Tag Archives: Technology

Mental health apps as therapeutic tools

By Lisa R. Rhodes April 5, 2023

A hand holding a smartphone with an app opened asking "How are you feeling?" and five emojis indicating various moods. Beside them is a cup of coffee and an opened laptop.

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Many people today rely to some degree on apps in their efforts to establish a sense of personal wellness. This has led some professional counselors to consider the use of select mental health apps with clients to help them reduce stress and counter their negative thoughts and emotions.

Jennifer Hart, a licensed professional counselor (LPC) in Wyncote, Pennsylvania, and Sarah Barry, a licensed clinical professional counselor in Butte, Montana, are using mental health apps both virtually and in person with their clients.

Hart believes “the possibilities are endless” in using these digital resources as supplemental tools in clients’ journey of mental health and recovery.

“Whenever someone is trying to implement change into their life, the easier it is to access the information, the more likely it is that a client will do the homework or work on implementing the changes,” she says. “No one wants to jump through hoops to do hard work. But if you can easily access items to help you do the work behaviorally, it’s more likely to get done.”

Security precautions

In their book Doing Counseling: Developing Your Clinical Skills and Style, published by the American Counseling Association earlier this year, Jude T. Austin ll and Julius A. Austin, advise counselors to “choose apps that can properly secure client data and support therapeutic options that are based on scientific evidence while also upholding ethical standards of conduct.”

Hart, who works at McPherson Clinical and Counseling Services, says her clients use a variety of apps, including Calm, Headspace, Mindfulness Bell, Word Search, Adult Coloring, Sparkle, Kindle and Audible, to help them manage their anxiety and depression or to assist them with emotional regulation and lifestyle changes. However, Hart uses mental health apps with her clients selectively and ensures that she makes careful notations concerning what mental health concerns she and the client are working on by using the app. She also notes how the app fits into a client’s overall treatment plan.

Hart’s clients largely report that they enjoy using these apps because of their accessibility, which factors in to helping some clients make progress in their therapeutic outcomes.

“Clients report feeling better, [having] less symptoms of anxiety, better sleep, better relationships and [a] better quality of life,” she notes.

Supplemental tools

Barry, owner of Mountain of Hope Counseling LLC, uses the CBT Thought Diary app to help raise clients’ awareness of their thoughts, emotions and behaviors. The app assists clients with reducing their stress levels, tracking their moods and changing negative thought patterns.

Among the tools the app provides is a thought log that allows clients to type in whatever thoughts they are having throughout the day. Barry and the client will then review the log in session and discuss whether they notice any connections between the client’s thoughts and their feelings of anxiety or depression.

Barry says the CBT Thought Diary app is helpful because clients can use it on their own time and whenever they feel triggered by an emotion.

The Calm app is also beneficial for clients who are experiencing depressive symptoms, Barry notes, because it helps them incorporate mindfulness and breathing exercises into their day.

“In my experience, someone who is struggling with depression also shows features of anxiety, so if a person is able to utilize deep breathing exercises with calm meditation, they are able to learn to cope in the moment without having these emotions build up and [having to] wait to process it all during their therapy appointments,” Barry explains. “It enables the individual to work toward their own healing, which builds self-esteem and resilience.”

Jessica Eiseman, an LPC supervisor at Ajana Therapy and Clinical Services in Houston, says mental health apps can be useful tools in either in-person or online therapy. However, she emphasizes that they are only tools and should not be used as a substitute for actual therapy.

“These should be supplemental to the work someone is already doing with a counselor,” Eiseman says. “Without the guidance of trained mental health professionals, like counselors, information can be misused or misinterpreted.”

For example, Eiseman says that while a meditation app may help to reduce some symptoms of certain mental health disorders or provide some temporary relief, it is unlikely to treat the totality of the client’s symptoms.

The Austins say that using extra online resources with clients can be helpful to create visuals, watch videos, listen to music, draw live genograms and draw cybernetic patterns. But they remind counselors that “the point of a technique is to transcend the technique.”

“If we want a client to process grief, using an app is not going to help them process grief,” the Austins stress in a joint email response to Counseling Today. “It may assist, but the processing needs to take priority. The dangers are when counselors become reliant on apps or technology to do the work. This is the same with any intervention. What makes the Myers-Briggs [Type] Indicator so effective is not the assessment itself, but the processing afterward. The same is true for apps in session.”

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The following resources may be helpful for counselors who would like to learn more about mental health apps and issues of privacy and security:

American Psychiatric Association’s App Adviser Initiative
Mozilla Foundation’s mental health apps privacy and security guide
“Peace of mind: Evaluating the privacy of mental health apps” by Stephanie Nguyen, Bobby Richter, Justin Brookman and Bill Fitzgerald, Consumer Reports Digital Lab, 2021

Read more on telebehavioral health and clinical practice in Counseling Today’s April cover story.

Lisa R. Rhodes is a senior writer at Counseling Today. Contact her at lrhodes@counseling.org.

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 telebehavioral health on clinical practice

By Lisa R. Rhodes April 4, 2023

A Black woman sits on a chair with a laptop; her hands are in front of her chest, palms together

denis kalinichenko/Shutterstock.com

Just a few years ago, telebehavioral health was not a service that many counselors provided for their clients. Jennifer Nivin Williamson and Daniel G. Williamson, both licensed professional counselors (LPCs) and core faculty at Capella University, say that the use of technology in counseling before the COVID-19 pandemic was often considered “avant-garde” or a “fringe” practice.

The Williamsons note that telebehavioral health was seldom billable and often considered risky, with a few exceptions such as distance counseling for military families.

But the reticence toward telebehavioral health services in the mental health field changed when COVID-19 hit the nation. Because of the national public health emergency, the Department of Health and Human Services Office for Civil Rights temporarily eased the restrictions of the Health Insurance Portability and Accountability Act (HIPAA), allowing mental health providers to more easily provide telebehavioral health services. (For an update on the HIPAA compliance rules for telebehavioral health, see the Risk Management for Counselors column on p. 10.)

This meant a lot of counselors had to learn how to use telebehavioral health whether they wanted to or not. “When the pandemic-mandated general shutdown occurred, there was no other choice but to do it [therapy] virtually for most people. Very few therapists would risk going into the office,” says Sam Lee, an LPC at the McLean Counseling Center in McLean, Virginia. “Some therapists, mostly the older demographic, resisted [going] virtual. Some clients were unhappy about having to do therapy virtually, but it was that or none.”

Some clients missed the physical face-to-face immediacy of in-person therapy and others questioned if virtual, on-screen counseling would really work, he adds.

But the increase in people seeking mental health services during the pandemic made telebehavioral health a viable alternative to traditional therapy, and now telebehavioral health seems to be here to stay.

“Most people have gotten so used to the online interactions because of the pandemic that it is integrated into our everyday lives in a way it hadn’t been prior to the pandemic,” says Jessica Eiseman, an LPC supervisor in Texas.

And the majority of people who receive online health care have a positive view of online therapy. According to the COVID-19 Telehealth Impact Study, a collaboration between the American Medical Association and the COVID-19 Healthcare Coalition, 79% of the patients who were surveyed in 2021 said they were very satisfied with the care they received during their last telehealth visit, and 73% said they would continue to use telehealth services in the future.

Research has also found that telebehavioral health is effective in treating some mental health disorders. A meta-analysis published in the Journal of Anxiety Disorders in 2018 found that in-person, traditional cognitive behavior therapy (CBT), internet-delivered CBT and bibliotherapy have equally effective outcomes in treating people with anxiety and depression.

Although adapting to telebehavioral health has been easy for some counselors and challenging for others, it has caused many clinicians to rethink how they use clinical skills designed for in-person therapy and gain new skills when building the therapeutic relationship, assessing clients and using therapeutic techniques in an online environment.

Expanding the reach

Telebehavioral health has also made therapy an option for people who might have never entered a counselor’s office otherwise. Jude T. Austin II and Julius A. Austin, co-authors of the book Doing Counseling: Developing Your Clinical Skills and Style, published by the American Counseling Association earlier this year, say clients struggling with social stigma can use distance counseling as “a jumping-off point for more fulfilling social interactions.”

“We have both worked with clients who start off only doing phone sessions, then they gradually move to virtual sessions, then in-person sessions, then group sessions. Distance counseling makes counseling accessible,” says Jude Austin, an assistant professor and clinical coordinator in the counseling program at the University of Mary Hardin-Baylor. (For a discussion on possible issues with access and telebehavioral health, see Chris Gamble’s article, “Rethinking the accessibility of digital mental health” in the July 2022 issue of Counseling Today.)

Distance counseling can also be a first step in mental health treatment for people of color who may want to seek help but don’t have the time to visit a therapist. “We grew up in a community where counseling was very much a ‘white people thing,’” says Julius Austin, an assistant professor in the clinical mental health counseling graduate program at Grand Canyon University. “It was not that Black, Indigenous and people of color [BIPOC] individuals in our community didn’t value mental health or find processing through life important. It’s just that no one had [the] time or resources for counseling; not to mention that finding a BIPOC counselor when and where we grew up was difficult.”

“Distance counseling is a game-changer for populations who understand the importance of counseling but never had the time or struggled to find a therapist they felt comfortable approaching,” says Jude Austin, an LPC and licensed marriage and family therapist with a private practice in Belton, Texas.

It can also remove barriers that prevent some clients from taking the first step toward getting help, Jude and Julius Austin add. For example, they note that a queer quarterback who doesn’t want to go to the university counseling center out of fear of being stigmatized or a BIPOC individual who does not see themselves represented by the counselors in their area can decide to reach out to a counselor in a surrounding city by making a telebehavioral health appointment. Similarly, a construction worker who wants to save their marriage but can’t find the time to go to counseling can now have a Zoom or phone session with a counselor during their lunch break.

“There has been a lot of work done by ACA, counselors themselves and clients to lower the stigma of seeking counseling,” says Julius Austin, an LPC and the clinical director of a community-based private practice in Lafayette, Louisiana. “Distance counseling can serve the ‘let me just see what this is all about’ population of clients who think counseling can be beneficial but they don’t necessarily know if they will like it. They just want to explore counseling.”

Adapting to the technology

With so many counselors providing telebehavioral health for the first time during the pandemic, training became essential. Jennifer Hart, an LPC who provides hybrid services at McPherson Clinical and Counseling Services in Wyncote, Pennsylvania, admits she was not comfortable with using technology at the start of the pandemic, so she had a steep learning curve.

“I am a somatic-oriented practitioner, meaning I am very keen to body language and physiological responses when having sessions,” she says. “Not having in-person sessions really changed how I assess and [develop a] treatment plan. It was tricky. But with time and training, using technology to provide care became easier and easier.”

Hart received one hour of telebehavioral health training from a former employer. The training included how to use the practice’s telebehavioral health platform and how to use apps on iOS and Android devices. (For more on the use of mental health apps, read the Counseling Today articles “Mental health apps as therapeutic tools” and “Using apps to promote client safety.”)

When the pandemic began, the counseling practice Lee was working at provided training for the employees on how to use the technology for virtual counseling. “We were guided by emails by the practice administration on how to set up [a] virtual platform to restart seeing clients at home through telehealth,” he says. “There were trepidations, but at least for me, it was not really a hassle.”

Jude and Julius Austin have used some form of distance counseling in their work with clients since they each opened their private practices five years ago, but it became a primary modality during the pandemic lockdown. They both learned how to use telebehavioral health technology through various continuing education opportunities and from multiple conversations with the IT support staff working for the virtual platform and smart devices that the Austins use. For example, the Austins say they reached out to Zoom and Apple support to learn how to make a breakout room, how to create meeting templates and how to set up virtual private networks — all the technical things they didn’t have time to learn in graduate or doctoral school.

Sarah Barry, a licensed clinical professional counselor and owner of Mountain of Hope Counseling LLC in Butte, Montana, where she provides hybrid services for clients, says the specialized training on telebehavioral health that she received at the beginning of the pandemic helped her easily adapt the technology. She received nine synchronous video continuing education credits through the University of Holy Cross while she was living in Louisiana before the pandemic as a part of a state requirement to provide certified telehealth services.

Jennifer and Daniel Williamson, co-editors of the ACA book Distance Counseling and Supervision: A Guide for Mental Health Clinicians, say that before the pandemic, they only saw clients in person at their private practice, PAX Consulting and Counseling PLLC in Waco, Texas. But when their building closed for six months during lockdown, they had to rethink how they were going to see clients. They converted their practice completely to distance counseling using a HIPAA-compliant synchronous video conferencing platform, and they provided practice sessions and technological assistance for any clients who were hesitant about trying this new platform.

“Eventually, they [clients] began to love this approach because of the convenience. They were able to continue sessions when quarantined, especially when gas prices were hovering around $5 per gallon and [when] the weather was inclement,” the Williamsons add.

They say working in distance education and in other technical roles, as well as their previous experience with technology, made it easier for them to transition to virtual counseling. Daniel Williamson, for instance, has served as the webmaster for the School of Education at Baylor University and has experience working in electronic commerce.

The combination of counselor training, technology training and the implementation of counseling services using technology has been a huge help, the Williamsons note. They are currently completing the requirements for the board certified-telemental health provider credential, which covers the basics of telehealth and was developed in 2018 by the Center for Credentialing & Education, an affiliate of the National Board for Certified Counselors.

Now that their clients are comfortable with telebehavioral health, the Williamsons say they have no plans to return to a physical location.

Building rapport virtually

Forming a trusting and empathic therapeutic relationship with clients is “at the heart of counseling,” says Eiseman, founder and clinical director at Ajana Therapy and Clinical Services in Houston. The relationship is the “biggest influence on the effectiveness of counseling,” she stresses, adding that this is true no matter if the session is in person or virtual. “Our authenticity should be able to come across to our clients no matter the setting. I try to make my clients feel as comfortable as possible, whether I sit in the same room or on a screen,” she adds.

In a telebehavioral health session, it may not be easy for counselors to see a client’s body language, so Eiseman suggests counselors pay more attention to aspects of nonverbal communication. For example, counselors can watch to see if a client is holding their breath when they talk about a particular event. Are they holding their hand over their chest or heart while they are talking? Are they biting their lips out of nervousness?

“After building rapport with clients, you learn the micro expressions that can help you identify movements or reactions they may have throughout their sessions,” says Eiseman. “At times, you may even learn how to keep track of someone’s breathing patterns on camera, which can be very helpful in sessions, especially with somatic work.”

Lee says when he is working with a new client in distance counseling, he follows all the clinical guidelines he learned for treating in-person clients, such as assessing the client’s cognitive and emotional state at the beginning of the session. He also does a friendly check-in by chatting with a client to break the ice, and he makes sure he expresses empathy in areas where the client is focusing their emotions.

“I ask every new client if they had previous counseling experience, and if it was in person or virtual,” Lee says. If it is their first time in a virtual session, he explains the challenges (e.g., initial unfamiliarity/discomfort about virtual therapeutic interaction, internet connectivity issues, a potential for electronic security issues) and benefits (e.g., more flexibility with scheduling).

If appropriate, Lee says he may comment on the background decor of a client’s room or space, such as paintings and posters on the wall, and share his own similar taste in art or an experience from his life regarding the posters. Discussing common interests helps counselors make a personal connection with clients, he explains.

Barry finds that engaging in active listening, including repeating client concerns and making eye contact, helps develop a solid rapport with clients and makes them feel comfortable. “Eye contact during telehealth is extremely important so the client can know you are engaged in the session. Eye contact is a sign of active listening and displays attentiveness during the session, which helps build the therapeutic relationship,” she says. “I’ve had previous clients tell me [about] their frustration with other telehealth experiences in which they felt the provider was looking at their cell phone and/or toggling through webpages, which caused the client not to feel prioritized during the session and to seek out treatment from another provider. As helpers, we need to be engaged in the therapeutic process as much as possible.”

It is also important for the provider to be attuned to cultural differences in which eye contact may not be the strongest form of communication for the client or the provider, adds Barry, who is also an LPC in Louisiana.

Barry applauds new clients for their courage and bravery in taking the difficult first step to seek out treatment in a virtual space. “Positive reinforcement helps to develop trust,” she says. And “if my patients, whether through telehealth or in-person counseling, know I am cheering them on every step of the way, I feel this helps them to know I’m a human being just like them. I just happen to be on the other side of a computer.”

Establishing guidelines

Another part of building the therapeutic relationship is for clinicians to talk about the nuts and bolts of conducting telebehavioral health sessions, particularly the security risks of meeting online, confidentiality, appropriate spaces to conduct therapy and the proper attire for a virtual session.

Lee says his practice provides new clients with the general guidelines for informed consent and therapy policy forms using the client portal on SimplePractice. The policies cover the benefits and disadvantages of telebehavioral health, as well as the risks of remotely meeting over a secure teleconferencing platform, the theoretical possibility of a security breach, technological malfunctions and the management of emergency situations. (For more on the specific requirements for informed consent for telebehavioral health, see the first chapter of Distance Counseling and Supervision).

Lee says his practice chooses not to include any formal dress code rules because he has noticed that the way clients dress for a telebehavioral health session can often provide insight into their social functioning.

“No one [has] ever dressed improperly for [a] session in my experience,” he continues. “I always present myself in professional and appropriate attire. [The] attendance and punctuality rules are all the same. I do ask if the client is in a secure setting to ensure privacy and confidentiality if they are at home or [in an] office area.”

Barry tells her clients to treat their telebehavioral health session as if they were going to the doctor. She says she asks them “to be dressed, out of bed and ready to address the issues that are taking place in their lives.”

So far she’s had only one client begin a telebehavioral health session inappropriately dressed: The client was lying in bed in their pajamas and was not fully awake. Barry told the client she was not able to continue the session unless they were fully awake and ready to begin. She asked the client to contact her when they were ready and logged out of the session. The client rejoined the session about 10 minutes later and apologized for not being prepared the first time.

Daniel and Jennifer Williamson remind counselors that they are obligated to provide the same standard of care online as they do in person. “We have heard horror stories of counselors trying to engage a client [who has the] video off while driving a car full of kids,” the Williamsons say. “There are many issues with that scenario. Creating a safe and trusting relationship must begin by creating strong clinical spaces for ourselves and helping our clients create clinical spaces within their own locations.”

For the Williamsons, a clinical space includes the following:

Being alone in a room that has a door
Having a door that is closed
Using a sound machine

They recommend clinicians help clients be creative when defining what a clinical space means for them. When privacy is a challenge, for example, clients can use a closet, bathroom or even a parked car, as long as it is safe. And the “sound machine” could be a radio or television set or a white noise machine.

Defining a clinical space also gives clients emotional permission to advocate for their own privacy, the Williamsons add.

Assessing clients virtually

These counselors interviewed for this article acknowledge that assessing clients virtually can be challenging, but they also say that if counselors remain curious and use their interviewing skills, then virtual assessments can be done properly. In addition, they recommend clinicians consider using virtual platforms that provide tools for clients to self-assess.

Hart admits that assessing clients is one area that has been a learning curve for her. “Because I am a somatic-oriented, body-oriented practitioner, I had to learn how to be more attentive [when assessing clients]. I have a trauma-informed approach too, so at first, I had doubts that I would be able to assess,” she explains.

Hart has also learned to be more inquisitive and exploratory with the client and ask more questions. For example, instead of saying, “I notice that you …,” she now asks, “What do you notice about yourself and your body when you mention this symptom?’”

Hart says she takes a more Rogerian approach to assessments now because it allows clients to become an observer as part of a therapeutic team. “Instead of making first-person observations and verbalizing them, now I teach clients how to be more mindful of their somatic responses,” she explains. “It has worked out well and has created more mindfulness for clients.”

When doing virtual counseling, Lee uses all the same in-person modalities for assessing clients, including motivational interviewing and paying attention to the client’s facial expressions, tone of voice and speech patterns, and body language. And although he can see clients only from their chest up during a virtual session, Lee says he is not missing much in regard to nonverbal communication.

“I can tell enough nuances on face and shoulder postures and movements and can very well see the telltale signs of lethargy or agitation and interest or disinterest as well as I do in person where I can see the entire body,” Lee notes. “What is different in the virtual encounter is the close-up focus of video’s visual framing, which accentuates these clues while, at the same time, the client shows much more of their natural emotional and physiological state in their daily surroundings, unlike being in a doctor’s office.”

The presenting symptoms and the types of online assessment tools the counselors use will help determine the success of a virtual assessment, Eiseman says. She recommends counselors consider online assessment tools such as those provided by Pearson Assessments, which allow clients to assess themselves and submit the assessment for scoring.

Lee and Barry use the SimplePractice virtual platform to assess clients. The platform provides clients with a link to a HIPAA-compliant client portal where they can access assessment forms that screen for depression and anxiety. Clients complete the forms during the intake process and submit them using their own secure portal, and it notifies counselors when the forms are complete.

“It is also important to know the limitations of what you need to assess, as you may need to refer [the client] out if what is best for the client is an in-person assessment,” Eiseman adds.

Jude and Julius Austin say assessing clients often involves counselors using their sixth sense, which is easier to do in person. For example, during an initial intake assessment, a clinician may ask a client about their alcohol usage. “It’s the way they answer that make us intuit that there is something deeper to process in this area,” Julius Austin says. “It could be the heaviness of the client’s voice or the briskness of their responses or their lack of eye contact. Other times, it is the way their feet are shaking or [their] hands are wringing.”

But when assessing clients virtually, it can be difficult for counselors to use their intuition to determine when and if they need to dig deeper. The Austins suggest counselors use themselves as a tool and approach assessments with a “childlike curiosity.” For example, when virtually assessing a client who says they are struggling with anxiety, the clinician can start by examining the client’s choice to use the word struggle. In this situation, the Austins may respond by saying, “What does the word struggle mean to you?” or “What does struggling look like?” And then they would take the same approach with the word anxiety.

“We might share with clients things about their experience that resonate with us. We won’t go into great detail, but we use our experience to deepen the client’s connection to their emotional process in session. If a client feels insignificant, we mentally ask ourselves, ‘When have I felt this way?’” Jude Austin explains. “Instead of processing our experience, we think about the connective emotions and thoughts surrounding our experience, like insecurity, fear and anger. Then we use our experience [to] guide our reflections. As a distance counselor, being curious about our own experience and having emotional courage when sharing can help create the in-person atmosphere when distanced.”

The more counselors use themselves as a tool by sharing aspects of their own experience with clients and approach the process with curiosity, the more they will instinctively use their sixth sense or intuition in this virtual space, the Austins say.

The limitations of virtual therapy

Although proper assessments can help counselors determine whether a client is suited for distance counseling, the counselors interviewed for this article say clinicians should be mindful that some mental health disorders should not be treated using telebehavioral health.

“There are some serious ethical concerns to consider when moving counseling online, but the appropriateness of seeing someone with a serious mental health issue is more nuanced than [whether] in-person or online counseling is better for those clients,” Jude and Julius Austin say. “Nonetheless, we think most counselors can acknowledge that some clients struggling with hallucinations, delusions, self-harming, suicide or homicidal issues need extra considerations.”

The Austins stress, however, that counseling is now being done in “all sorts of nontraditional, personalized and practical ways.” As a result, they say whether a client with a serious mental illness can be treated online depends on the situation and the creativity of the counselor.

The Austins advise their peers to use their clinical judgment rather than a sense of fear as a guide when helping any client to gain the most from counseling.

Eiseman says counselors should look for aspects about their clients that may make virtual therapy more difficult, or even potentially harmful. “Even if a client tells you that they feel comfortable with virtual sessions, it is still our duty to assess that online therapy is right for the client based on our clinical opinion,” she stresses.

Therapeutic interventions in virtual sessions

Counselors can use many traditional therapeutic approaches without having to adapt them for distance counseling. “I don’t have to alter therapeutic techniques like CBT, dialectical behavior therapy, and acceptance and commitment therapy because they are empirically based theories that have existed for decades and therefore have more virtual resources available,” Eiseman says.

CBT is the backbone of Lee’s work. He says virtual clients learn to identify cognitive distortions and correction skills in the same way clients do in person.

One advantage in using distance counseling, Lee says, is the opportunity to see and interact with clients in their personal surroundings. Viewing clients on their “home turf” often gives him insight into their lifestyle, personality, socioeconomic status and even what kind of neighborhood they live in, and he says that these insights can help in a client’s treatment. For instance, he once worked with a married couple who were struggling with a hoarding issue. They initially came to therapy for relationship issues, but as the therapeutic trust was building, the clients were willing to show him their entire living space using a laptop camera, which allowed Lee to see the exact nature of their hoarding. He worked with them during their sessions in real time to catalogue the accumulation and their piling and storage patterns, and he helped them strengthen their reorganization skills so they could reduce their tendency to hoard materials while still being able to access what they needed. By being supported and held visually accountable through the virtual sessions to adhere to the treatment plan, the clients were highly motivated to implement both short- and long-term goals, which improved their standard of living and their relationships, Lee adds.

Barry says she uses the SimplePractice platform’s whiteboard to help virtual clients process feelings of anxiety or depression. She draws the CBT model on the whiteboard during a virtual session and works with clients to help them understand how their thoughts and behaviors work together to create an anxious or depressed state.

“The whiteboard really helps them to see a technique visually, so we are able to interact together,” she says.

Although most therapeutic approaches can be used with clients in person or in a virtual setting, some therapeutic techniques, such as play therapy, exposure therapy, brainspotting and ecotherapy, are not suited for distance counseling, Eiseman adds. Play therapy, for example, relies on the use of tangible items such as sand trays and toys. Although this can be done virtually, she finds it difficult to engage clients in the same way using virtual sand trays compared with in-person counseling. And brainspotting may require the client to have special equipment set up in their home to do it online, she says.

Looking forward

To stay abreast of technological advances and ensure that they are learning to properly integrate in-person counseling skills into virtual counseling, clinicians should continue to seek additional training opportunities. And graduate counseling programs must be intentional about including online therapy in their curricula.

“As this is a new modality for treatment and is gaining more attention and appreciation from both providers and clients, there is growing interest in bolstering educational training,” Jennifer and Daniel Williamson note. “Just prior to the pandemic, it was attended to as much as it now needs to be.”

Graduate counseling programs need to ensure that they train “counselors and supervisors to do distance work ethically and skillfully,” Jude Austin adds. “The more complicated answer is shifting the culture of distance counseling from convenience to a modality with just as [many] nuances as other modalities.”

As a counseling supervisor, Eiseman says all her students and employees are required to complete training on the best practices of telebehavioral health and HIPAA compliance. She also supports digital mental health training in graduate school programs.

“It is also my responsibility as a supervisor to stay up to date on any rules or regulations regarding digital mental health practices, as well as [to] model and teach appropriate practices,” she adds.

Because states may have different rules and regulations for the encrypted programs used in virtual counseling or for online communications and reciprocity, Jude and Julius Austin advise counselors to be aware of the rules their state licensing boards have for providing telebehavioral health services in other states.

In many ways, new counseling graduates are “stepping into a profession that might seem a bit like the Wild Wild West” regarding the guidelines for telebehavioral health, the Austins say. “States have different rules. Some have reciprocity; some don’t. Some are ‘duty to warn’ states and others are not. Some states make counselors wait what seems an arbitrary five years to get to a supervisor status; others have less time.”

The counselors interviewed for this article also say that as telebehavioral health continues to evolve, the counseling profession can play an important part in developing new technologies for its practice. Important legal, ethical and clinical standards of care will likely be left out of the equation if counselors aren’t involved in the decisions around telebehavioral health, Eiseman notes.

Jude and Julius Austin agree. “Counselors should be involved in innovation. Our trained ears, hearts and minds can help shape technology to suit healthy therapeutic relationships,” they say. “Being a part of innovation can also put us in a position to advocate for ourselves as some digital mental health platforms can be a bit predatory and unfair to counselors and clients.”

Hart also thinks that counselors can be the pulse of telebehavioral health in the future. “I think that compassion and empathy — these two very human traits — are rarely found in technology alone,” she says. “If we can bring about more ways to display these human traits within technology, that would be helpful.”

hand holding phone with an image of a person sitting, knees to chest, arms across their legs. Text above the phone reads, "Need help?"

Nadia Snopek/Shutterstock.com

Preparing for virtual emergencies

Securing a client’s safety is a critical step when engaging in telebehavioral health sessions. After a counselor determines that distance counseling is appropriate for the client, they need to work with the client during the intake process to create a safety plan in case the client experiences a crisis during the virtual session. The plan should include the following:

An emergency telebehavioral health consent form. This form outlines what would happen if a client had an emergency or crisis while being treated virtually, says Jessica Eiseman, a licensed professional counselor supervisor at Ajana Therapy and Clinical Services in Houston. It provides the counselor with an emergency contact and gives the counselor permission to call that contact in the event of an emergency.
A list of emergency resources. Jennifer Nivin Williamson and Daniel G. Williamson, licensed professional counselors and core faculty at Capella University, say this list should include an emergency contact person — someone who is within 5-10 minutes of the client, the client’s doctors, the client’s medical conditions and the first responders in the area. Jude T. Austin II and Julius A. Austin, licensed professional counselors and counselor educators at the University of Mary Hardin-Baylor and Grand Canyon University, respectively, add that the list can also include a local hospital and police station and the name and contact information of a local counselor or other colleague who is willing to see the client in person, if necessary, during an emergency.

Eiseman reminds counselors to always verify a client’s location when they are in a telebehavioral health session. If that location is not a client’s residence, it is important to get the address of where they are during the session. The Williamsons also recommend counselors document the client’s location in the case notes for every online session.

Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.

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 benefits of a multisensory experience in therapy

By Ashley Heintzelman February 14, 2023

a child points to drawings of shapes on a whiteboard and a woman sits in the chair watching the child

Studio Romantic/Shutterstock.com

Since the beginning of the pandemic, I have been providing and receiving in-person and virtual therapy. Initially, my own therapy was 70% virtual and 30% in person, and my client schedule averaged about 60% in person and 40% virtual. Being on both sides of the couch gave me a unique perspective to consider the advantages and limitations of virtual therapy.

I have always viewed my own therapy process as staying active at the “mental gym” to help me cope with anxiety and for self-care. My anxiety symptoms manifest with challenges regarding perfectionism and being cognitively inflexible during times of change. Unsurprisingly, the COVID-19 pandemic triggered my anxiety.

Although it was not an initial goal of my own therapy, I relearned something I had known about myself and human nature: our need to use all our senses and connect the mind with the body. Throughout this process, I discovered that in-person therapy best meets my needs (and most likely my clients’ needs) because virtual therapy often lacks a multisensory experience.

Finding the right fit

I have attended therapy throughout my professional life, but moving to a new home, raising children and other life challenges have led to periods without therapy. When the pandemic began, I was not currently engaged in counseling, but I recognized the added stress of these circumstances for everyone, including me, made this a good time to continue therapy again.

I had several goals this time. First, I wanted to process coping with the same issues many others faced as the pandemic progressed (e.g., school closings, vaccination decisions). Second, I explored how the pandemic affected me professionally as a therapist. Clients typically do not know much about the lives of their therapists unless mental health professionals choose to self-disclose. The idea that the pandemic and telehealth might lead to added exposure of my personal life to clients triggered a fear of loss of competently managing the potential changes in the therapeutic relationship. I wanted to ensure I found a good balance of self-disclosure for my clients.

When I decided to reenter therapy in 2020, I found a counselor who offered only virtual appointments. Telehealth was more accessible for me with my responsibilities at the time, and it also made sense given the uncertainties of life and the shifting work schedules during the pandemic. I was lucky to find Sophia (pseudonym). She was a good fit for me. She is soft-spoken, nonjudgmental, gently challenging and intelligent. She conveyed support and understanding and shared additional perspectives. Sophia appropriately self-disclosed about her experiences as a clinician and working parent of young children during the pandemic. I felt she understood my anxieties. Her compassion and shared experiences helped normalize and diffuse my fears. And she helped me set realistic expectations of myself.

Even though I was making good progress with Sophia and most of my own work as a therapist was virtual, I felt something was missing from my virtual sessions with her. I just couldn’t put my finger on it yet. It wasn’t until I experienced multisensory engagement in therapy again that I realized that was what was missing.

A multisensory experience

In the spring of 2021, I decided to transition to a new counselor — one I could meet in person. A good friend and colleague recommended I see Lily (pseudonym), a therapist my friend thought would be a good fit for me. When I started with Lily, I felt immediate comfort and ease with her.

During my third session, we explored whether I needed a shift in work-life balance and discussed the potential barriers that made that change difficult. Lily responded saying, “I need to draw this out.” She then drew a model concept of what we discussed regarding my shame, anxiety and boundaries on a whiteboard. We were in sync concerning the model; it made sense to me.

The model created one of those powerful moments in therapy where I felt understood and validated. The use of the whiteboard also highlighted the multisensory experience that I felt was missing during my virtual sessions with Sophia. I could now better articulate how I felt after seeing what she was saying drawn out. The model also contained the trigger point where my anxiety would begin to ramp up, so it allowed me to gain a new coping strategy that I could use moving forward when I felt anxious because I could better understand what started an irrational thought loop. The visual display of my feelings and fears helped me gain a new perspective about my emotions. After Lily finished the whiteboard model, I took a picture of her drawing using my cell phone, which allowed me to view it whenever I felt overwhelmed.

Lily continues to use the whiteboard in session with me, and every time, I process even more sensory details from the experience. I have noticed, for example, that Lily is left-handed, and the slant of her wrist reminds me of my left-handed daughter. I have often watched her dangly earrings bounce while her arm moves when writing, and I have observed how her nail colors change with the seasons.

Being in person also engages my senses in other ways. I sometimes contemplate the exact shade of the moody dark gray paint in her office. I have noticed how the office smells of mint and vanilla, and I wonder if the scent is the remains of essential oils or a candle. I hear the hum of the white noise machine in the hall. Lily’s calming energy permeates the room — a full in-person experience matters in many ways. And I feel safe on her couch, sitting next to a soft blanket in her warm office.

The exposure of all my senses to the surroundings helps me stay grounded during our sessions. The multisensory engagement creates a calming effect on my whole body — one I could not have experienced remotely from a screen. In addition, the surroundings and in-person contact enhance my ability to fully take in Lily’s feedback. Although a multisensory experience is not necessary for change, this experience with Lily reminded me of what I often miss when doing virtual therapy: the benefit of engaging the mind and body.

My knowledge and experiences are consistent with research on the science of calm approach to emotional well-being and the neuroscience of learning, which emphasizes that we learn best when multiple senses are stimulated. For example, Dr. Daniel Siegel, a prominent mindfulness researcher, explored learning to focus and become more aware via practices using our five senses and feeling of connection to other people in his 2020 book Aware: The Science and Practice of Presence — The Groundbreaking Mediation Practice. Dr. Siegel found that sensory experiences and feelings of connection to others promote the growth of neural connections, leading to less stress and anxiety. Thus, the lack of a three-dimensional experience that activates all the senses and helps to stimulate novel ideas could hold clients back from powerful and lasting breakthroughs.

The whiteboard exercise that Lily used during our session symbolizes the strength of the therapeutic alliance. It instantly reminded me of my vulnerability as well as Lily’s unconditional positive regard and brilliant conceptualizing skills. And the experience also helped me learn a new cognitive and emotional framework for coping. This opportunity was therapy at its finest.

Incorporating sensory elements with clients

Drawing on my personal experience in therapy, I continue to think about how to incorporate multisensory experiences during my own professional sessions with clients. In the past, I mapped out client conceptualizations of presenting concerns or coping strategies on paper during sessions. But based on my experience with Lily, I realized how I was underutilizing multisensory engagement as a therapeutic tool. Using the large windows in my office and pens made for writing on glass, I can map and draw out concepts to help clients have more sensory experiences, which will help them visual it better.

I am also seeking to experience my senses and body movements in the presence of clients and recognize the clients’ bodies and movements and verbal descriptions of sensory and emotional experiences. For example, I am now more attuned to clients’ and my own body language after observing Lily’s body language when drawing on the whiteboard.

Clinicians can also explore how to increase multisensory engagement virtually and consider if certain clients may benefit more from multisensory and in-person sessions. For example, clients with anxiety who have a treatment goal of calming their overactive sympathetic nervous system may benefit more from in-person counseling than a client who is primarily working on improving depressive symptoms.

Because the pandemic is ongoing and our lives are demanding, we must be realistic. The convenience of virtual sessions will likely continue to create demand among clients. It’s important to remember that having a therapist who is a good fit is always a better choice than not going to counseling because of a lack of in-person opportunities. Therefore, the best-case scenario might be a hybrid model, depending on the clients’ and therapists’ joint decisions. But no matter if counseling is virtual or in person, I encourage other clinicians to find ways to emphasize the sensory experience in session, including visually mapping concepts.

Ashley Heintzelman is a licensed psychologist who specializes in the treatment of eating disorders. She is the founder of the Ampersand Psych Clinic in Overland Park, Kansas, and co-author of the book Free to Be: The Non-Diet Path to Peace With Food and Body. Her other clinical passions include mentoring early career professionals and supervising graduate students in training to become counselors. Contact her at heintzelman.ashley@gmail.com or through her website at ampersandpsychclinic.com.

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

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.

Embracing fandom in counseling

By Samantha Cooper November 7, 2022

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

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

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

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

Using fandom to build rapport

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

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

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

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

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

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

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

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

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

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

Kashawn Hernandez/Unsplash.com

Finding a sense of community

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

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

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

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

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

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

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

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

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

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

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

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

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

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Parasocial relationships

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

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

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

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

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

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

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

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Related reading, from Counseling Today:

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

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

Are counselors ready for the metaverse?

By Staci Hayes November 4, 2022

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

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

Embracing technology

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

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

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

The metaverse of today and tomorrow

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

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

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

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

The potential benefits

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

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

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

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

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

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

A few words of hope and caution

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

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

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

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

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

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

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

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

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

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

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

Final thoughts

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

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

Athitat Shinagowin/Shutterstock.com

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

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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.