Tag Archives: Technology

Voice of Experience: The miracle of 28 days

By Gregory K. Moffatt September 17, 2020

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

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

The answer: “Twenty-eight days.”

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

Making the ‘new’ normal: Five tips for providing teletherapy

By Andrea Chandler September 1, 2020

I awake, shower, dress and head into the office. I will see my first client of the day at 9 a.m., and I have arrived at my desk a half-hour early. I go to the office much earlier these days.

I start to ready myself and my space for work, spraying sage and lighting a palo santo stick to clear and bring in positive energy. I turn on my music, a surrogate noise diffuser, then close my eyes. Sitting in my high-back chair, I ask the universe again today to equip my mind, ears, eyes and words to support my clients in their healing journeys.

This is my new normal, but it is not so normal for me because my clinical office is now in my home. This is not a space that I originally set up to do private practice. Rather, it was a den I had designed for family escapism, reading, relaxing and spiritual grounding.

As I sit contemplating my schedule of clients for the day, I turn my attention to the bookshelves in the room. Among the different clusters of books sits a bobblehead doll of Jack Sparrow, a figurine of Ruth Bader Ginsburg, angel ornaments and angel sculptures. Also on the shelves, scattered and occupying space, are grounding rocks. Some are face-up so that I can see a word stamped on them from my vantage point: peace, calm, harmony, laughter.

I reflect on my past in-person sessions. At the start of sessions or during sessions, I would invite clients to select a grounding rock, hold it in their hands and set an affirmation, either verbally or silently, in harmony with the word on the rock. Or I would ask an anxious client to select a rock, and then I would guide them in a tactile grounding exercise. Most of my established clients know about the availability of the rocks — when they need to use them and how they will choose to use them. Among the comments I have heard from clients using a rock in session: “This gives me focus”; “It is comforting”; “I feel less anxious.”

On the table where the computer sits, there are writing pads I would previously give to clients to take home for journaling or suggest as a memory tool for those having trouble with remembering. In a corner of the sofa that sits along the far back wall of the den are several squeeze balls, which are great devices for releasing anxiety in session. In an off-white 5-by-6-inch box, sitting on the middle shelf of my computer workstation, are my business cards. These items all seem almost meaningless now because they are things I once provided for clients during in-person sessions.

Teletherapy vs. in-person

The reason that I now work completely from home, providing therapeutic services for clients by way of video and voice calling, is because I work with a population that is at higher risk for severe illnesses. This has been the protocol for many behavioral health workers for many months now. The current environmental situation dictates this change, and my obedience to moral and ethical obligations to clients guides me to protect and minimize harm.

I have found that teletherapy, telecounseling, telemental health and distance counseling — among other descriptives used to define the provision of remote mental health psychotherapy — takes a slightly different way of working with clients than does providing in-person sessions. I liken the two approaches to watching a movie versus reading a book of the same title.

An in-person therapy session, like watching a movie, involves the art of active listening. I am paying attention to what the client is saying while also focusing on their body language and behavior. The body language and nonverbal gestures can be picked up readily in in-person sessions.

On the other hand, I compare teletherapy with the way that written words in a book detail a story and convey information; it requires enhanced attentiveness to detail to see the full picture. I must use sharper observation to recognize the subtle messages of facial gestures and voice tonetics in teletherapy sessions.

Five areas of focus

Here are five areas of focus that have helped me make clients feel more comfortable and safer with the teletherapy process.

1) Distance counseling technology: Verification of a client’s identity and location are important. These things should be established before starting the first session and at the beginning of each session thereafter. Know that the person you are providing counseling service to is really who they claim to be and where they reside. In addition, know the definitions for the scope of practice and regulations for professional practice in both your state and the state in which your client resides because these items can differ between state licensure boards.

Ensure that the platform you are using for your teletherapy session is secure. Use applications that have an end-to-end (two-way) encryption capability. There are several good ones out there, but do your research.

Likewise, be careful not to use text messaging and email applications that are not compliant with the Health Insurance Portability and Accountability Act (HIPAA). Outside of the use of HIPAA-compliant text messaging applications, HIPAA does allow for texting clients on the condition that they have been informed of the risk of unauthorized disclosure and consented to communicate by way of text messaging. Both communication of the risks and consent from the client need to be documented.

Personally, I limit text messaging to clients to scheduling or confirming appointments. These text messages hold no personal client information, not even in the salutation. With email messaging, I never assume that the client has an internal email network with firewall protection. For this reason, all email correspondence that I send is by way of a secure messaging application.

2) Informed consent and confidentiality: In conveying aspects of the teletherapy process, counselors need to give clients a clear understanding of the therapy they are entering into and ensure that they feel comfortable and safe with the process. In this way, clients can make a choice to engage in therapy. The “consent for treatment” form should state the following at minimum:

  • Platform from which the counseling will be delivered (Zoom, Google, etc.)
  • Therapeutic modality that will be used (cognitive behavior therapy, solution-focused brief therapy, etc.)
  • Risks, benefits, confidentiality and boundaries involved in engaging in teletherapy, plus an acknowledgment that although measures will be taken to ensure the confidentiality of the session, there are no guarantees
  • Possibility of technology failure and alternate methods of service delivery
  • Location and setting of the practitioner, along with the practitioner’s credentialing and contact information

I have found it helpful before beginning sessions to show clients the confidential space in which I am working. I pan the monitor camera around the room so they can see the space I’m in is safe and free of distraction. Similarly, I encourage clients to use a quiet, calm space for their sessions when possible. It also helps for practitioners to be consistent with the counseling space location and background that clients see from session to session on their monitor screens. This allows clients to become comfortable with the predictability.

3) Technology slip-ups and client crises: Slip-ups inevitably happen, so it is wise to prepare as best you can before a session. First and foremost, test your video connection capability so that issues do not cause session delays. Unfortunately, some things cannot be anticipated, such as audio or visual problems in session. I have found it beneficial to address difficulties and concerns of this nature with clients in initial sessions and to plan together a backup alternative, such as having a phone session.

Just as with technology slip-ups, crisis situations can occur. It is important when conducting the initial client assessment that potential crisis situations for the client are discussed and a crisis plan is developed, documented and put in place. I ask an array of questions in considering the client’s risk for a crisis. As part of the crisis plan, it is important to have the client’s emergency contact numbers, local and national emergency crisis numbers, and language stating that the police could be called to provide a welfare check if the client’s safety is a concern.

A crisis can sometimes occur for clients at the end of an especially difficult teletherapy session. In these instances, I have used various techniques, such as relaxed breathing, having the person hold something in their hand and mindfully describe it, and the use of grounding exercises to help clients orient back to space, time and place.

4) Practical tips: At times, I have found myself focused on the computer’s video camera, checking my eye alignment so that I do not appear to be looking downward or too high upward. As a result, my awareness of the subtle movements and body language of the client has been obscured. Likewise, although I engage in active listening, I sometimes miss the tonetic detail of information being provided.

Some of the techniques I find most useful in keeping me attuned with the client in the therapeutic process draw on the principles of mindfulness practice. Having a moment-by-moment awareness of what is unfolding visually and tonetically allows me to help clients feel supported and understood.

When I mindfully remind myself to sit back from the screen, I see a wider area. I can better catch the slight facial expressions and eye gestures of the client and use these observations to reflect on helping the client gain awareness of the messages they are conveying. These days, I pay additional attention to noticing, understanding and noting what the client’s voice nuances, tempo, pitch and inflection are conveying. These hold equal importance with visual focus in creating a therapeutic alliance with the client.

5) Best self forward: Putting your best self forward begins with self-care. A great part of self-care is maintaining good boundaries, both inside and outside of client sessions. This includes establishing a clear line of demarcation between work time and personal time and creating a space of time between each scheduled client so that you are able to replenish your mind and body.

I like to replenish my mind through meditation and my body through movement. Meditation helps me create inner calmness and renews my focus. Fitting short exercise into my workday, such as a short cardio workout, walking the dog, and resistance-band exercise, helps me to reenergize. I also find great mental fortification in connecting with clinical colleagues with whom I can share challenges, problem-solve and get overall support.

In facing the changing times of our new normal, it is useful to know that we can move forward by being proactive in our thinking, preparation and approach. The more equipped we are, the fewer obstructions we will face. The fewer obstructions we face, the better we can be of service to our clients, upholding nonmaleficence, beneficence, justice and respect for the autonomy of the person.

 

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For more on the ins and outs of telebehavioral health, see the American Counseling Association’s resource page for counselors: counseling.org/knowledge-center/mental-health-resources/trauma-disaster/telehealth-information-and-counselors-in-health-care

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Andrea Chandler is a licensed counselor with more than 12 years of practice. It is her passion and privilege to serve individuals through counseling and advocacy efforts. Contact her at Achandler123@gmail.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.

Utilizing evidence-based practices in telehealth

By Krystal Vaughn, Kellie Giorgio Camelford and George W. Hebert August 23, 2020

The field of mental health is undergoing unprecedented challenges during the COVID-19 pandemic. Professional counselors who worked with children and adolescents before the pandemic have found that some traditional in-person techniques are not appropriate via virtual platforms.

These circumstances are requiring counselors to consider the selection of treatment approaches and interventions that are adaptable to or created for the provision of telemental health. Today, counselors must determine how to select and implement evidence-based practices (EBPs) when working with child and adolescent clients via telemental health during times of crisis.

History of EBPs

In 1996, David L. Sackett and colleagues stated that evidence-based medicine was “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Additionally, Leslie Greenberg and Frederick Newman recognized in 1996 that there were different types of study designs that lead to the evidence base, each suited to answer specific types of research questions. For example, according to a 2005 American Psychological Association task force, one may use any of the following to build evidence: clinical observation, qualitative, systematic case studies, single case design, ethnographic, process-outcome, random control trails or meta-analysis.

EBPs and the terminology associated with them have gained popularity over the past few decades in all health care fields. However, their exact origins are mixed. Parts of the nursing profession, for example, posit that EBP originated with Florence Nightingale, whereas the mental health field argues that Lightner Witmer used a similar approach with his creation of the first psychological clinic in 1896.

Regardless, the concept of EBP marked a paradigm shift among health care professionals to consider data-based research rather than relying on the opinions of authorities to guide clinical practice.

Evidence levels

The rigor, or degree, of scientific evidence is often presented in the form of an evidence pyramid analogous to Benjamin Bloom’s taxonomy of educational objectives.

This evidence pyramid traditionally moves from expert opinions at the base to case series/case reports to case control studies to randomized control trials to systematic reviews and, finally, to meta-analyses at the pinnacle.

 

Expert opinions

These sources of evidence range in forms from editorials to book chapters. They are good resources for an early understanding of clinical areas because they discuss definition, assessments and treatments. However, these sources lack statistical inferences to reach scientific conclusions.

An expert opinion might come in the form of a textbook chapter in which a person who is generally very knowledgeable in the field opines on the subject matter without referencing a specific compilations of facts. While expert opinions can be very informative and insightful, they should be regarded only as a minimal form of scientific evidence. Few of these expert opinions speak to our current predominant practice of telemental health.

Case series/case reports

These are descriptive studies that may be from a single clinical case or from a series of clients with similar presentations. While traditionally missing inferential statistics, single-case experimental designs will often be implemented. However, control groups or conditions are clearly lacking. Despite these limitations, case series/case reports are often heralded for illuminating novel concerns that generate additional research.

Classic examples of case studies in the mental health field seemed to begin with Anna O., who received psychoanalysis for what was termed “hysteria.” Sigmund Freud wrote about her case and how the “talking cure” led her symptoms to fade. Biopsychologists often cite the case of Phineas Gage, who demonstrated personality changes after a large iron rod was driven through his head in a railroad accident. Then there is the behaviorist report on Little Albert (by John Watson), in which fear was actually instilled into a baby through conditioning.

Case control studies

Case control studies are generally retrospective in nature and investigate the risk of exposure to an event with an eventual negative outcome — usually a disease or disorder. Comparison or control groups are then utilized with people who did not have the initial experience or the disease/disorder. However, these studies are able to declare only relationships, not cause-and-effect relationships. Despite this limitation, evidence for a cause and an effect begin with a correlation.

A typical case control study in the field of mental health might investigate the relationship between physical activity and depressive traits. To that end, the investigators would harvest information from a previously administered questionnaire to patients receiving services at a mental health facility. Additionally, these investigators would use a matched control group of participants without mental health concerns who also completed the questionnaire. Although a control group or comparison group is part of the study, it lacks the characteristic that makes it a true experiment: randomization.

Randomized controlled trials 

It has often been stated that randomization is what brings an investigation from quasi-experimental to truly experimental. Randomized controlled trials assign patients with similar presentations to either the treatment group or the control group based on chance alone. This allows for other mitigating factors to balance themselves between the groups and for the “treatment” itself to cause the scale to tilt. This strategy allows a treatment to be compared with no treatment, an alternative treatment or a waitlist controlled treatment.

A typical randomized controlled trial investigation for a new treatment for depression would involve randomly assigning half of the participants to the new treatment, while the remaining half would be assigned to an existing treatment. Then pretests and post-tests for each group would be compared to evaluate the efficacy of the new protocol.

Although regarded as the gold standard for clinical research trials, randomly assigning patients to treatments may not reflect the best ethical practice without consideration of other mitigating factors.

Systematic reviews 

Systematic reviews evaluate and synthesize the results of similar studies to reach a higher-order conclusion than could be achieved by any one study by itself. Usually, the authors will select a priori factors or themes for which the studies are to be rated. Then, all of the factors or themes are considered and tabulated to reach this conclusion.

Frequently, systematic reviews will limit themselves to only studies that used randomized controlled trials. This way, the results from the group of similar randomized controlled trials can be integrated for a truly convergent conclusion.

In building upon our previous examples of possible depression studies, a systematic review might be used to identify the best treatment protocol for adolescent depression that involves psychopharmacology, individual therapy or both. Additionally, the investigators might restrict the investigation to include only those studies that utilized random assignment. Then, rubrics might be created to gauge the treatments along themes such as symptom reduction, satisfaction of the approach and time commitments. Generally missing from typical systematic reviews is an objective measure that uniformly assesses the results from the different studies. 

Meta-analyses

Meta-analyses are often referenced as a type of systematic review meriting the gold standard of clinical knowledge. Meta-analyses, like all systematic reviews, evaluate similar studies along factors or themes that are selected a priori. However, these forms of evidence utilize a statistical procedure — effect size — to reduce sources of bias in the conclusions. This is the objective uniform measure that is lacking in systematic reviews.

Basically, effect sizes report the magnitude of progress from a treatment. It has often been stated that effect size actually indicates the importance of the results rather than the likelihood that the results are not due to chance, as is the case with statistical significance.

Increasing the rigor from our previous example of a systematic review to that of a meta-analysis would therefore involve utilizing effect sizes. Rather than building upon the a priori themes for comparison, this meta-analysis would compute the effect sizes from measures reported in each study. Then, from the selected studies, average effect sizes would be computed for each treatment protocol so that meaningful comparisons could be made and so that each protocol could be graded on its efficacy.

Beyond the evidence

While the concept of EBP originally relied on the practitioner to consider only data-based research rather than the opinions of authorities to guide clinical practice, the field of medicine built upon this to include other parameters. Specifically, this newer definition defines EBP as the integration of the best research evidence with clinical expertise and patient values. The expansion of this definition clearly illuminates the additional paradigm shifts that account for cultural sensitivity and patient involvement for treatment decisions, while acknowledging that there are advantages and disadvantages.

Advantages

EBP has advantages and disadvantages. The 2005 American Psychological Association Presidential Task Force on Evidenced Based Practice described EBP as the integration of science and practice. It acknowledged that much research is needed to determine that a treatment is effective. However, the research demonstrating a treatment protocol effective then needs to become a practice offered by clinicians who are treating patients in the field. So, one must consider both the efficacy and the clinical utility of the treatment.

The APA task force defined efficacy as the way in which we evaluate the protocol and examine how strong the evidence is within that evaluation. The clinical utility of the protocol must then explore if the treatment is generalizable and feasible and the cost benefit of the treatment. The marriage of research and practice leads to better clinical outcomes for clients.

EBPs offer clinicians and their clients information on the efficacy of a treatment. This research can inform the expected time frame and outcomes of a given treatment. It clearly demonstrates what the EBP will treat and the age groups for which evidence is provided. It is then up to the counselor to determine if the EBP is a good fit for the child and family. After all, most children do not present with the exact parameters as the control group in a research study. Nor does the current COVID-19 pandemic offer counselors traditional clinical sittings or historic data mirroring the current situation. 

Disadvantages

Not all individual differences can be accounted for in each EBP. For example, one should consider how development, gender, gender identity, culture, ethnicity, race, age, family context, religious beliefs and sexual orientation play a role in treatment. Clients should also have input into their treatment protocol and be afforded informed consent. This may lead to their desire or preference for one type of treatment over another.

As counselors, it is our duty to inform clients of the costs and benefits of treatment approaches but, ultimately, clients determine whether they will proceed with the EBP. During our current times, clients may agree with a treatment approach but have difficulty with technology or face other barriers that decrease their comfort with telemental health.

One example of considering fit for EBP is with cognitive behavior therapy (CBT). Pamela Hayes discussed the specific challenges between CBT and multicultural therapy. She acknowledged that CBT is evidence based for many disorders and populations, but it may have limitations when applied to some cultures.

Specifically, she named three major limitations:

1) CBT has strong assertiveness themes, overlooking cultures that favor subtle communication.

2) CBT has present focus, neglecting the past.

3) CBT cognitions are focused on individualism, with less regard for environmental interventions.

The last limitation may be especially problematic for individuals with physical disabilities, for whom the disregard of environmental barriers may be great. In response, Hayes recommended culturally responsive CBT modifications.

However, not all EBPs have recommendations on how to modify them to fit certain clients or populations with which the counselor may be working. Therefore, while a treatment may be proved effective for a particular age or disorder, it may be in contradiction to the client’s values. In addition, there may be other barriers to consider, such as technology, privacy or logistics, as is the case currently for many practitioners.

COVID-19 forced many counselors to examine their “practice as usual.” Many sought to gain certification in telemental health so that they could continue offering services to existing clients. This in many ways followed best practices and guidance from the 2014 ACA Code of Ethics, which prohibits abandonment of clients.

At the same time, this also forced clinicians to consider whether their treatment of choice was still possible via telemental health or whether another practice/protocol made more sense. For example, in the field of child and adolescent counseling, many play therapists examined the feasibility of child-centered play therapy (CCPT), which is an EBP, via telemental health. Dee Ray expressed the opinion that CCPT might not be the best treatment for telemental health but acknowledged that a similar theoretically oriented treatment involving the parents — filial therapy — could be amenable to telemental health.

Case study

Jane is a 7-year-old girl who experienced anxiety, reportedly resulting in behavioral outbursts and refusals to comply. Jane was seen by her counselor for approximately six sessions prior to the clinic’s closure due to COVID-19 and a statewide stay-at-home order. Jane’s counselor met state board requirements to provide telemental health services, but she could not conceptualize how to work with Jane using CCPT as she had prior to the stay-at-home order.

Jane’s counselor researched the EBP literature and identified other options for the treatment of childhood anxiety. However, the counselor found herself limited in her training, which restricted her ability to provide EBP services outside of her current scope of practice.

Jane’s counselor discussed the options, including a referral, with Jane’s parents in a scheduled telemental health parent consult. In the consult, the counselor discussed the benefits of filial therapy and the typical populations with which the modality is used in therapy. The counselor also explained that the parents would be more involved in session because filial therapy utilizes parents as change agents.

Jane’s counselor stated that this type of therapy would translate to telemental health in ways that CCPT would not. For example, CCPT relies on the therapist-child relationship to facilitate change. This may be difficult to achieve via telehealth because the therapist is not in the room. Filial therapy, on the other hand, relies more on the parents as change agents and may work well via telemental health because the parents are in the room with the child. In addition, they meet with the therapist via telemental health to learn the techniques to use with their child. Through the weekly telemental health sessions, parents are able to discuss challenges while receiving guidance and supervision, making this method more amenable to telehealth.

EBP databases and clearinghouses

Mental health practitioners can access several EBP databases and clearinghouses online, allowing them to consider different approaches to meet the individual needs of clients and cases. A wide range of techniques and programs is available, and through these clearinghouses, practitioners can make comparisons and learn about the reliability and evidence for the techniques and programs. We will highlight a few examples of databases and clearinghouses that we use within our practice when working with children and adolescents.

The seventh edition of the Collection of Evidence-Based Practices for Children and Adolescents With Mental Health Treatment Needs is an educational tool that specifically highlights available mental health treatments for nonclinicians. The guide breaks down treatments into what works, what seems to work, what does not work, and what has not been adequately tested. It highlights disorders such as adjustment disorder, autism, anxiety, depression and many more.

The Results First Clearinghouse Database is powerful because it combines available EBPs from nine national clearinghouses encompassing the categories of crime and delinquency, child and family well-being, education, employment and job training, mental health, public health, sexual behavior and teen pregnancy, and substance use. The programs can be broken down by category, setting, clearinghouse or rating. The rating scale breaks down programs based on highest rated, second-highest rated, mixed effects, no effects, negative effects and insufficient evidence. The following clearinghouses highlighted in this article are included in the Results First Clearinghouse.

Blueprints provides information on programs to promote healthy youth development and to decrease antisocial behaviors in children and adolescents. The database is geared toward youth, families and their communities, from prevention to intervention programs. The database breaks programs into three categories of research: model plus, model and promising.

The California Evidence-Based Clearinghouse for Child Welfare provides information and resources used by any professional who may work with children and families in the welfare system. The database breaks down treatments based on a scientific rating scale that includes well supported by research evidence, supported by research evidence, promising research evidence, evidence fails to demonstrate effect, concerning practice, and not able to be rated.

Social Programs That Work provides information on social policy programs. The goal is to enable policy officials and other readers to readily distinguish these programs from other available programs that do not have supportive evidence. The guide breaks down programs into top tier, near top tier and suggestive tier. Of particular interest to practitioners, it highlights some early childhood, parenting, substance abuse and suicide prevention programs.

The National Institute of Justice’s CrimeSolutions provides information on criminal justice, juvenile justice, and crime victim services outcomes to inform practitioners and policymakers about what works and what does not. The database breaks down programs and practice outcomes into effective, promising and no effects.

The Substance Abuse and Mental Health Services Administration Evidence-Based Practices Resource Center provides clinicians, community members and policymakers with resources and information on a variety of topics, including mental health services.

The U.S. Department of Health and Human Services Teen Pregnancy Prevention Evidence Review identifies programs with evidence of effectiveness in reducing teen pregnancy, sexually transmitted infections and associated sexual risk behaviors. The database breaks down studies based on a quality rating of high, moderate, low or not applicable.

 

Additional resources

  • For practitioners hoping to learn more about the EBP process, Evidence-Based Behavioral Practice is a useful online training resource.
  • “Evidence-based practice in social work: A contemporary perspective” by James W. Drisko and Melissa D. Grady, Journal of Clinical Social Work
  • “Evidence-based practice in psychology” by the American Psychological Association Presidential Task Force on Evidence-Based Practice, American Psychologist
  • “Clinical expertise in the era of evidence-based medicine and patient choice” by R. Brian Haynes, P.J. Devereaux and Gordon H. Guyatt, BMJ Evidence-Based Medicine
  • Evidence-based practice for the National Association of Social Workers
  • “Evidence-based practice: A common definition matters” by Danielle E. Parrish, Journal of Social Work Education.

 

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Krystal Vaughn is a licensed professional counselor supervisor specializing in children ages 2-12. As an associate professor at Louisiana State University Health Sciences Center-New Orleans, she enjoys both teaching and providing clinical services. Her research interests include autism, supervision, play therapy and parent consultation. Contact her at kvaugh@lsuhsc.edu.

Kellie Giorgio Camelford is a licensed professional counselor supervisor specializing in parenting, women’s issues, children and adolescents. She has received specialized training in the fields of play therapy, school counseling, parenting and perinatal mood disorders. As an assistant professor at Louisiana State University Health Sciences Center-New Orleans, she enjoys teaching and supervising students, as well as providing clinical and community services. Her research interests include ethical issues in counseling and supervision. Prior to teaching, she was a professional school counselor at a local parochial high school in New Orleans, and a private practitioner.

George W. Hebert is a faculty member in both the Department of Clinical Rehabilitation and Counseling and in the Master of Physician Assistant Studies Program at the Louisiana State University Health Sciences Center-New Orleans. He is a licensed psychologist and holds certificates as a school psychologist and supervisor of school psychological services. He specializes in the assessment and treatment of learning and behavior problems for school-age children and their families, and supervises interns and practicum students in the university-based Child and Family Counseling Clinic.

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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.

Using apps to promote client safety

By Marissa Gray and Victoria Kress August 12, 2020

Daily, professional counselors work with clients who live in unsafe situations involving exposure to violent and exploitative relationships. These unsafe situations might include experiencing partner violence or being the victim of child abuse or human/sex trafficking.

Especially now, during the coronavirus pandemic, partner violence and child abuse are on the rise. Clients are at a heightened risk of violence during the pandemic because of increased stress (which can exacerbate violence), isolation from support systems, and more time spent in close quarters with potentially abusive family members.

When working with clients who are being victimized, counselors have an obligation to promote these individuals’ safety. While perpetrators often use technology against clients to control and further victimize them, recent technology apps have been developed that can help counselors facilitate client safety. We will discuss several of these apps in this article.

Harnessing technology to empower clients

Many client safety concerns must be considered in counseling. First, technology is often used by perpetrators as an additional vehicle for abuse. Technology outlets provide perpetrators with opportunities to antagonize, stalk and ultimately continue abusing and exploiting their victims. Technology that can be used to perpetuate abuse includes tracking devices, location-enabled applications on cellphones, cameras, microphones, social media apps and even simplistic communication methods such as abusive text messages, emails and phone calls.

Clients are often forced to surrender their devices completely, especially if their technology use is being monitored by their abuser or if their number is in any way known by their abuser. Clients might consider changing their phone numbers and presence on social media, but this can be difficult, expensive and time-consuming.

Although taking steps to maintain digital — and, thus, physical — safety involves placing thick boundaries around technology use, it is important to realize the role that technology can also play in supporting survivors’ safety, autonomy and empowerment, all of which are crucial factors in a trauma-informed counseling approach. Counselors can work with clients to maintain their desired level of digital connection while also encouraging them to take measures to be safe. 

Overview of apps for client safety

Several apps exist that can offer crucial support and assistance to clients. These apps are free and are compatible with iOS and Android devices, meaning they are widely accessible regardless of the devices clients use. These apps can be powerful and empowering resources. They are particularly helpful for those in violent relationships and for trafficking survivors seeking to extricate themselves from unsafe relationships. They can also empower clients who have been sexually abused or assaulted, as well as those looking to enhance their safety “just in case.”

All of these apps can be easily incorporated into clinical practice. For example, counselors can support survivors in setting up and configuring these apps and talk with clients about how best to use these apps to promote their safety. For many survivors, these apps can be a small step on the long road toward rehabilitating a sense of personal safety. Thus, counselors can play a crucial role in supporting survivors as they process the tangled emotions that accompany the steps of starting to feel safe again.

In this way, the use of technology via apps is an interactive and engaging intervention that can help empower survivors. By incorporating these safety apps into counseling, clinicians can help survivors begin to feel, perhaps for the first time, that they are worthy of protection and deserve to feel safe.

myPlan

Safety plans are an important part of counseling when working with clients in unsafe relationships. Historically, counselors have developed written safety plans on paper with clients, but these can be dangerous because abusers can discover them, and this may invite violence.

One app that can be useful in developing electronic safety plans is myPlan. This app allows clients to craft safety plans and keep them stored in the cloud of their devices. Plans are saved in the app itself, which is then backed up in the cloud, making it difficult for perpetrators/abusers to access.

On this app, individual survivors respond to several brief questions (automatically generated by the app) regarding their relationship and situation. The app then produces a safety plan tailored to the specific needs of the survivor, based on the responses the person provided to the questions.

Use of this app puts a more secure and technologically advanced spin on safety planning. Keeping safety plans in the cloud allows clients to have immediate access to their plans. In addition, this app connects survivors with local resources, live chats with advocates (trained volunteer advocates working with loveisrespect.org) and even emergency medical/shelter options. The live chat option provides real-time support for survivors that can complement and enhance the safety plan.

Noonlight (formerly SafeTrek)

Noonlight allows individuals to call emergency services without having to dial 911 or make any sudden motions that could alert the abuser that the person is seeking help. In actively unsafe situations, this app can save lives. The app can be especially useful for clients who remain in harm’s way or continue to have contact with their abusers.

Noonlight allows users to simply hold the phone in their pocket, purse or another location that is not suspicious. The app comes equipped with a large safety button that, when gently touched, gives real-time notification to local emergency services to send help. The app is location enabled and holds an individual’s data to pass along to law enforcement in the event that the individual is unable to speak, text or otherwise seek help.

This app can prove especially useful for individuals who are being restrained or are unable to verbally communicate their distress. Furthermore, it helps to provide peace of mind and a sense of empowerment to clients. If an individual is at risk of ongoing abuse, this app can assist them in acquiring emergency assistance.

Aspire News

Another app helpful for clients affected by unsafe situations or ongoing abuse is Aspire News. In the event that a client’s phone is being monitored, this app appears as an ordinary news app with daily headlines, weather reports and so on. Embedded in the “Help” section of the app, however, are emergency contacts, resources, and information on shelters and other supportive services offered to those affected by abuse. The app is location enabled, meaning that it can tailor resources for wherever the client is at that particular moment.

Although this app is geared mainly toward clients affected by relationship violence, it can be equally useful when working with clients in other unsafe situations. It may be especially helpful to those being trafficked because these individuals are moved around frequently and may not be aware of local resources or shelters where they can go for assistance. Aspire News can connect these individuals with resources wherever they go, regardless of their familiarity with the area.

Many resources in the app target survivors of intimate partner violence and sex trafficking, but they also service those experiencing sexual abuse or exploitation. Aspire News connects clients with resources such as shelters, food and hygiene pantries, case management, law enforcement and even counseling. Aspire News may be a helpful app to provide to any client concerned about an abuser searching their phones or punishing them for seeking help.

bSafe

The relatively new bSafe personal safety app offers a variety of helpful tools and resources. It provides specific supports to clients who may be enduring ongoing abusive situations and wish to record or gather evidence against their abusers. The evidence can then be saved to the cloud so that it cannot be destroyed.

The bSafe app has both audio and video recording capabilities (the form used is selected by the app’s user) to capture whatever abusive act may be occurring. The app also offers the ability to livestream an abusive incident or assault as it is occurring. All of these evidentiary recordings can be saved to the cloud to ensure that they are not lost or destroyed by an abuser, even if the abuser destroys the device itself. The app also forwards the footage or recording to trusted people whom the client has previously identified and included on their emergency contact list.

For clients who choose not to report their abuse, it can still be empowering for them to know they have evidence to document the trauma they have survived. This leaves the door open for them to report their abuse in the future if they so choose. Accruing such evidence may also help clients feel heard and believed concerning their lived experiences within an abusive relationship. The evidence gathered by the bSafe app may also assist clients in obtaining protective orders against their abusers or perpetrators.

In addition, the app can automatically alert contacts to call 911. The app is location enabled, meaning that it equips trusted social supports with the individual’s location in the event that the individual is in distress and unable to call for help themselves. The app also offers an SOS button and a “fake call” service, further allowing survivors to reach out for support during an abusive situation without pinging the radar of a perpetrator who may notice or monitor cellphone usage. By simply pressing the button, individuals are able to notify emergency services to send help immediately through use of the app’s location-enabled technology.

National Human Trafficking Hotline

Safety planning is crucial when working with clients who have experienced sex trafficking. These clients may be at ongoing risk as various abusers and pimps attempt to wrangle these individuals back into a life of exploitation. As counselors, we can empower this specific population with knowledge of ways to maintain safety during the recovery process.

The National Human Trafficking Hotline has recently begun offering more advanced and accessible options for individuals to use. The hotline provides a plethora of resources and assistance to help clients keep themselves safe. One such resource is the BeFree Textline; individuals can reach out for assistance by texting “HELP” to 233733 in the event they cannot speak freely in the presence of their traffickers or johns. This text line is a powerful resource to share with clients because it offers a great deal of support.

Crisis Text Line

The Crisis Text Line (CTL) can be reached by texting 741741. Callers are then connected with a trained crisis counselor. The CTL is a valid resource for all clients but has immense value for those impacted by relationship violence, trafficking or sexual abuse.

Given that the CTL communication occurs over text, many clients may find it less threatening, or perhaps less noticeable to their perpetrator, to connect with an advocate. The CTL will then connect clients with appropriate referrals and resources that they can use to find support and maintain their personal safety.

Empowering survivors with technology

The aforementioned resources offer examples of apps and other tools that can support clients in their ongoing struggle to maintain safety. Technology can play a unique and emerging role when we work with these resilient clients as counselors. These apps and text tools demonstrate recent advancements in technology that can foster support, safety planning and healing for clients.

Use of these tools is one small way to remind clients that they are indeed worthy of protection, safety, peace and healing. As counselors, we have the privilege of walking alongside these clients in their brave and unique recovery journeys. These technological nuggets provide resources to empower clients while helping to preserve their safety, dignity and healing resilience.

 

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Marissa Gray is a licensed professional counselor working at Youth Intensive Services in Youngstown, Ohio. She provides trauma counseling to those who have been involved in the sex trafficking industry. Contact her at mgray@youthintensiveservices.com.

Victoria Kress is a professor at Youngstown State University. She is a licensed professional clinical counselor and supervisor, national certified counselor and certified clinical mental health counselor. She has published extensively on many topics related to counselor practice, particularly regarding work with abuse and trauma survivors. Contact her at victoriaEkress@gmail.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, go to ct.counseling.org/feedback.

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

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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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.