategy during the pandemic has been to continue learning. She recently completed a training on offering disaster mental health and crisis counseling over the phone, including best practices on strategies and language to use.

A little humor can also go a long way when anxiety is swelling, Diaz-Murphy says. During the toilet paper buying frenzy (and ensuing shortage) that accompanied the first several weeks of COVID-19 in the United States, she found a website that calculated how much toilet paper each household would need to make it through quarantine. She shared the site with a few clients to lighten the mood.

“It’s a source of humor, but [there’s] also a reality that people are afraid that others will take resources and there won’t be enough left. It’s the same with food. This [toilet paper calculator] puts things into perspective for people, and then it helps in other ways,” says Diaz-Murphy, a member of ACA.

Most of all, she has focused on making sure her clients have appropriate self-care and coping mechanisms in place to deal with the worry and uncertainty that have accompanied the pandemic.

In times of crisis, professional counselors must remember to trust themselves and fall back on their core counseling skills: empathy, communication and listening. “You want [clients] to be in control and feel empowered,” she says. “Behave the same way that you would in the office: Don’t panic, stay calm, and treat your clients with respect. Let them know that they can manage this, and give them the tools to manage.”

Finding connection on camera

Chris McClure still drives to her Manassas, Virginia, private practice to conduct telebehavioral health sessions, even though clients are no longer coming in. Sitting in the same chair and being in the same space where she used to conduct in-person counseling helps her to focus and “switch gears” from the personal to the professional, says McClure, an LPC and a member of ACA.

She also thinks it is important to retain that familiar setting for her clients. When Counseling Today interviewed her in April, McClure was working to set up her laptop so that clients would see her at the same angle and with the same backdrop as if they were sitting in the client chair in her office.

She admits that she is still struggling to strike the right balance while using telebehavioral health. Initially, she felt too detached and too “pulled away” from clients through video. Sometimes she feels that she has to “project my empathy larger than life” to get through to clients.

“Video doesn’t feel very intimate, and therapy is a very intimate interaction,” McClure says. “It can be kind of intrusive. I am coming into a client’s home, and some are uncomfortable with that.”

McClure also tries to use her facial expressions to connect more with clients. The human brain is hard-wired to recognize emotions in others’ faces, so clients can pick up subtle cues, she says. “If they can see us looking reasonably calm and conveying very soothing messages, then they are better able to handle their anxiety,” she says.

When clients express discomfort about using video for counseling sessions, such as remarking that their home is messy or apologizing for family members who wander into the screen, McClure acknowledges that adjusting to the new medium is hard. To further validate their feelings and set clients at ease, she sometimes remarks that it would be difficult for her to “let someone in” to her home and that she is grateful for their hospitality. Complimenting something that she sees on camera, such as a pet or a piece of art on the wall, can also help, she notes. With clients who still seem a little uncomfortable, McClure revisits the topic in future sessions to help them continue to adjust.

“For most clients, after a time, they forget that they’re not in the office and just focus on me. Others are more aware of the limitations of it,” McClure says. “I’m very much a perfectionist and very much a caretaker, and I want this to be as comfortable and smooth for clients as possible. I’m very much aware when things are missing. [But] I do think that it’s possible to get there with this technology.”

One particular challenge McClure has noted while using telebehavioral health is picking up on clients’ nonverbal cues — something she says comes as second nature to her in person. Recently, she was conducting a session with a client, and the image quality and delay of the video feed made it difficult for McClure to recognize that the client was on the verge of crying until tears were streaming down his face.

“I’m working overtime to listen for those subtle cues in their voice. After almost 30 years [as a counselor], a lot of that is second nature, autopilot, and [now] I have to bring that up to a more conscious level of listening,” she says. “When you’re together with a [client], you can notice the slightest twitch of an eyelid or small facial movements that can convey so much, especially when people are trying to hide their emotions.”

At the same time, McClure acknowledges that her clients are expressing more basic needs right now, such as managing anxiety and getting enough sleep, which aren’t as dependent on nonverbal cues, or at least not at such a deep level as other counseling topics might involve. “It would be exaggerating to say that people are regressing [in therapy], but there is some truth to that. Some of what I’m doing is crisis management,” McClure says.

So much has felt like a moving target as the COVID-19 pandemic continues to unfold and new information becomes available, McClure notes. She has been trying to find a balance between staying informed and limiting her exposure to the news.

“I see a lot of [clients] with anxiety, and I’m trained to help them with [distinguishing between] rational fears and irrational fears, and it’s been very unclear between those two. I have some people who are absolutely terrified and don’t want to leave their homes, and others who think we’re overreacting. It’s hard to feel like I, as a counselor, have an authoritative message when there’s so much mixed information out there. … I think the vast majority of Americans are feeling a considerable amount of anxiety. This [virus] is a substantial threat to our way of life, our well-being, both health and economic.”

McClure has completed a number of trainings on telebehavioral health over the course of her career, although she didn’t use it much until the COVID-19 pandemic hit. She plans to seek more continuing education to keep adjusting to the medium. Eventually, she’d like to transition to semiretirement and be able to counsel clients via telebehavioral health while traveling.

“I’m excited by the possibility that a lot more people are going to get comfortable and used to [telebehavioral health],” McClure says. “Part of the reason I’ve been interested in distance counseling is that there are a lot of underserved populations [that could benefit]. I specialize in working with transgender clients and clients with gender concerns, and there are not that many practitioners who are genuinely trained and qualified to work with these clients once you’re past major cities. There are huge parts of [my] state that are just not well served on certain issues. I really like the idea that a client could get really quality therapy, even if there’s not a therapist within 50 miles. … Hopefully some of the temporary things that have happened during this [pandemic] will stay in place and [result in] positive change.”

‘We’re stronger than we think’

Celine Monif has a private practice near the junction of two states, Iowa and Nebraska, that have not enacted shelter-in-place orders. That has created a sticky situation, Monif says, because she can only suggest telebehavioral health and encourage her clients to use it. The other option would be to voluntarily close her office, but Monif is unwilling to do that because it would disrupt or suspend treatment for clients who are unable to use telebehavioral health. For those who opt to continue with in-person sessions, she has been seeing clients at her Bellevue, Nebraska, office, spacing out sessions so that no two clients cross paths and risk infecting each other.

“It’s been a heavy mix of demand and resistance to go to telehealth, which would not happen in a shelter-in-place state,” Monif says. “Some [clients] are coming in because this is their safe space, and they don’t feel they would get the [needed] privacy or freedom to talk freely at home.”

Monif, an ACA member, holds two licenses. She is a licensed mental health practitioner in Nebraska and a licensed mental health counselor in Iowa. She estimates that roughly one-third of her caseload continues to come in for in-person sessions. Some of these clients simply aren’t comfortable with telebehavioral health technology. For others, it poses logistical challenges. For example, one of Monif’s teenage clients continues to come to the office for in-person sessions because she doesn’t have a cell phone of her own and her large family has only one computer to share between them.

To minimize the risk of infection, Monif has been sanitizing her office and waiting room after every client, taking her temperature each morning, washing her hands regularly, and opening the door for each client so they don’t have to touch the doorknob. She has also posted a sign on her office door asking that people who are sick or have a fever not enter.

Monif admits that she has experienced a roller coaster of emotions this spring. “Because it’s the Midwest and we’re not the epicenter of the virus, we still have a percentage of people who are not taking this as seriously as they probably need to. This can be frustrating,” she says. “But at same time, there’s compassion. I understand about their fears or hesitancy to give up the safe space of my office. I understand the anxiety and feel a lot of compassion for them. … My emotions fluctuate so quickly throughout the day.”

In the past, Monif typically accommodated one or two pro bono clients at any given time to help those who couldn’t afford counseling or had lost their insurance coverage. With the recent economic downturn in the wake of COVID-19, that number has increased, with Monif offering pro bono sessions for several clients who have lost jobs or been furloughed.

“It would be unethical for me to stop [treatment] and not try and help them,” she says. “My husband and I are both working and will be OK for the near future. We have that luxury, so I will continue [to offer pro bono services].”

A trained volunteer for Nebraska’s Critical Incident Stress Management program, a statewide team that offers mental health debriefing for first responders after major incidents, Monif is also offering free sessions for first responders who need counseling.

The counseling profession’s swift and unexpected pivot to telebehavioral health this spring has revealed a few challenges that will need to be addressed for the long term. For example, there have been mixed messages concerning which telebehavioral health platforms are compliant with health privacy laws. Professional counselors need clearer guidelines both from licensing boards and insurance companies, Monif says.

“[Practitioners] in my area often have clients across state lines, and there’s some confusion on what our license allows. It’s a new territory,” Monif says. “When everything comes out, we’re going to have a little bit to unravel. … It used to be that online therapists were a specialty, and now it will be more of the norm. There will be a huge influx of providers who provide online therapy.”

“If there’s a silver lining to this,” she continues, “I’m hoping this helps raise the awareness that this [telebehavioral health] is something we need. It’s an essential service. People need access, and right now it’s an imperfect system, and we need to work on it.”

The fallout from COVID-19 has ushered in an opportunity (even if unwanted) to learn and see things from a new perspective, Monif says. She has witnessed counselors in her area rise to the occasion and rearrange their entire practice to work online, all while caring for family and dealing with both the personal and professional stressors of the coronavirus pandemic.

“I have learned that if I have to adjust quickly, I can,” Monif says. “I went from having zero telehealth clients to [those clients being a major] part of my caseload in seven days. I learned that we’re all in the same boat and we don’t have the answers, but we’re learning as we go. This threw us all off-kilter, and we’re still day by day, [but] we’re all so adaptable, and that’s great to see. … We’re stronger than we think, [but] we also need to make sure we’re taking care of ourselves. Find a balance between managing your own emotions, taking care of family, and being responsible for clients and helping them. Find that balance, and you’ll be OK.”


Identifying potential in crisis

Although the COVID-19 pandemic has forced some unexpected changes to the way professional counselors are working, it has also brought immense potential for practitioners to flex their outreach and advocacy muscles, says David E. Jones, an LPC in the Cincinnati area.

Counselors are well suited to help with the many needs that have arisen alongside COVID-19, from the anxiety and isolation that can accompany shelter-in-place mandates to the distress and burnout felt among health care workers and first responders, says Jones, an ACA member and assistant professor in the Department of Counselor Education and Family Studies at Liberty University.

“There is a chance of having a mental health pandemic after all of this. What are we [counselors] doing? What can we do? What should we do to help our communities? What are we going to do six months from now, beyond just our individual clients?” asks Jones. “Part of this is getting outside our walls of one-on-one thinking and coming together as a profession and collaborating across professions to address at-risk populations and structural disparities. We need to be collaborating with public officials and sitting at those tables for long-term planning and thinking of the mental health aftermath.”

Jones urges counselors to take their role as advocates seriously and to think about how they can reach across disciplines to address mental health in their communities. This could include collaborating with local organizations, schools and even houses of worship, but it should involve thinking outside the four walls of the counseling office, he emphasizes.

“Show up at town hall meetings or sit down with local politicians. Offer to go to your local firehouse and talk about mental health first aid. Or send them a letter and offer to have coffee with them and offer your insights,” suggests Jones, who was a public health researcher, including time spent as an infectious disease epidemiologist, before switching careers to become a professional counselor. “It doesn’t have to be a huge elaborate thing, but it’s a drop of water in a pond, and if you have a lot of people putting a drop of water in, it’s going to ripple and make a difference.”

For example, there will be immense need for career and employment counseling in the coming months, with millions of Americans being unemployed or underemployed. Counselors could host community workshops focused on learning job search and interview skills, seeking job training or studying for the General Educational Development exam.

“Counselors have so many points of contact to make a difference, [including] schools, parents and other nonprofits. Who do you know that could make a difference? Go and speak at groups, provide psychoeducation [about mental health], and shine light on local resources. We need to get out of our silos and work across professions. There’s connection points that can be made, and sometimes you just have to think outside the box to make them.”

In the wake of the coronavirus crisis, there is great potential to expand the counseling profession’s reach and impact while meeting needs in counselors’ communities, Jones stresses.

“During a time like this, we get a chance to reflect on who we are. And that’s a good time to make us pause and look at things that are working, and things that aren’t working, and have a potential place to effect change,” Jones says. “You can focus on the distressing part of this, or you can introduce yourself to fellow counselors in town and ask if they need anything. It’s time to reflect and be more person-centered than we were before.”

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Professional resources

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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.

Hey, Siri: Did you break confidentiality, or did I?

By Nicole M. Arcuri Sanders January 14, 2020

Did you know that your tech devices have the potential to break your clients’ confidentiality just by being in the counseling setting with you? Imagine that you have worked a full day seeing an array of clients for the various concerns they are facing. Then, at the end of the day, you snuggle up on the couch and scroll through your phone’s applications. You notice numerous ads and suggestions that relate to the topics clients have shared. For instance, imagine a client sharing about a traumatic event that happened in the Catskills, and now you have Airbnb suggestions for that area, along with resources for dealing with sexual abuse.

You may be wondering, “How did that happen? Was my phone listening to our session?” The answer might be yes.

In other cases, you might not be made aware that your phone was listening, but it is important to know that it has that capability. The reason for this is the voice assistant technology on your devices. While on, these devices are constantly listening. For instance, Apple iPhone is listening for the word “Siri”; anything said after that is considered a command. The same is true with Amazon’s voice assistant Alexa and with Google Assistant. Each of these devices is waiting for its name to be called so that it can follow up with whatever assistance the person using it desires.

However, it has been found that the devices sometimes mistake certain words and are activated unintentionally.

This past July, The Guardian newspaper shared shocking reports from an Apple contractor. This whistleblower reported that Apple contractors “regularly hear confidential medical information, drug deals, and recordings of couples having sex, as part of [Apple contractors’] job providing quality control.” These workers are tasked with listening to grade the responses of the company’s Siri voice assistant. For example, the workers will grade if the response from Siri was accidental or deliberate and if Siri’s response was appropriate.

But what does this mean for professional counselors? Just think invasion of privacy and breach of confidentiality concerns.

Voice assistant concerns in the counseling setting

This next section is going to present a hypothetical counseling office to address some of the confidentiality concerns that surround the counseling experience with technological voice assistants. Consider whether you address these concerns in your informed consent with clients. Would these occurrences align with Health Insurance Portability and Accountability Act (HIPAA) regulations?

Waiting room: Counselors strive to create a warm and inviting setting to foster a comfortable feeling for clients because they are in a vulnerable situation. Perhaps some relaxing music is playing in the waiting room. Consider Alexa being programed to shuffle through various playlists of calming songs throughout the day.

As clients await their sessions or end their sessions, they may need to discuss billing with the front-desk assistant or call their insurance companies. Clients may even take a call during this time for other purposes. Alexa hears all of these conversations throughout the day. Therefore, the potential is there for the entrance to this “safe place” for clients to instead become a place where personal information is leaked to Alexa and to those who monitor Alexa or have access to Alexa’s recordings.

Additionally, clients may not even realize that while they are in your office discussing billing, diagnosis, and plans moving forward, their smartphone’s voice assistant can be eavesdropping as well. The same goes for all of the other smartphones located in the waiting room, including those being used by personnel working the front desk.

In session: When clients and counselors meet in an office, safety is a concern. Therefore, counselors may choose to keep their phones in their pocket or nearby in case they need to call for help. Some sites may even have a policy requesting that counselors have their cellphones on them at all times. However, now these phones’ voice assistants can have access to the dialogue that occurs within the room. This also means that whoever is monitoring the voice assistants have access. What was intended to be a safe place for clients to navigate and process concerns is now compromised.

Can you imagine if you, as the counselor, were facilitating a group and each client had a smartphone with a voice assistant? Consider also if you take notes on an iPad that has voice assistant technology. As counselors, we understand there are some limits to confidentiality. However, these voice assistant technologies have the capability to leak what clients and counselors once believed to be confidential information.

 

Disconnect: Don’t be considered liable

A number of considerations need to be taken into account by both the counselor and the client regarding confidentiality of sessions when voice assistant technologies are present. First and foremost, this issue should be addressed. Now that you are aware of the implications for your practice, you are ethically responsible for addressing these possibilities with your clients.

According to the 2014 ACA Code of Ethics, clients have the right to confidentiality and an explanation of it limits (Standard A.2.b.). Understanding these limits, clients have the right to make an informed decision regarding whether they would like to participate in counseling services with you (Standard A.2.a.).

Therefore, if you choose to utilize voice assistant technologies, you need to inform clients of the benefits and risks prior to them beginning counseling services. This explanation is not limited only to the counselor using these technologies but also acknowledging whether the counseling site allows its staff or clients to use them. If your site chooses not to utilize voice assistant technologies, you will need to address what your protocol is concerning this matter. For instance, will all cellphones be turned off? How will this be regulated?

What if your site requires cellphones for safety concerns or if clients are not willing to turn their phones off? How can you still protect client confidentiality and be in alignment with HIPAA regulations? The simple answer is to turn off your voice assistant technologies. You might consider noting the confidentiality risks in your informed consent and then sharing some of the directions noted below for how to disable these technologies.

 

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For iPhones and iPads, to turn off Siri, complete the following directions:

1) Open your settings.

2) Click Siri and Search.

3) Toggle OFF, listen for “Hey Siri.”

4) Toggle OFF, Press Home (or side button) for Siri.

5) Toggle OFF, allow Siri when locked.

 

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To turn off “Hey/OK Google,” complete the following directions:

1) Open your settings.

2) Under Google Assistant, tap Settings again.

3) Under Devices, tap Phone.

4) Turn OFF Access with Voice Match/Assistant.

 

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To turn off Amazon Alexa, complete the following directions:

1) Open your settings.

2) Select Alexa Privacy.

3) Tap Manage How Your Data Improves Alexa.

4) Turn “Help Improve Amazon Services and Develop New Features” OFF by tapping the switch.

5) Confirm your decision.

 

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These steps can provide clients with a choice while also informing them of the risks of their choices. In group counseling, however, as a safeguard to clients’ confidentiality, I would recommend not allowing any client to keep their cellphones, iPads or any other voice assistant technologies on.

Because these devices may travel with us basically everywhere we go, our conversations are being monitored for product improvements, but in the process, our confidentiality is being breached. Currently, with some simple options for turning off these technologies, clients can continue to maintain the level of confidentiality to which they originally thought they were agreeing.

As counselors, we take many safeguards to protect our clients’ confidentiality. I encourage you to toggle off your voice assistant technology options to keep your devices from being the reason you are held liable for breaking confidentiality. Moving forward, as technologies continue to transform, we as counselors need to be ready to address implications in the counseling setting.

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Nicole M. Arcuri Sanders is a licensed professional counselor, national certified counselors, approved clinical supervisor, and core faculty at Capella University within the School of Counseling and Human Services. Contact her at Nicole.ArcuriSanders@capella.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.

The impact of internet self-disclosure on the counseling relationship

By Laurel Shaler December 16, 2019

It was only our third session, but “Anne” and I seemed to be connecting well. She was thrilled to finally have time for counseling, given her busy life as a stay-at-home mom to three young boys and with a husband who traveled extensively. Over time, Anne began to relax and feel more comfortable opening up about some of her painful past experiences. She started sharing that one of the particularly challenging times in her life involved her and her husband’s struggle to conceive.

As soon as the words were out of her mouth, however, I could almost see her wrestle to pull them back in. She stumbled to recover but seemed to be saying that she had no right to complain about their journey to parenthood because “at least” they had been able to have children. As my mind began to process what was happening, it hit me: She has seen my website.

Anne was one of my first clients after I opened a small solo practice. After leaving my previous clinical position and moving into counselor education, I had created a website on which I posted blogs and links to online articles I had written, listed speaking topics, provided links to videos as well as radio and podcast interviews, and shared about my books. Anyone who reviewed my website and read about me would learn that a part of my journey had been through infertility.

There was always a risk that students would search my name on the internet and come across my website, but that was a risk I was willing to take because I felt called to reach out to the community at large regarding topics related mostly to emotional well-being. Along the way, I shared a bit of my story.

When I opened my counseling office, I included the information about my practice on my website, but it did not occur to me that clients would review the website and bring what they found into the sessions with them. I knew that I would never be “friends” with clients on social media, nor would I search for my clients on the internet, and I included that information in my informed consent. But Anne’s reaction to her own vulnerability helped me realize that my internet self-disclosure was having a negative impact in the counseling room and that it might impact future clients as well.

Soon after my interaction with Anne, I consulted with another counselor regarding next steps. I did not want to shut down my website or stop speaking and writing, but I also did not want to cultivate an environment where my clients were so concerned about me that they filtered what they were saying so as not to hurt me (based on their own ideas regarding what would hurt me, that is). The counselor with whom I consulted had one suggestion: Separate my one website into two, with one being a personal website and the other a practice website.

I saw numerous flaws with this solution. First, I could not manage (or hire someone to maintain) two websites, especially with my private practice being very small. Second, a client could still easily locate my personal website by performing a simple internet search. (After all, the name “Laurel Shaler” is not a common one.) I thought there had to be another option for addressing this dilemma. I began to realize I could do several things to mitigate the effects reading my website might have on my clients, but at the same time, there were certain things I could not control. The same is true for any of us who self-disclose on the internet.

I cannot control a client searching for my information online, for instance. Because I have something of a public presence given my public social media accounts, trade books, and blogs/articles on the internet, clients are likely to run across some information about me that goes beyond the scope of my private practice. I have to be OK with that to maintain both an online presence and a clinical practice. Likewise, my clients need to be aware of the pros and cons of learning more about me over the internet.

What it will really come down to is the same factor that affects every counselor-client relationship: therapeutic rapport. If my client and I can establish safety and trust, as well as appropriate boundaries, and can communicate effectively, then we can more than likely work through whatever may arise as a result of the internet self-disclosure.

Through a self-supervision process, I have come to realize that Anne may have overidentified with me. In other words, in the same way she might not want to hurt the feelings of a friend, she did not want to hurt my feelings. She assumed that because I had been through an infertility journey that did not result in biological children, that sharing her journey that did result in biological children would upset me. Although I did not address the issue head-on at the time, if given a second chance, this is what the communication might have sounded like:

Anne: I shouldn’t complain because I know not everyone can have children, and I am really lucky and fortunate and blessed to have children even though I did go through infertility. I know it’s not the worst thing in the world, and others have a much harder time than we did. I shouldn’t have said anything about it.

Laurel: It sounds like even though you are grateful that your infertility journey ended by having children, that you had a hard time going through that experience. Can you help me understand why you think you should not say anything about your infertility?

Anne: Well, to be honest, I read on your website about your infertility journey, and I am so, so sorry for what you went through. I don’t want to compare my story to yours, in particular since I was able to have children and you weren’t.

Laurel: Your sensitivity to me says a lot about who you are as a caring and compassionate person. At the same time, I want this to be a safe space for you to feel free to openly share about your entire story. I want to encourage you to hold nothing back on account of me. You are welcome to read what I post — keeping in mind what you read may impact your view of me or our counseling relationship.

Anne: Yeah, I like what you write but did not want to offend or upset you.

Laurel: Thank you, Anne. I do not believe I will be offended or upset. However, if I am, that is my own issue that I need to work through with a counselor or supervisor. It would not be your fault. Are you open to exploring the infertility issue and the turmoil that brought to your life and marriage?

Anne: Yes, because it really messed me up for a while and my relationship with my husband too.

Laurel: OK, please start wherever you would like.

Anne: It all started …

Obviously, this fictional dialogue could go many different directions. This is a good-faith guesstimate of how the conversation might have unfolded based on the relationship I had with the client at the time.

In reality, even though I was a bit flustered internally and did not address head-on the client learning about me online, we were able to move forward with our therapeutic relationship. Anne came regularly to see me for about six months before she and her husband decided to pursue marriage counseling, at which time she needed to pause individual counseling.

My personal takeaways from this experience were twofold:

1) Counselors must think thoroughly and carefully about how having an online presence might impact their counseling practice and the clients they are serving. Counselors have to decide whether the two are compatible and if they can still be effective counselors. Is there controversial content that may lead a client to feel uncomfortable with the counselor? Is the counselor something of a “celebrity,” leading clients to be a bit star-struck and concerned about disappointing the counselor? Numerous aspects of internet self-disclosure need to be considered. Additionally, counselors must decide how to navigate the two or more hats that they wear. For example, counselors must decide whether to have two separate websites or one website that incorporates both a personal/commercial side and a counseling practice side.

2) If counselors have an online presence, this should be addressed early on in the counseling relationship. This can be part of a written informed consent, along with other information regarding the counselor not searching for clients online, not accepting or sending friend requests on social media, etc. This can also be addressed verbally in session, wherein counselors discuss their online presence and talk through how a client’s review of the counselor’s internet information might affect the counseling environment. Counselors must be aware that disclosing their online presence is, in and of itself, self-disclosure. Therefore, as with all self-disclosure, this must be addressed solely for the benefit of the client.

There is absolutely a way to have both an online presence and a successful counseling practice. Many counselors have done so beautifully. My personal experience taught me a valuable lesson about how these two can work in tandem rather than against each other. Anne — like all clients — deserved to have an authentic counselor with whom she could truly be transparent, without filtering herself based on information she knew about the counselor.

Although I believe knowing less about the counselor can be beneficial to clients, I am well aware that in our internet-driven and instant-knowledge society, many clients will desire to learn all they can about us before, during and after the counseling process. Getting out ahead of potential problems that could arise as a result may prove helpful for clients. Because my online presence is not going anywhere, this is an ever-evolving process that I must pursue for the sake of my clients.

 

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Laurel Shaler is a licensed professional counselor, national certified counselor, and licensed social worker. She is an associate professor in the Department of Counselor Education and Family Studies at Liberty University. Contact her through her website, drlaurelshaler.com.

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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.

More than simply shy

By Bethany Bray July 29, 2019

Social anxiety is different from — and much more than — simply being shy or introverted or having poor social skills. Even so, people who live with social anxiety often find the disorder trivialized or minimized by others, including some mental health professionals, according to Robin Miller, a licensed professional counselor (LPC) and a member of the American Counseling Association.

“Shyness doesn’t necessarily have a negative impact on someone’s life. That’s an important thing to remember from a clinical point of view,” explains Miller, who specializes in working with adults with anxiety disorders at an outpatient practice just outside of Milwaukee. “Many of my clients get a pat on the head from people and [comments such as], ‘You’re just shy. You have nothing to worry about.’ But you wouldn’t get that for [symptoms of] posttraumatic stress disorder or other mental health issues. You wouldn’t say there’s nothing to worry about.”

Most of all, clients with social anxiety need support and reassurance as they try to discontinue old patterns and behaviors that they have adopted to cope with the paralyzing fear that often accompanies the disorder, says Brad Imhoff, an LPC who was diagnosed with social anxiety disorder in 2012 as he was working on his doctorate.

One characteristic of social anxiety is a constant feeling of apprehension regarding social situations. It is difficult to express just how oppressive and pervasive that feeling can be, says Imhoff, an assistant professor of counseling at Liberty University who lives in central Ohio and teaches in the university’s online program. “You carry this feeling of ‘I just can’t do this’ all the time,” he says. “As human beings, we’re social. And apprehension in every one of [those social situations] can be overwhelming.”

Imhoff, a member of ACA, says he recognizes the irony of his career choice: a person with social anxiety who speaks regularly to rooms full of people, both as a counselor educator and as a frequent presenter at conferences, including giving a session on social anxiety at the ACA 2019 Conference & Expo in New Orleans.

Imhoff has learned to navigate the challenges of social anxiety since his diagnosis, but he acknowledges still feeling anxious before speaking engagements. “The question is, how do I manage it and not let it get in the way of life?” he says. “I will have to manage this, to some extent, for my entire life and not let it get to the extremes it has in the past.”

Navigating life through avoidance

Social anxiety is one of a number of related issues — including specific phobia, panic disorder, separation anxiety disorder, generalized anxiety disorder and others — that fall under the anxiety heading in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Called social phobia in decades past, social anxiety disorder is characterized by persistent fear over social or performance-related situations, according to the National Institute of Mental Health, which cites diagnostic interview data to estimate that 12.1% of U.S. adults will experience social anxiety disorder during their lifetime. Among adolescents ages 13-18, the lifetime prevalence is 9.1%. For all ages, social anxiety disorder is more prevalent in females than in males.

Researchers have not singled out a specific cause for social anxiety disorder, pointing instead to a combination of biological and environmental factors as contributors. Genetics appears to play a large role in many cases, as can negative childhood experiences such as family conflict or being bullied, teased or rejected by peers. It is also believed that individuals who have an overactive amygdala may experience more anxiety in social situations.

According to the Center for the Treatment and Study of Anxiety at the University of Pennsylvania, “Social anxiety disorder can affect people of any age. However, the disorder typically emerges during adolescence in teens with a history of social inhibition or shyness. The onset is usually accompanied by a stressful or humiliating experience, and the severity varies by individual. … There is a higher incidence of social anxiety disorder in individuals with first-degree relatives affected by other panic and anxiety disorders. However, there is no one gene that explains this biological trend. General findings indicate that personal experiences, social environment and biology all play a role in the development of the disorder.”

People often experience symptoms of social anxiety disorder to varying degrees across the life span, according to the center. Symptoms may lessen for stretches of time and then worsen during periods of change or stress, such as a job transition or when dealing with feelings of grief and loss.

What sets social anxiety apart from general anxiety is not only the social component but also an intense fear of judgment by others, explains Holly Scott, an LPC whose Dallas private practice is a regional clinic of the National Social Anxiety Center. People with social anxiety often harbor strong and pervasive feelings that others will notice their anxiety and judge them, which triggers avoidance behaviors, she says.

At the same time, there are nuances to the diagnosis, and social anxiety can look different in each client, Scott adds. For example, someone may be fine with public speaking and yet not be able to walk into a room in which they don’t know anyone.

“People think it’s not treatable,” Scott says. “Clients label it as ‘this is just the way I am, and I can’t change the way I am.’ It can be difficult to treat or to find a qualified practitioner, but it is treatable.”

Imhoff says he has read that on average, people go 15 years before seeking treatment for social anxiety. Counseling itself is a social interaction, he notes, and people with social anxiety may avoid treatment out of a fear of the close interaction or of being scrutinized by a practitioner.

Because people with social anxiety typically adopt avoidance as one of their coping mechanisms, and perhaps because of the way that social anxiety tends to get minimized or passed off as simply being introverted or shy, these clients often live life without seeking treatment until they reach a breaking point. As Imhoff points out, people can self-manage their social anxiety for an extended period of time by maintaining the same small circle of friends and following certain behavioral patterns such as always using the self-service checkout line at the grocery store.

Living with social anxiety is their reality, Imhoff explains, and they “forge ahead until something causes [them] to realize it’s more significant.” For Imhoff, that “something” was the impending scrutiny involved in defending his doctoral thesis.

“For social anxiety, it’s possible to navigate life with avoidance and survive for a long time. Then something comes up — a life change, such as entering the workforce — that causes them to need help,” he says. “A lot of these safety behaviors aren’t being done consciously. They are things we’ve done throughout our lives to find safety.”

Assessment and core beliefs

Avoidance behaviors are one of the biggest red flags that a client might be dealing with social anxiety, Miller says. These behaviors can extend to staying in situations in which the person is unhappy yet comfortable, such as a bad romantic relationship, a toxic friendship or a job that the person doesn’t enjoy or isn’t advancing in.

Other indicators include rumination and overthinking social experiences. This can include asking oneself over and over again, “What did that person think of me?” Miller explains, whether it’s an interaction with a neighbor while walking the dog or a yearly performance evaluation with one’s supervisor.

Counselors should be aware that social anxiety often co-occurs with other mental health issues such as depression and substance abuse (which often becomes a coping mechanism) that may need to be treated first or in tandem with the disorder, Miller adds. In addition, other issues such as grief may be complicating a client’s social anxiety. “They’re not always struggling with one thing. Make sure you’re working on what they’re struggling with the most,” Miller says.

Scott suggests asking clients at intake about how they deal with social situations and how often they go to gatherings or parties. Are they uncomfortable introducing themselves to new people, making a phone call or using the restroom in public places? If Scott hears symptoms that might indicate the presence of social anxiety, she uses a questionnaire (she recommends the Liebowitz Social Anxiety Scale, available at nationalsocialanxietycenter.com) to pinpoint the client’s fear level and to identify goals to focus on in therapy.

It can also be helpful to identify a client’s core beliefs and values and how those are affecting the person’s choices and behaviors, Imhoff says. People with social anxiety often carry a core belief that they’re inadequate or inferior, which spurs a fear of being judged, he explains. These clients frequently place weight and focus on situations that seemingly confirm their core belief and discount those that might disprove it. They might ruminate over a conversation with a colleague that didn’t go well, for example, without giving any consideration to all of the past conversations that did go well, Imhoff notes.

“They move through life paying very close attention to and taking to heart scenarios that confirm their core belief,” he says. “It’s important to help the client take off the blinders. Talk through ways they are competent, and get to the root of their concerns. Be aware of the multitude of their experiences and not just those they struggle with.”

To identify core beliefs, counselors can listen for themes in the way that clients talk about themselves, other people and the world. These themes can suggest deeply held beliefs to challenge or to explore further in therapy. Having clients work on thought journals can also be helpful in finding patterns, Imhoff says. He also suggests using a prediction log, in which clients name upcoming social scenarios that make them anxious and describe what they assume will happen. After the scenario occurs, clients can look back at their predictions with the counselor to talk through how accurate these foresights were.

After core beliefs and values have been identified, the counselor can work with clients to reframe their perspective around new core beliefs. For example, clients who place value on providing for their family could focus on that value to help them overcome their anxiety and discomfort over applying for a new job.

“Look for evidence that supports their new core belief,” Imhoff says. “If their belief is ‘I am capable,’ have them write down even the most minor piece of evidence [in a journal]. It makes it concrete and documented so they can refer back to it and talk it through with a counselor.”

From there, the counselor can work with clients on challenging cognitive distortions and black-and-white thinking, Imhoff suggests. Acceptance and commitment therapy (ACT) can be helpful, as can guiding clients to adopt a growth-focused orientation. With that mindset, every social interaction becomes an opportunity to learn rather than a pass-fail situation, Imhoff explains.

Clients with social anxiety may also feel that they’re failing because they can’t assume an extroverted, life-of-the-party façade. Counselors can help these clients learn that there is a continuum of social skills, Imhoff says. For example, perhaps they got through a work meeting and contributed their thoughts despite having a shaky voice and sweaty palms. “Work on [helping them realize] that it’s not black and white, it’s not all success or failure. There’s an in between for almost all scenarios,” he says. “Help them to recognize that in all social interaction, there is ebb and flow. It’s not a pass-fail exercise but an opportunity to connect with someone and learn moving forward.”

Additionally, ACT techniques can help clients learn to accept their anxiety rather than trying to get rid of it or avoiding triggering situations. Imhoff uses the imagery of “keeping anxiety in the passenger seat because I know it’s coming along but not letting it take control of the wheel.” Clients can learn to say, “There you are anxiety; I knew you were coming,” even as they move on with life and navigate situations they previously would have avoided.

Scott regularly uses cognitive restructuring and cognitive behavior therapy (CBT) with her clients who have social anxiety. She also uses a mindfulness technique called curiosity training that helps clients label their anxious thoughts as “background noise.” With this technique, users try to adopt an approach of curiosity about and interest in what is being said by others rather than assuming that others are judging them.

“In any situation,” Scott says, “whether they’re having a conversation, public speaking or sitting somewhere having lunch, they’ve usually got a constant dialogue going in their head. [It’s] self-criticism about how people must be thinking of them: ‘They don’t like my clothes’ or ‘I just stuttered while speaking.’ Curiosity training helps keep your mind on the present and learn how to pull your mind back when it starts wandering.”

Elizabeth Shuler, an LPC who has been working as an international school counselor in Amman, Jordan, for four years, recommends mindfulness techniques. She has often used Kristin Neff’s self-compassion practices in addition to dialectical behavior therapy, meditation and yoga for clients with social anxiety, both when she was in private practice in Colorado and Wyoming and currently in her work with adolescents and adults at her school.

“When we dig into their fears, most clients with social anxiety are really afraid that other people will agree with their own negative judgments of themselves. They’re worried that they will be proved right,” says Shuler, an ACA member. “I had a client who walked through the office the same way every day to avoid the people he was afraid of interacting with and had panic attacks when his route had to change or people he was avoiding crossed his path. These types of behaviors are meant to stave off panic but end up reinforcing it. My role as a counselor is to help clients see how these behaviors are actually making their panic worse and help them to slowly replace them with more helpful behaviors.”

Exposure

Exposure techniques are often central to treating social anxiety because they gradually reintroduce clients to anxiety-provoking situations in a healthy way.

Miller is trained in exposure and response prevention and finds it a powerful tool for working with clients with social anxiety. The behavioral technique requires clients to put in a lot of work themselves outside of sessions. The counselor collaborates with the client to develop a hierarchy of exposure based on the client’s needs and treatment goals and supports the client throughout the process.

As Miller explains, exposure assignments start small and build over time as clients become comfortable with each homework task. She describes this as a “Goldilocks situation” — not too much challenge and not too little, but just the right amount, tailored to each individual client. Miller says she emphasizes to clients that the treatment is in their hands — they have to do their part to experience a successful outcome.

“A lot of people have anticipatory anxiety, but once they do it [complete the exposure assignment], they’re OK,” Miller says. “A lot of people get over that hill of worry. They do it for a week or two and realize they can do it. Trust between a client and clinician is huge because we’re asking them to do really scary things.”

Miller often gives clients who are early in treatment the assignment of calling multiple businesses to ask what their hours are. Clients might have to overcome feeling a little foolish because that information is readily available on the internet, she notes. However, the goal is for clients to complete the task without falling back on habits they formed to avoid social situations, such as relying on technology in lieu of having personal interactions. Clients repeat the task over and over until they no longer feel anxious about picking up the phone and making a call, she explains.

Once they’ve mastered that task, clients might move on to going inside a store and asking a question in person. Or they might switch to walking their dog in their neighborhood during a busy time of day and saying hello to at least one other person during each walk.

As clients complete each task and return to their next counseling session, they process these interactions with Miller, discussing how the interactions felt to them and what went right or wrong. “Sometimes the client will come in and say, ‘I’m so bored with this.’ I say, ‘Great! That means it’s time to move on to something bigger,’” Miller says. “You need repetition with assignments. You need to do [tasks] over and over for your brain to get used to it. … The more you do it, [the more] it overwrites [old] patterns and anxious feelings.”

As a practitioner who specializes in treating social anxiety, Scott has a laundry list of exposure assignments that she uses with clients, ranging from making eye contact during a shopping trip to asking for directions from a stranger to calling into a radio talk show to singing karaoke. As clients progress, it can be helpful to assign them tasks that are certain to create some level of discomfort or awkwardness, such as going into Starbucks and ordering a hamburger, she says. This can be especially hard for clients who have a strong fear of being judged by others, but dealing with the responses they receive desensitizes these clients over time as they repeat the tasks.

Miller acknowledges that counselors may need to provide their clients with some ongoing motivation during exposure work. If clients come to session without completing their assigned tasks, she suggests asking leading questions to find out if they are avoiding the work or genuinely struggling to make it a priority among their other challenges.

“Who wants to go home and do anxiety-provoking things?” Miller says. “[We] have to find a way to motivate them. We want them to feel empowered to go out and do [an assignment]. Remind them that they’re in pain because something is not changing. … You can’t snap your fingers and make this go away. It’s going to be hard work and take time.”

It can be useful to circle back and remind clients of their core beliefs and the goals they want to achieve. For example, consider clients who say they ultimately want to start a family but whose social anxiety prevents them from entering the dating scene and potentially meeting a partner.

“They may not see how calling a drugstore [as an exposure assignment] is getting them to be able to date. But remind them that they’re building a foundation to be able to do that,” Miller says. “It may not have an immediate payoff, but the easier these things become for you, everything builds.”

Miller often uses the metaphor of training for a marathon to keep clients motivated. You don’t run 26.2 miles right away, she tells them. You start with one or two miles and then keep adding more distance, mile by mile.

Social skills

In addition to exposure work and cognitive restructuring, the counselors interviewed for this article recommend social skills training for clients with social anxiety. Avoidance behaviors may have kept these clients from learning and practicing social skills that are commonplace among their peers who do not deal with social anxiety.

“If you’ve been avoidant for years, you miss out on learning from all of the social interaction that others have had,” Miller says. “Sometimes they’ve built a life to minimize their pain, their anxiety.”

Goal setting and planning ahead, with support from a counselor, can help these clients navigate situations that are foreign to them and that naturally provoke anxiety. Miller suggests troubleshooting with clients. For instance, if their office holiday party is coming up, a counselor can talk through expected behaviors with clients and work on small talk and other exercises to help them get through the evening.

Setting realistic goals can also be comforting, Miller adds. “[They] don’t have to go in and work the room, [but] if they haven’t had a lot of social experience, they may not realize what’s expected,” Miller says. Instead, clients might set a goal of talking to three people whom they already know. Maybe at next year’s party, they can increase that goal from three people to five people.

Miller also reminds clients that a certain measure of social anxiety is simply part of being human. Even she, a therapist who makes a living talking to people, acknowledges sometimes being uncomfortable in social situations.

Kevin Hull is a licensed mental health counselor with a private practice in Lakeland, Florida, who specializes in counseling children, adolescents and young adults on the autism spectrum. Social skills training, along with group therapy, plays a large role in the work Hull does with clients around social anxiety, which he says often goes hand in hand with autism.

In individual counseling sessions, Hull uses puppets with clients to role-play social situations and work through what is expected. For example, Hull might instruct clients to verbalize a food order to his puppet without the usual help from mom or dad or ask his puppet for help finding a certain building on a school campus. Afterward, they process the experience together and talk about the emotions clients felt as their puppet had to interact and ask questions.

Humor can also be a great tool for overcoming the fear associated with social anxiety, says Hull, a member of ACA. He often shows clips of TV shows or movies (via YouTube) in client sessions as a lighthearted way of starting conversations about what is and isn’t appropriate when it comes to social skills. Particularly popular with clients are scenes with The Big Bang Theory’s Sheldon Cooper wrapping himself in bubble wrap to stay safe or wearing a second set of “bus pants” over his work outfit when taking public transportation. Another favorite is the title character in How the Grinch Stole Christmas, who initially can’t stand being around the Whos but ends up transforming over the course of the story.

“Using humor is a great thing to counter the fear,” Hull says. “When you can laugh at something, that gets people opening up and listening.”

Group work

Group therapy — a format in which clients are expected to interact with others and contribute to a discussion — would seem to be a nightmare for individuals who are socially anxious. But that’s not necessarily the case, according to Hull.

Although it can take clients some time to warm up to the idea, group therapy can play a powerful role in imparting the skills needed to navigate social anxiety, says Hull, an assistant professor and faculty adviser in Liberty University’s online master’s counseling program. In addition to helping participants sharpen their social skills, group counseling can instill perspective — something with which Hull’s clients who are autistic sometimes need extra help.

“With autism, clients have a hard time putting themselves in others’ shoes, so group is a great way for them to hear from the mouths of peers [and] hear them talk about what they’re going through,” Hull says. “Maybe someone [in group] had to ride a different bus than usual. It was terrifying at first, but they were OK and actually ended up talking to the person they sat next to.”

The group format, in which participants take turns offering comments, can model and teach the back-and-forth “tennis match” that is the basis of healthy conversation, Hull adds. It can also help clients learn to tolerate and listen when someone is talking about a subject that doesn’t interest them — a circumstance that previously would have triggered their fight-or-flight response and caused them to exit the situation.

Hull often has group participants speak for five minutes each on something they are passionate about. Afterward, he urges all of the group members to ask questions or make a comment about what was said.

“This is really hard with autism. If they don’t like something, it’s utterly meaningless to them,” Hull says. “This has them put themselves in others’ shoes and imagine how it’s like [something that they] like. This can transfer to social situations outside of group, such as a dinner party where other people are talking about whatever. Can you listen and learn something? It’s teaching their brain to overcome fear and learn a new normal. Everyone is scary when you first meet them, but you can do it. If you can do it in group, it’s the same as at school or a new job.”

Hull also uses video games in sessions as a way for participants to learn about group dynamics, leader/contributor roles and overcoming frustration (see sidebar, below).

It is important to prepare individuals with social anxiety for the group setting as much as possible ahead of time. Hull often shows clients the group room at his office (or emails them photos of it) and explains the format and what sessions will entail before they join group counseling.

“I walk back to the [group] room with the client and their caregiver before a group session so they can see it,” Hull says. “I explain, ‘Everyone who is coming here feels what you feel, and they’re all struggling with this.’”

When new clients join a group, he never makes them introduce themselves or speak right off the bat. He also allows them to bring anything that might boost their courage, such as a favorite stuffed animal or even a parent in the cases of younger clients. With social anxiety, it is important to allow clients to warm up and contribute at their own pace, he says.

“I can see group members five or six sessions in and they haven’t talked yet. I never stop trying to get them to engage or open up, even if all they can do is a head nod or fist bump,” Hull says. “[I emphasize that] I’m just happy they can be in the room.”

Hull acknowledges that group counseling isn’t a fit for every client who struggles with social anxiety. Social anxiety falls on a spectrum, and for some clients, the disorder is so severe that a group setting would be too much, he says. It is important to continue individual sessions with these clients, with group counseling becoming a possible long-term goal for some of them, he says.

When it comes to group counseling and social anxiety, it is crucial to take things step by step and to celebrate little victories, Hull emphasizes. With clients on the autism spectrum “the victories are fewer and far between,” he acknowledges, “but when they happen … you feel like you’ve won the Super Bowl.”

The long haul

Hull says that counselors should view social anxiety as a process rather than something to “fix.” Neuroscience tells us that the brain responds better to slow and steady change rather than forced or rushed adaptation. This is especially true for clients who struggle with social anxiety in addition to neurodevelopmental issues, past trauma or other mental health diagnoses, Hull notes.

Something else that counselors should avoid is projecting their assumptions onto clients with social anxiety. Just because the counselor went to prom as a teenager doesn’t mean that should automatically become a goal for every teenage client or, for that matter, even be considered the rite of passage that it once was, Hull says.

Counselors should really get to know their client’s world first before doing anything else, Hull says. “Avoid putting your agenda or perceptions on a client. We often see the potential in our clients, and it’s hard not to say, ‘Just do it!’ It can be discouraging and slow going at times, [but] be patient.”

 

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Technology and social anxiety: A double-edged sword

We live in a world where a person can text a happy birthday message to a friend, order a week’s worth of groceries for delivery and apply for a loan with the click of a button — all without having to speak to another human.

So, when it comes to social anxiety, technology can be a double-edged sword. Clients can certainly use it as an easy escape route to avoid social situations. At the same time, mental health practitioners can use it as a teaching tool with clients and as a bridge to overcoming long-held behavioral patterns.

“As great as it can be, technology can be part of avoidance,” says Robin Miller, a licensed professional counselor (LPC) who specializes in treating adults with anxiety. “Learn how to have conversations [about technology]. Make sure a client isn’t too reliant on it and unable to do things in a more social, direct way.”

Miller suggests that professional clinical counselors ask clients about their technology use at intake along with other questions about avoidance behaviors. Counselors can prompt clients to provide examples of situations where they feel most anxious and then listen for overreliance on technology, such as texting to ask someone out on a date or habitually using the self-service checkout line when shopping.

Social media can also exacerbate the assumption of judgment that often accompanies social anxiety, Miller adds. Clients who see photos and posts about friends’ and peers’ vacations, children or happy life events may come to believe that their lives pale in comparison.

Elizabeth Shuler, an LPC and an international school counselor, agrees. She says social media has created a new layer of social anxiety “centered around likes, comments and followers” in many of the adolescents with whom she works.

“I see students every day who are upset — to the point of panic attacks — that they’ve lost followers or that no one is liking their Instagram pictures. Instead of being afraid of being seen as stupid, these kids are afraid of not getting likes. It is a whole new world of judgment that has been unleashed on our teens, and it is taking a toll,” Shuler says. “However, many people who find face-to-face interaction intimidating can benefit from starting with digital interactions. Using texting, video and other digital means of conversation can help people with social anxiety learn social skills and give them a chance to practice new skills in a safer, lower stakes environment.”

Kevin Hull, a licensed mental health counselor in private practice, finds technology — specifically, video games — a natural tool for working with his young clients, many of whom are on the autism spectrum. In group counseling, Hull uses multiplayer games such as Minecraft to introduce clients to interacting and working together in a way that provokes less anxiety than face-to-face conversation might. Group members take turns being a “foreman” and leader in Minecraft sessions. The group learns to communicate and work together while dealing with frustrations and the nuances of the leader/contributor roles. “If technology wasn’t there, these kids would be even more regressed,” Hull says.

Conversations about technology use can also be an important part of social skills training in counseling, Hull adds. For example, young clients might claim that they are “dating” someone when they are actually just texting or playing video games together over the internet.

Hull often talks with clients about how texting is a good place to start communication but that it should not become their be-all, end-all. He’ll say to the client, “It’s great you’ve made a connection through texting, but what about the next level? Your brain’s process to communicate in text is the same as in speech. It’s just a different route.”

— Bethany Bray

 

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Social anxiety and college

The transition to college — leaving home, living with a roommate and establishing a new social circle, all while navigating academic responsibilities — doesn’t have to be paralyzing for students with social anxiety. Read more in our online exclusive, “Heading to college with social anxiety.”

 

 

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Contact the counselors interviewed for this article:

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

Letters to the editor: ct@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.

Learning to love (or at least leverage) technology

By Lindsey Phillips May 22, 2019

A client suffers from one of the oldest and most common fears: arachnophobia. The mere thought of a spider causes her anxiety, and she often has a friend check a room for spiders before she enters. She wants to get help, but she lives in a remote area without access to a clinical expert. Could the use of augmented reality help the client overcome this phobia and actually touch a tarantula?

Arash Javanbakht, an assistant professor of psychiatry and director of the Stress, Trauma & Anxiety Research Clinic (STARC) at Wayne State University in Michigan, has found that it can. At STARC, Javanbakht uses augmented reality along with telepsychiatry as a method of exposure therapy for clients with phobias.

The client with the spider phobia, for example, would put on the augmented reality device and connect with the therapist through a wireless telepsychiatry platform. The therapist, who has full control of the augmented exposure scenario, sees a map of the client’s environment on a computer monitor. At first, the therapist places a small spider across the room in front of the client. Then, the therapist adds a larger spider that crawls across the wall. The therapist notes what the client sees and asks how she is doing. By the end of the session, several types of spiders — all moving around — and spider webs surround the client. In this safe, controlled environment, the therapist and client work together to help her overcome her fear.

The impressive part is how quickly this method can help clients. For Javanbakht, the ultimate goal is to have clients touch a real-life tarantula (or a tank containing one). Comparing traditional therapy with the augmented experience, Javanbakht discovered that what would take on average six face-to-face sessions could often be accomplished in 40 minutes with the use of augmented reality. He contends that pairing technology such as this with traditional therapy approaches can significantly improve treatment efficacy for other phobias, anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder.

Despite the possibilities that new technologies offer, however, counselors are often reluctant to use them. Many prefer face-to-face counseling and question the impact that technology may have on the therapeutic relationship. Others are unsure of what technology to use or how to use it. Most counselors worry about possible ethical implications. For some, the overarching counseling principle of do no harm translates into do not use tech

Olivia Uwamahoro Williams, an assistant professor of counselor education and college student affairs at the University of West Georgia, says this hesitancy to embrace technology is understandable because counseling is a person-centered profession. However, counselors shouldn’t think about technology as a means of removing the person completely, she argues. Instead, they can use technology to enhance mental health and counselor training outcomes, she says.

“There’s a general lack of understanding in the counseling community about high technology such as artificial intelligence [AI] and how it will impact the field,” adds Russell Fulmer, who is part of the core faculty at the Counseling@Northwestern program with the Family Institute at Northwestern University. Some counselors incorrectly assume that they have to be well-versed in the inner workings of technology or must learn how to code, and many counselors even fear losing their jobs to high technology such as AI, he says.

However, Fulmer, a licensed professional counselor (LPC) and a member of the American Counseling Association, doesn’t believe that counselors’ livelihoods are in jeopardy from technology in the short term. The jobs most in danger of becoming obsolete are ones that are repetitive, he says. Thus, occupations such as counseling that involve social and emotional intelligence are better positioned in the long term, he explains.

Holly Scott, an LPC and the owner of Uptown Dallas Counseling in Texas, used to be adamantly against using technology in counseling. Now, however, she is a technology convert, citing at least five ways that counselors can use technology in their practices:

  • Helping clients find mental health practitioners who are a good match for their presenting issues
  • Finding and disseminating evidence-based information
  • Improving clients’ mental health through the use of virtual or augmented reality
  • Encouraging clients to follow up on treatments and the skills they learn in session through the use of mental health apps
  • Reaching a broader range of clients through telehealth 

Meeting clients where they are

Younger generations have a difficult time imagining a world in which libraries and encyclopedias were the only means of researching school projects. Today, they simply pull out a smartphone and Google it — sometimes while still sitting in class. According to the Pew Research Center, in 2018, 95% of teenagers reported having a smartphone or having access to one, and 45% said they were online on a near-constant basis.

Technology is not just for the young, however. Pew also found significant growth in tech adoption in recent years among older generations, particularly Gen Xers and baby boomers. In fact, boomers are significantly more likely to own a smartphone today than they were in 2011 (67% in 2018 versus 25% in 2011), and the majority (57%) now use social media.

James Maiden, the assistant dean of student affairs and an assistant professor of counseling at the University of the District of Columbia (UDC), finds that clients are outpacing counselors in terms of technology. Counselors need to do a better job of meeting clients where they are, he says. “Don’t think [technology] is going to replace you,” he argues. “Think of how [it] can extend the good work that you’re doing.”

In fact, Maiden, an LPC and an ACA member, views technology as “a gateway into seeking a professional [counselor].” Counselors can begin by providing peer-reviewed, factual information and tools online for people who search the internet for help, he says. Making this information readily available to the public will help lessen the stigma around mental health and open the door for more individuals to eventually take the next step of going to see a counselor, he explains.

Scott says most clients find her private practice in Dallas through her website or by Googling “anxiety” and “Dallas.” She acknowledges that this is a more “selfish” use of technology — one that helps counselors get their names out there. However, if counselors share with the public their specialties and what they offer, then it’s a win-win for both the counselor and the client, she says.

Part of the purpose of Scott’s website is to remove as many stressors for potential clients as possible. The information it provides can help address people’s fears and concerns and normalize the counseling experience, she says. For example, a counselor’s website can include pictures of the office and address common questions that first-time clients might have: Where do I sit in session? Are people going to see me in the waiting room? What do I say to people if they see me sitting there? How much does counseling cost? Where do I park?

Of course, the counseling profession has made some strides in meeting clients where they are through the use of technology. For example, distance counseling and telehealth remotely provide services to clients who may not be able to see a counselor in person because of location or limited mobility. 

More widespread use of telehealth has led to a significant decrease in the number of psychiatric admissions among those residing in geographically isolated areas, according to Panagiotis Markopoulos, the clinical lab director and a faculty member in the counselor education program at the University of New Orleans. He touts several benefits to using distance counseling:

  • Safety (clients can express themselves more freely)
  • Less social stigma (clients can avoid public encounters)
  • Accessibility (clients can receive help regardless of their geographical location or daily schedule)
  • Affordability (clients can receive counseling services at a lower cost than with face-to-face counseling and save on transportation costs)

For clients who prefer or need to use distance counseling, Markopoulos, an LPC in private practice in New Orleans, recommends video- and text-based communication tools such as My Clients Plus and Zoom. In addition, Second Life, a 3D virtual game, offers an encrypted way of communicating, Markopoulos says. If clients value anonymity yet want to be present with a counselor, they can create avatars, enter the “virtual session” and talk through a headset or text-based chat, he explains.

Counseling: There’s an app for that

The high cost of some technologies prevents private practitioners from using them, but mental health apps are an affordable way for counselors to incorporate technology into practice. In addition, these apps can allow people who face barriers to traditional mental health services to access help.

According to Psycom.net, health experts predict that apps will play an important role in the future of mental health care. In particular, mobile apps for cognitive behavior therapy (CBT), relaxation and mindfulness interventions are gaining momentum as supplements to in-person therapy.

Scott, who serves on the board of the National Social Anxiety Center, personally knows the power of using CBT apps with clients. When a client comes to Scott, she offers to use either paper handouts of CBT activities or MoodKit, a CBT app developed by two clinical psychologists. She’s noticed that most clients 35 years and younger prefer to use the app. “For a certain population, [the MoodKit app] really increases the speed of the change and the efficacy of the therapy,” she adds.

Scott has also observed that when she asks clients to record their moods between sessions, those who do it manually often wait until the last minute — sometimes in the waiting room — to complete the assignment. Clients generally respond better to the app, she says, perhaps because it lets them easily chart their moods and provides them with a visual diagram.

When Scott introduces MoodKit, both she and the client open the app on their phones, and she walks the client through all the activities such as daily mood tracking, thought records and behavior activation. With thought records, the app guides users through all the important questions and helps them label the cognitive distortion with prompts such as “Is this all-or-nothing thinking?” Scott also thinks the app’s section for behavior activation is brilliant. With a client who has social anxiety, for example, the app provides a choice of therapeutic activities such as introduce yourself to a stranger. After the client selects an activity, the app prompts the individual to select a day and time to complete this activity.   

Incorporating a CBT app with regular counseling also encourages clients to put the CBT skills they are learning in session to use in their everyday lives, Scott continues. The outcome is best if counselors follow up with clients about the app and the progress they are making, she notes. For example, counselors can ask: What do you like about the app? What activity did you complete this week? When you did that activity, what did it feel like? “The therapist’s input … is what will change [the app] from just something [clients] play with on their phones into a real therapeutic, mental-health-changing application,” Scott says.

Scott, who volunteers as a crisis counselor for Crisis Text Line (which provides free crisis intervention via text messaging), has also discovered that several of her clients already use the meditation/mindfulness app Headspace. If clients are using an app, counselors can see if the app works with their therapeutic goals before using it in session with them, she advises.

Before meditation apps, Scott would play a recording (such as background noise at a bar) and have clients focus on the conversation. Then she would tell clients to do the same thing outside of sessions, starting with 10 minutes a day and working up to 30 minutes. Clients often felt too busy to set up a place where they could play a recording and work on meditation, but the app creates the environment for them, increasing the likelihood they will practice the skill outside of session, she says.

Maiden, like Scott, is a technology convert. He started learning more about incorporating technology into counseling while serving as the principal investigator for UDC’s Verizon Innovative Learning program, which provides educational experiences that promote and support the involvement of ethnic minority boys in science, technology, engineering and math. The program included free summer sessions, led by counselors-in-trainings, that discussed how to maintain one’s mental health. Afterward, the boys created apps that featured information on mental health stigma, stress prevention, anxiety, depression, suicide awareness and local mental health resources (such as counseling centers). Participants also received a year of mentoring and follow-up workshops.

Through their involvement in the program, the students learned the importance of seeking help when dealing with issues such as bullying, death and violence. They grew more likely to reach out to mentors or parents or to access the local resources included in the apps, according to Maiden, who presented at the 2019 ACA Conference on using technology to increase mental health awareness.

Through his involvement, Maiden realized the potential apps have for functioning as counseling tools that supplement the face-to-face work. Tech tools such as those created in Maiden’s program also allow people to share information with others who may not be inclined to discuss their mental health, he continues. For example, when the friend of one of the boys who had participated in the program joked on the phone about killing himself, the boy quickly informed his friend that suicide was not a laughing matter and that he was going to tell his mother, who would tell his friend’s parents. The boy also provided his friend with local resources from the app. As a result of his actions, the friend’s parents sought help for their son.

Exposing clients to a virtual world

As Scott points out, exposure therapy can be time-consuming and expensive to do when using real-life props and scenarios. As Javanbakht’s impressive results demonstrate, however, virtual and augmented reality can allow therapists to remotely expose clients to feared objects or situations. This approach is more time- and cost-efficient and provides a safe, effective outcome, Scott says.

Markopoulos finds the immersive quality of virtual reality particularly helpful for clients with autism spectrum disorder (ASD). Research indicates that individuals with ASD are drawn to technology, and they often learn and understand visually, he says, so using virtual reality with this population makes sense. “The higher the immersion, the more likely the child who has been diagnosed with autism will be able to apply the social skills that he or she has been taught in a real-life situation,” Markopoulos explains.

Markopoulos, an ACA member, has received several awards, including the 2018 Graduate Student Research Award from the International Association of Marriage and Family Counselors and the 2017 Make a Difference Grant award from the Association for Humanistic Counseling, for his work with virtual reality in the treatment of children with ASD. He also presented on the topic at the 2018 ACA Conference.

Markopoulos developed a virtual mall for individuals with ASD and for those who present with social anxiety. Both Markopoulos and the client put on the head-mount display (box-shaped glasses that allow the user to see the virtual/augmented scenario) and enter the virtual mall, which is busy and noisy. The client will see and hear coins falling from the ATM and televisions playing, see flashing lights from a photo booth in the center of the mall and see avatars constantly walking past. All of these visual and auditory elements serve as checkpoints to figure out the source of anxiety for the client.

As the client passes by a large television producing a high-pitched frequency, the client pauses and stares at it, and Markopoulos takes note. Markopoulos has attached a heartbeat sensor to the client, and upon hearing the television, the client’s heart rate escalates. At this point, the client says the mall is overwhelming and removes the head-mount display.

Through the use of virtual reality, Markopoulos has identified what is causing the client’s anxiety — the high-pitched frequency he programmed into the television. With this information, he creates a new scenario with checkpoints focused on the same high-pitched frequency, and he allows the client to control the volume. Upon entering the virtual world again, the client reports the sound is loud and overwhelming, so the client lowers the volume. Slowly, with Markopoulos’ help, the client is able to cope with the sound at a low frequency. Then Markopoulos gradually increases the sound, helping the client slowly build capacity for handling more noise.

Scott and Maiden are excited about the possibilities of incorporating virtual reality into counseling practice. In fact, Maiden plans to use virtual reality in the Verizon Innovative Learning program at UDC this summer. He wants the boys who participate to create virtual safe spaces so they can process and cope with all the stressors they experience. He hopes these safe spaces will be tools the boys can use at home until they are able to make it to their next counseling sessions.

Mental health chatbots

Fulmer doesn’t think that AI will eclipse the human need for face-to-face interaction that counseling provides. Instead, he equates AI to a multivitamin — one that will serve as a supplement to counseling.

To learn more about the intersection of AI and mental health, Fulmer reached out to X2AI, an AI startup in Silicon Valley that is, according to language on its website, “building an AI that will … make the lives of people suffering from various forms of mental illness much better.” Fulmer offered his services and now serves as a consultant and on the company’s advisory board.

As Fulmer explains, Tess is X2AI’s largest and most versatile mental health chatbot. She provides psychological support for people using automated chat conversations through text-based messaging apps that are compliant with the Health Insurance Portability and Accountability Act (HIPAA). When a person talks to Tess, she not only analyzes the conversation but also remembers details and learns from what the person says.

Along with X2AI, Fulmer conducted a randomized controlled trial to test the efficacy of using Tess to reduce symptoms of depression and anxiety in college students. Depending on the group, participants received unlimited access to Tess for either two weeks with daily check-ins or four weeks with semiweekly check-ins. The college students used Facebook Messenger (a text-based communication) to interact with Tess. She provided psychoeducation and interventions to help the students cope with their depression or anxiety.

Fulmer and his colleagues found that having access to Tess resulted in a significant reduction in symptoms of anxiety and depression among the students. In addition, the participants said they felt comfortable and satisfied with the therapeutic experience. One student said it felt like talking to a real person and noted the benefits derived from the specific tips Tess provided for ways to improve mental health. Another student reported learning new ideas for making small changes.

Fulmer points out that this study and the students’ feedback suggest that chatbots can help with two of the most common counseling issues — anxiety and depression. Thus, counselors might want to explore the use of mental health chatbots such as Tess, in conjunction with traditional therapy, to see if it improves the mental health of some clients.

Mental health chatbots can also reach a wider, more diverse group of clients, Fulmer says. For example, X2AI has developed a chatbot (Karim) to help Syrian refugees and a chatbot (Sister Hope) designed for clients who are Catholic. Fulmer also notes that rural populations that don’t have much access to mental health care and older adults who often experience loneliness could benefit from mental health chatbots.

“AI is the biggest opportunity that humankind has ever had,” Fulmer says. “When there’s opportunity and the potential of power and influence, it must be monitored. It must be crafted, and it … must evolve appropriately. And counselors can play a role in … the evolution of psychological AI.”

Virtual role-play

In graduate counseling classes, students often engage in role-play, with one student playing the role of the client — including assuming the client’s mannerisms and personal history — and the other student embodying the role of the counselor. This traditional training method offers several benefits, including helping students develop empathy and experience what it takes to be vulnerable in a session, Williams points out.

However, because students would often “break” from their role-playing if they were caught off guard, Williams, an ACA member and LPC at the Healing Center for Change in Georgia, felt the immersion aspect was not as authentic as it could be. To make the experience more immersive, she started using virtual simulation to create these role-playing scenarios — a topic she presented on at the 2019 ACA Conference.

With virtual simulation, students go into a virtual lab and interact with avatars. The scenarios are limited only by counselor educators’ imaginations, she says. It could be a client with bipolar disorder or a family session with two adults and three children. She points out that a virtual space is also less stressful for students because it allows them to focus on the counseling role. 

Another major benefit is that counseling instructors can easily manipulate or alter the student–avatar interactions and virtual scenarios to further challenge students and prepare them for real-world counseling sessions, Williams says. Instructors can also pause the simulations when students are feeling frustrated and process with them, she says.

For example, recently, when an avatar’s voice became low and choked, the counseling student doing the simulation did not pause to address the emotional change but just kept processing the client’s story. Williams wanted to check this, so she stepped over and asked the person managing the equipment to make the avatar cry. When the avatar started crying, the student froze, not knowing how to respond. Williams paused the session to process this issue with the student, who admitted that she didn’t handle it well when people cried. The other students who had been observing and taking notes on the virtual session acknowledged that they wouldn’t have known how to respond either.

This virtual experience made the counselors-in-training realize that they needed to work on handling clients’ emotions and led to a class discussion on strategies. Williams says she wouldn’t have been able to recreate the same scenario in a traditional role-play because she can’t easily walk over to a student and whisper, “Start crying.” That wouldn’t create the same effect, she says. 

Because students know the avatar is not a real client and recognize that the virtual simulation is a safe space, they are also more willing to take risks, Williams adds. A year ago, a student went into the virtual lab and started asking the avatar close-ended questions, which every counseling textbook and instructor advises against. When the student came out 10 minutes later, Williams asked her why she had used those questions. The student replied that she had been curious about what would happen; now she understood that it resulted in the counselor and client going around in circles.

Providing a safe space to role-play often gives counselors-in-training the courage to “mess up,” Williams says. “They can get it wrong — really wrong — and that’s fine because you can stop the simulation, give them feedback, assess how they’re doing, and start it back over and give them an opportunity to practice that skill again.”

Williams still recommends blending traditional role-play with virtual role-play. She uses the traditional method when students are learning the basic counseling skills, such as listening and developing a therapeutic alliance. Then later in the class, she uses virtual simulation to have students practice those skills and experience more complex scenarios such as crisis intervention, a client with psychosis, or couple and family sessions.

Counseling students can also use avatars to learn how to talk with clients’ families and caregivers, she adds. For example, the virtual scenario could involve a school counselor discussing with a child’s parents how the child mentioned having suicidal thoughts. The counselor-in-training can practice having that conversation with the parent and figuring out how to work together to create a safety plan, she explains.

“As educators, we need to be mindful of the students that we’re teaching,” Williams says. “The millennial generation … [is] exposed to a level of technology that is beyond what any of us were exposed to over the course of our lifetime. It’s naïve to think that we can continue to teach effectively these new sets of students and keep their level of excitement and keep their level of enthusiasm without incorporating more exciting technologies in their learning experiences.”

Technologically ethical

Because technologies change so quickly, counselors may find themselves in uncharted waters when debating whether to incorporate things such as virtual reality therapy or mental health apps into their counseling practice.

The first questions Scott typically hears related to counseling and technology revolve around ethics. She acknowledges that a lot of misinformation tends to circulate about using technology within one’s counseling practice, so she advises counselors to continually check the ethics codes of counseling organizations such as ACA and state-level regulations to see if new guidance or rules have been put in place.

The ACA Code of Ethics doesn’t specifically mention chatbots or mental health apps, but as Joy Natwick, ACA’s ethics specialist, points out, the decision to make the code a general set of guidelines and principles for using technology was intentional. “If we were to write a code that specifically names types of technology, it would be out of date before we printed it,” she says.

Natwick encourages counselors to pay special attention to Section H of the ACA ethics code, which discusses distance counseling, technology and social media. “If you feel like you can’t find [an answer in that section], go to the preamble of the code because that’s where the [professional] values are, that’s where the principles [of professional ethical behavior] are,” she advises.

When counselors encounter a new technology or have ethical questions about technology, Natwick suggests they use an ethical decision-making process such as Holly Forester-Miller and Thomas Davis’ “Practitioner’s Guide to Ethical Decision Making.” (ACA members can access both an infographic and a white paper on the seven-step model at counseling.org/knowledge-center/ethics/ethical-decision-making.) ACA is also in the process of creating tip sheets to provide practical guidance regarding social media and distance counseling, she adds.

“Technology becomes more and more ingrained in everyday life and, therefore, we as counselors need to keep up,” Natwick says. “We don’t want our profession to get left behind.” She hopes the practical guidelines provided by ACA will serve dual purposes: 1) Encourage those eager to use technologies in counseling to pause and consider the ethical implications, and 2) encourage reluctant counselors to engage more with technology.

Natwick also stresses the importance of competency, privacy and confidentiality when it comes to technology in counseling. “Technology is another way we are supplementing therapy or interacting with our clients,” she says. “[As with] anything we introduce to our clients, we need to really educate them about the risks and benefits.”

Scott is well aware of privacy concerns online, so her informed consent document explicitly details her online and social media policies and lets clients know appropriate ways to contact her. For example, she will not friend clients on Facebook, but they can follow her on Twitter. Clients can also contact her through a form on her website or by posting comments on her blog (which require her approval). She also addresses these issues during her intake session
with clients.

“Tech privacy means something very different in the tech space than it does in the health care space,” Natwick warns. For this reason, she recommends that counselors use technologies created or informed by mental health professionals because these vendors should share similar values with counselors and understand the HIPAA privacy rule. 

Teaming up with tech

Of course, professional counselors can also benefit from technology apart from using it with clients. Scott often turns to Twitter to find information and to get practical suggestions from fellow mental health practitioners by using hashtags such as #CBTworks and #SoMePsychs. For example, she recently saw a Tweet asking other mental health practitioners for their favorite clinical handouts for doing cognitive restructuring with clients with anxiety or depression. Several people replied with resources, including handouts, infographics and links.

Scott discovered MoodKit, the CBT app she uses with clients, through the Academy of Cognitive Therapy Listserv. A quick search on the Listserv led her to a research study on three CBT apps. The study found that MoodKit was effective in decreasing depression and increasing mood.

All of this reveals that technology is changing the way that clients and counselors communicate and form relationships. This suggests that counselors will need to be open to finding new ways to build relationships, and it may mean that some of the initial relationship building will happen in different ways than they are used to, Natwick points out.

Smartphones already have built-in sensors that record users’ movement patterns, social interactions, behaviors, and vocal tone and speed. According to the National Institute of Mental Health, apps in the future may be able to analyze the data to determine a user’s real-time state of mind and alert mental health professionals that help is needed before a crisis occurs.

In fact, AI has already made great strides in medical diagnoses. New Scientist magazine recently reported that human doctors annotated medical records (including text written by the doctors and lab results) to help train AI. This partnership resulted in AI that could diagnose children’s illnesses in unseen cases with 90% to 97% accuracy. 

Fulmer believes a type of symbiotic relationship could also form between counselors and technology. He sees technology such as AI working alongside counselors in the same way that counselors often work in multidisciplinary treatment teams. For example, a chatbot could detect a person’s emotional or behavioral state and provide the counselor with the client’s data and a possible diagnosis.

“Rather than just one counselor meeting [clients] during their initial interview and having to write down a provisional diagnosis, it might be pretty helpful to also meet with an AI and get their input on the diagnosis,” Fulmer says. “That could probably enhance reliability and even validity.”

The partnership aspect is key. Technology is most likely to assist mental health professionals, not replace them. Fulmer is an optimist about the intersection of technology and counseling and believes “that if done the right way, everyone can benefit.”

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

 

Letters to the editor: ct@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.