Tag Archives: therapy

Learning from highly effective counselors

By Sidney Shaw March 10, 2020

The term “supershrink” has been used to refer to counselors and other mental health professionals who are very good at what they do and who attain significantly better client outcomes than average. It is perhaps not surprising that such a witty and playful term would come from an adolescent.

In the early 1970s, David Ricks conducted an analysis of the long-term outcomes of “highly disturbed” adolescents treated in a metropolitan guidance center. In this center, some of the youth had labeled one provider “the Supershrink.” Upon subsequent data analysis, Ricks found that adolescents who received treatment from this provider had significantly better long-term outcomes than did those who saw another provider. Turns out that the teens were right; the provider was a supershrink.

The idea that some counselors are exceptional and have very high success rates with clients is not new. In fact, this phenomenon has been verified empirically. Research over the past several decades has demonstrated that some counselors consistently achieve higher client improvement rates than do other counselors. With that in mind, it is important to consider what we can learn as counselors from so-called supershrinks and how we can embody the characteristics and actions of highly effective counselors to improve our own effectiveness.

Counselor effects and outcome research

The term “therapist effects” or “counselor effects” refers to variation in counseling outcomes that are attributable to the counselor, in contrast to other factors such as techniques or theories that contribute to counseling outcomes. Findings of counselor effects appear in a variety of study settings such as naturalistic clinic settings and in randomized clinical trials (RCTs). Counselor effects in RCTs are particularly intriguing because these studies are tightly controlled. In RCTs, counselors commonly adhere closely to a treatment manual (i.e., following specific steps in adherence to a specific theory), and there is also control for client severity. RCTs are the gold standard for comparing efficacy of specific treatment approaches for specific disorders.

Although there have been important findings about the efficacy of different treatment approaches or theories from RCTs, another finding that has received less attention over the years is that counselor effects are the better predictor of counseling outcomes. In other words, who the counselor is makes more of a difference in terms of client improvement than does which theory the counselor professes to use. It is impossible to completely disentangle counselors’ characteristics and actions from the theories that they use, but meticulous research and meta-analyses by renowned researchers such as Bruce Wampold have indicated that counselor effects are up to eight times stronger at determining client outcomes.

As Wampold and others have pointed out, these findings about the relative strength of counselor effects in comparison with theoretical approach are not justification for tossing out counseling theories. Framework, structure, a road map for navigating clinical territory, and conceptualization are just some of the benefits of grounding our work in theories of counseling. That said, outcome researchers have for decades focused predominantly on comparing different theoretical approaches while giving relatively little attention to a more powerful factor — the characteristics, pan-theoretical practices/actions, and attributes of the counselor.

Five characteristics and actions of highly effective counselors

Although the existence of counselor effects in outcome research has been around for several decades, empirical attempts to discern pan-theoretical characteristics and actions of highly effective counselors are rather new. There are limits to developing a list of such characteristics because new research is frequently emerging. In fact, it is noteworthy that the five characteristics highlighted in this article are just some of the major characteristics and actions of highly effective counselors.

The list contained here is composed of qualities that counselors can actively cultivate in their current practice. In other words, there are some strategies for growth with each of these five qualities. There are other characteristics of highly effective counselors in the research literature for which it is not currently clear how to increase or enhance those characteristics (e.g., attachment history, facilitative interpersonal skills). Thus, this list focuses on characteristics and actions that can be enhanced to improve counselor effectiveness. Accompanying the descriptions of these characteristics are some tips for developing each of them in your own counseling practice.

1) Presence and
2) countertransference management

The counselor’s “way of being” serves as a vehicle through which therapeutic actions and interventions take place. Two related concepts from the counselor effects research that speak to the counselor’s “way of being” and “way of relating” are presence and countertransference management. Both concepts have theoretical roots.

For instance, in the existential-humanistic tradition, presence refers to counselors being “in the moment,” connected with clients’ experiences and their own, and fully engaged in the I-Thou relationship with a client. Presence can also be defined by identifying it as the opposite of absence (e.g., distraction, boredom, disconnectedness, remoteness).

Countertransference, of course, has theoretical roots in psychoanalysis. Sigmund Freud considered it to be when a client’s transference activated a counselor’s unresolved childhood conflicts. More broadly, a totalistic view of countertransference is that it encompasses all the counselor’s reactions to the client. Although countertransference reactions are commonplace, the impact of countertransference on counseling outcomes is largely due to how the countertransference is managed. Meta-analytic research by Jeffrey Hayes and colleagues has indicated that successful management of countertransference predicts better counseling outcomes. Similarly, presence has been described by Shari Geller and Leslie Greenberg as a “prerequisite for empathy,” and counselor empathy is a strong predictor of client improvement.

Multiple factors can lead counselors toward increased presence and better countertransference management, including self-insight (e.g., awareness of self in relationship, cognitive and emotional awareness), anxiety management, intentionality and mindfulness. Given all these factors, counselors can be left feeling a bit overwhelmed by methods to strengthen their presence and countertransference management. Fortunately, research evidence supports a few overlapping practices to enhance both of these qualities.

> Meditation/mindfulness practice: Sustained and consistent meditation practice has been shown to increase effective countertransference management, promote emotion regulation and nonreactivity, sharpen awareness and increase presence. Many different types of meditation and mindfulness practice exist. Counselors are advised to investigate these practices, to choose a practice aligned with their own preferences, and to maintain a consistent mindfulness practice.

> Self-insight and anxiety management: Counselors should work on their own psychological health and consistently practice self-observation and self-reflection. This can be done in supervision, in one’s own experience as a client, and through deliberate planning aimed at increased self-awareness.

Relatedly, anxiety management is an important component of countertransference management and presence. Although it is not unusual for counselors to experience anxiety within sessions, unmanaged anxiety can have untoward effects on a counselor’s presence, ability to manage countertransference reactions, and the therapeutic alliance. A first step is developing sensitivity to noticing anxiety when it appears. Second, counselors likely already have anxiety management skills (e.g., behavioral, cognitive, mindfulness-based) that they use with clients. Counselors can apply these skills to themselves.

> Pre-session centering: A study by Rose Dunn and colleagues revealed that counselors perceived themselves as having higher levels of presence when they engaged in a brief mindfulness centering exercise within five minutes of a counseling session. Additionally, clients perceived the sessions to be more effective when the counselor used the mindfulness exercise prior to the session. The basics of the centering exercise are consistent with acceptance and commitment therapy principles.

In this case, counselors would simply sit comfortably with a straight spine, take and notice gentle and full breaths, notice physical sensations, notice thoughts that emerged, acknowledge the existence of those thoughts and allow them to be present, imagine creating additional space for the thoughts with each breath, and then let go of focus on the thoughts to broaden attention to the environment around them. In this mindfulness approach, counselors aimed to accept the thoughts and experiences as an observer rather than clinging to or pushing away those thoughts. For more detailed information on mindfulness and acceptance centering, I recommend the work of John Forsyth and Georg Eifert.

> Self-care: This term is frequently discussed in our field, and self-care activities can vary greatly among individual counselors. It is important for presence, countertransference management and multiple other reasons that counselors engage in consistent self-care actions. One self-care behavior that seems relatively universal, and which has an impact on attention (i.e., presence) and emotion regulation, is sleep. Practicing healthy sleep hygiene (keeping room temperature at 62-68 degrees, sticking to a consistent sleep schedule, maintaining a dark environment, having technology limits at night, etc.) can provide conditions that are favorable for increased presence and greater countertransference management.

3) Professional self-doubt

The essence of this quality of highly effective counselors is captured in the title of an article by Helene Nissen-Lie and colleagues: “Love yourself as a person, doubt yourself as a therapist?” At first glance, the idea of professional self-doubt may seem like an unproductive place to be as a counselor. However, if we consider just a basic definition of “doubt” (i.e., to be uncertain), then the benefits for clients become clearer.

Counselors who possess certainty that they are helping a client are likely closing the door to self-critique and thoughtful consideration of ways to improve their work. Indeed, several studies by researchers such as Corinne Hannan and others have indicated that counselors consistently overestimate the effectiveness of their work with clients. Regarding self-doubt, two studies of experienced counselors by Nissen-Lie and colleagues revealed that counselors higher in professional self-doubt had stronger alliances with clients and higher levels of client improvement than did counselors lower in professional self-doubt.

Importantly, a third study by Patrizia Odyniec and colleagues showed that increased professional self-doubt among trainees/students resulted in poorer client outcomes than did lower professional self-doubt. One explanation for these findings is the difference in developmental stage of the counselors. Experienced counselors likely have higher confidence in their basic skills as counselors. Thus, professional self-doubt about their effectiveness can be beneficial as they strive for improvement due to their own uncertainty about client outcomes. In contrast, high professional self-doubt among trainees may be debilitating because of their earlier stage of counselor development and lower confidence in their basic counseling skills.

All that said, there appear to be clear benefits for clients when experienced counselors cultivate professional self-doubt. Here are some strategies for doing that.

> Prevent the “overconfidence effect.” This concept from social psychology is particularly relevant here due to numerous studies that have shown that counselors commonly overestimate whether and how much their clients are improving. Just being aware of this tendency to inflate their own client success rates can help counselors become increasingly humble and self-reflective about their effectiveness. Consciously questioning our own self-serving biases is an important step in maximizing client improvement rates.

> Monitor your effectiveness. Counselors should use some type of outcome measure (e.g., Outcome Rating Scale, Clinical Outcomes in Routine Evaluation-Outcome Measure, Outcome Questionnaire-45) to assess the degree to which their clients are improving or not. Routine outcome monitoring has repeatedly been found to improve client outcomes, and concrete client reports of their improvement level can help keep counselor overconfidence in check. Additionally, outcome monitoring can promote the beneficial stance of professional self-doubt because awareness of clients who are not improving or who are deteriorating
can lead counselors to act intentionally to improve.

> Love yourself as a person. An important caveat in the studies by Nissen-Lie and colleagues is that counselor self-doubt can improve client outcomes more when coupled with what is referred to as a “self-affiliative introject.” In general, this refers to higher levels of self-affirmation, self-love and self-acceptance. When a self-affiliative introject or self-affirmation is an area of struggle for counselors, it can affect their work with clients and their capacity to embrace professional self-doubt. Steps to build and strengthen a self-affiliative introject or stronger self-affirmation could include self-help, support groups or personal counseling.

4) Deliberate practice

Deliberate practice, a concept that originates in the expertise literature from researchers such as Anders Ericsson, refers to intentional and individualized exercises and actions aimed at strengthening specific areas of one’s performance. Early research on deliberate practice examined its effects in noncounseling domains such as chess, music and sports, to name a few.

In counseling, a promising study by Daryl Chow and colleagues of more than 1,600 clients working with 17 counselors found that the top quartile of counselors (i.e., those whose clients showed the most improvement) spent nearly triple the amount of time engaged in deliberate practice than did counselors in the lower quartiles of client improvement. Consistent with some previous research, Chow and colleagues found that the following factors were not significantly related to client outcomes: counselor age, professional discipline, gender, years of experience, highest qualification level and theoretical orientation. Below are some core components of deliberate practice combined with recommendations for integrating them into your counseling practice.

> Establish your baseline. To improve as a counselor and to determine if you are increasing effectiveness over time, you need to know how effective you already are with your clients. Routine outcome monitoring is a way to establish a baseline. Using an outcome measure and then tracking your client improvement rates over time is an initial step in deliberate practice.

> Record sessions with difficult or stalled cases. While not intrinsically motivating, we stand to learn a lot about areas for improvement with cases in which our weaknesses are most evident. Video recording is simple these days, and it is an indispensable tool that is not just for practicum students. Video recording can help counselors identify gaps in awareness and skills that simple self-reflection alone is unlikely to reveal. Relying only on our self-assumed clinical wisdom by mentally reflecting back on a session is unlikely to interrupt and change unhelpful patterns that may have emerged outside of our conscious awareness.

> Work with a consultant or consultation group. Stepping out of our own perspective and potential for self-serving biases is a critical ingredient of deliberate practice. By working with a competent consultant or consultation group, we can obtain diverse perspectives on our areas of weakness as counselors and thus develop specific goals and plans for growth while receiving ongoing support and feedback.

> Develop clear, targeted goals. Our goals need to be very clear and specific. It is not very effective to set a goal to “improve as a counselor.” Instead, a first step here would be to identify specific areas for potential growth as a counselor. This could be done in collaboration with your consultant/consultation group. With deliberate practice, the real growth takes place outside of actual client sessions. Outside of session, you have time, support and opportunity for reflection and practice as you engage in intentional efforts to develop new therapeutic skills or “ways of being” with challenging cases.

The specifics of deliberate practice are very detailed. Thus, counselors are encouraged to read the works of scholars such as Daryl Chow and Scott D. Miller on this topic for a more comprehensive review.

5) Multicultural orientation

Multicultural orientation is a rather new construct that differs  from multicultural competencies. As described by Jesse Owen and colleagues, multicultural competencies are considered a “way of doing,” whereas multicultural orientation is a “way of being.” Multicultural orientation is a way of being that communicates the counselor’s
attitudes and values about culture to the client. Specifically, multicultural orientation consists of three overlapping pillars. Each of the pillars is described below and accompanied by recommendations for strengthening it in your counseling practice.

> Cultural humility: This refers to an interpersonal stance that is “other oriented” and open to understanding the client’s cultural experience and background. In addition to this interpersonal dimension of cultural humility, there is also an intrapersonal dimension in which counselors have an openness and eagerness to reflect on their own limits and blind spots in understanding the cultural experience of another. Four studies with more than 3,000 clients have found a significant positive correlation between client ratings of their counselor’s cultural humility and counseling outcomes. An important consideration here is that the “client’s perception” of their counselor’s level of cultural humility was related to client outcomes.

There are some strategies and actions that counselors can take so that clients are more likely to experience them as being culturally humble. First, given the intrapersonal domain of cultural humility, counselors are encouraged to self-reflect upon and analyze their own areas of potential biases and cultural blind spots. Pamela Hays’ “ADDRESSING” model can be a useful framework for determining domains in which a counselor has a privileged status because these domains of privilege are likely sources of blind spots.

Second, counselors are encouraged to broach the topic of culture at the intake session with clients in an open-ended manner. This strategy also overlaps with the pillar of “cultural opportunities” (broaching strategies will be described in that section).

Third, counselors should check in with clients frequently to ensure that they accurately understand the client’s cultural perspective. This “cultural check-in” should be one part of a broader culture of feedback that is created by the counselor in the session. Specifically, counselors need to acknowledge with clients that they strive to understand clients’ perspectives and cultural experiences, but despite their best efforts, they may sometimes misunderstand. Openly and repeatedly inviting clients to provide candid feedback (especially negative feedback) is a way to express humility and to make repair attempts if and when a counselor misunderstands or unknowingly commits a microaggression.

> Cultural opportunities: This pillar refers to opportunities in sessions for the counselor to broach the topic of culture with a client. Importantly, research on this topic indicates that “missed cultural opportunities” (i.e., the client’s perception of the counselor missing and not acting on opportunities to discuss/broach culture) are negatively correlated with client outcomes. In other words, as the counselor misses more cultural opportunities, client improvement declines.

One way to enhance the positive effects of cultural humility and cultural opportunities is for counselors to broach the topic of culture at the intake session. For example, “How does culture influence the problem?” The purpose of such an open-ended question is to better understand the client’s perception of culture. If clients are unclear about what is meant by “culture,” alternative phrasing ideas can be gleaned from the “Cultural Formulation Interview” in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The interview offers numerous examples for asking open-ended questions about clients’ cultures.

Broaching or inquiring about the influence of culture should not be limited to the intake session. Counselors need to attentively engage with clients to understand how they
see the role of culture as sessions progress. This can lead counselors to sensitively seize upon cultural opportunities in sessions in a way that resonates with clients.

> Cultural comfort: The final pillar of multicultural orientation is counselors’ level of openness, ease and comfort in working with diverse clients and engaging with clients about the topic of culture. In a 2017 study, Owen and colleagues found that counselor cultural comfort level predicted client dropout rates. Higher levels of counselor cultural comfort were associated with lower client dropout rates. This is particularly important given that a high dropout rate is one of the more pernicious challenges for our field to address. Indeed, a 2012 meta-analysis by Joshua Swift and Roger Greenberg found that the average dropout rate in counseling is 20%.

In terms of counselors increasing their cultural comfort levels, some of the strategies mentioned for cultural humility and cultural opportunities (e.g., intentionally reflecting on/analyzing biases and blind spots, broaching the topic of culture in sessions) can apply. One additional strategy that can help in this regard is role-playing and rehearsal — specifically, role-playing with colleagues in which the counselor practices engaging with mock clients around the topic of culture. Counselors are advised to practice broaching the topic of culture in situations that represent a wide range of challenge. For example, if a counselor has had little or no contact with clients who are transgender, then role-playing a scenario in which the counselor broaches culture with a mock client who is transgender would be a way to expand the counselor’s cultural comfort. Inviting and receiving feedback from colleagues in such mock sessions is essential for counselors to expand and enhance their broaching skills and increase their level of cultural comfort.

Conclusion

The number of factors that contribute to effective counseling is vast and incalculable. As research continues to evolve on this topic, we develop a richer understanding of some of these factors. We now have abundant research support for counselor effects and the relative strength of these effects in comparison with theoretical techniques.

The lines between counselor characteristics, common factors (e.g., therapeutic alliance, placebo effect) and specific factors (e.g., treatment interventions, techniques) are not neat and discrete. Instead, each of these has some overlap with and multidirectional influence on the others. That said, recent research indicates that the characteristics, qualities and pan-theoretical actions of counselors are prominent in potentiating the therapeutic alliance and theoretical techniques to improve client outcomes.

 

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Sidney Shaw is a core faculty member in the clinical mental health counseling program at Walden University and a certified trainer for the International Center for Clinical Excellence. Contact him at sidneyleeshaw@gmail.com.

 

Letters to the editor: ct@counseling.org

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.

Technique without soul is dead

By Peter Allen December 10, 2019

As a licensed professional counselor, I am interested in what is helpful or effective for my clients. As a client in therapy, I am equally interested in what helps me to reduce my own suffering and develop better skills for navigating the larger world in which I live. Therefore, I consider myself a student in both respects. The clinician in me studies to achieve greater skill and experience, whereas the client side of me is ever sensitive to what is helpful in everyday life. I have had many experiences as both clinician and client that inform my approach, depending on which chair I happen to be sitting in on any given day.

There is one particular experience I had in therapy that has taken me years to integrate and use toward positive ends. At the time, I had been seeing a therapist for a few weeks. I was there to work through some old resentments and anger that were bogging me down and interfering with what was an otherwise good life. A trusted colleague and friend had referred me to this particular clinician, an older man with years in the field and a positive reputation.

After a few sessions, I remember thinking that the therapist was a little aloof for my tastes and perhaps a bit too professorial. He was kind but in a detached way. I had the sense that he did not think about me or my problems after he left the office for the day. Reflecting on my experience with him, I realize it was not what he did that sticks in my memory so much as how he taught me what not to do.

I had been attempting to work through some of my aforementioned anger issues with his help but had become somewhat stuck. He gestured toward a large, cube-shaped pillow on the ground in his office, measuring roughly 3 feet on each side. I hadn’t paid this object much attention until that moment, which is strange because a large cubed pillow in any office strikes me as noticeable in hindsight. The therapist asked me to repeatedly strike the pillow while verbalizing the very things that were upsetting me. I looked at him incredulously, and I remember specifically thinking, “This is stupid.”

I voiced my reservations, telling him openly that I did not think hitting a pillow and venting my anger in this way would be of much help. He smiled at me, trying to be reassuring, and encouraged me to try the exercise despite my misgivings. And so, I did.

Not surprisingly, I felt stupid. I was a grown man standing in a quiet therapy office hitting a large, cube-shaped pillow and trying to muster real anger in hopes that it would overtake my embarrassment. It did not. It caused me instead to feel like a petulant child who was not getting his way. Later, I would in fact feel the anger that was elusive in that moment, but my anger would be directed at the therapist rather than at the other people in my life.

What went wrong?

We processed this event immediately afterward in a somewhat perfunctory way, owing to my new resentment toward the therapist. I told him that I felt stupid, and he listened without comment. He was less interested in how the exercise reflected on him and more interested in my experience of it. The session ended on an anticlimactic note. I left his office and decided not to return. I should note that I could have given him more decisive verbal feedback about my experience, or inquired further about his intentions or technique. I did neither of those things, so in a way, perhaps I cheated him out of an opportunity to learn and grow. I take some comfort in the thought that his training and development were not my responsibility.

Upon reflection, I came to see that this therapist had disregarded valuable information and feedback I had given him in session. He used an intervention with me that he had likely used countless times before with other clients, and perhaps with some success. After all, he had gone to the trouble of purchasing that strange cube-shaped pillow. He executed a technique despite my obvious resistance because he thought he knew better than I did about what might be helpful. My experience was that I felt unimportant, unheard and embarrassed.

After reflecting on this somewhat minor event, I finally came to understand some of the dynamics that had played out in that room. The therapist was applying a technique without any soul — or, in other words, without first establishing an emotional bond or connection with me. Because he had not forged such a connection with me, the intervention was an abject failure. He assumed that the technique alone was powerful enough to overcome my reservations or, as I’ve said, that he knew better and I just needed to trust him. In my attempt to be the good client, I placed my trust in him, and he showed me that he had not earned it yet.

A basic critique I have of this method is that it does not translate to my life in the world. Hitting objects when one is angry has no application in the real world. We cannot repeatedly hit the table if we become angry in the middle of a corporate board meeting. This method is not encouraging the development of further skills; rather, it is reinforcing a negative human behavioral habit.

Although it took me many years to understand what I had experienced in that therapy session, I eventually arrived at an obvious answer: I went there assuming the therapist was, in fact, an expert, but the person who instructed me to hit the pillow was simply a flawed human being using a flawed methodology. He, like me, is in the process of learning and growing, and, as such, he is still making mistakes. I accept this, and I accept him as being in process.

Cause for reflection

Being on the receiving end of this intervention gave me license to truly examine its effectiveness, or lack thereof, in my own life. This small experience also led me to reflect on how often I — and perhaps, we, as clinicians — may be deploying techniques in a mechanical and disconnected fashion, whether we learned these methods in school, from a trusted mentor, or from a celebrity therapist. I have come to believe that when we do this, we are elevating and accenting the academic concept at the expense of an interpersonal connection.

What benefits our clients is subject to debate, of course, and reasonable people can disagree about this. We learn a variety of evidence-based practices, techniques and theories in the hope that we can help reduce our clients’ pain and suffering. I have colleagues I trust and respect enormously who approach therapy from a more scientific standpoint. They have a toolkit of interventions they use for a variety of presenting problems. Presenting problem A gets intervention B and so on and so forth. I also know brilliant clinicians who use a primarily interpersonal approach, in which the central and ongoing interventions are kindness, consistency, nonjudgment and acceptance.

I would be willing to gamble and say that the majority of therapists artfully blend the scientific with the interpersonal. What is scientific in counseling is by definition methodical, detached and concerned with evidence. What is interpersonal is by definition emotional, involved and subjective. There need not be tension between these two concepts; skillful therapists braid them together.

Carl Rogers, the founder of client-centered therapy (also known as person-centered therapy), came to the conclusion that the interpersonal approach actually produces scientific, measurable results. I will not dive too deeply into discussions of duality and what the superior approach might be (in part because I don’t know), but it is incumbent on the professional counseling community to ascertain anew each day what is effective versus what is ineffective.

My conclusion was that my therapist at that time was relying on pure scientific technique, which lacked warmth. Therefore, what I experienced was his detachment from me and his failure to respond to the verbal and nonverbal feedback I was conveying to him in that moment. My bias, of course, is the golden thread in this entire experience: I lean mostly Rogerian as a counselor, and my therapist had failed to honor one of Rogers’ most important insights — namely, that I am the expert on myself. My therapist put himself in the role of expert, which was a natural result of his unique life experiences, training, upbringing, biases and blind spots.

Undoubtedly, this therapist’s approach has been helpful and effective for many people over the decades that he has been in practice. With the enormous variety of human beings on this planet, an enormous variety of styles and approaches in counseling is merited.

I have concluded from this experience that technique without soul is dead. The cold application of scientific knowledge in the therapy office lacks humanity. However, using only warmth and empathy without technique can be amorphous and ungrounded. I occasionally find myself wanting to revert to technique alone for its definitive attraction — namely, that it is an intellectual and finite concept and therefore seems easier to grasp. Conversely, when I rely too heavily on an interpersonal connection, even as a Rogerian, I find this to be limiting in a different way.

For me in my process of development now, the interpersonal connection is what builds trust, and that is what allows techniques to flourish and gain traction. When techniques are successful and helpful, and when clients experience real change from them, the interpersonal connection thrives. In this way, a skillful pairing of these approaches serves to reinforce the strength of both of them.

I have tremendous empathy for my previous therapist, despite my obvious critiques of him. It was easy for me to see, both then and now, that he meant well. I also have the benefit of being able to evaluate his approach, whereas my own approach is not subject to his scrutiny. I have an inherent advantage in this sense because nothing I have done is under the microscope. That being said, readers of this article may find fault with my analysis, and I welcome a robust debate. I am grateful to him in a noncynical way for showing me what type of therapist I do not want to be: detached, professorial, expert. I strive to become more and more who I want to be as a counselor: someone who is involved, humble, and allied with my clients. In short, I strive to become the professional whom I needed that day in his office.

 

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Peter Allen is a licensed professional counselor at East Cascade Counseling Services in Bend, Oregon. Contact him at peterallenlpc@gmail.com.

 

Letters to the editor: ct@counseling.org

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.

What does therapy mean to you?

Compiled by Bethany Bray June 11, 2019

What does therapy mean to you?

Jessica Ferrence, a licensed professional counselor (LPC) in Fayetteville, North Carolina, was a little taken aback when a client posed this question to her in a session. However, it sparked Ferrence’s interest and led to some self-reflection.

Therapy is what counselor practitioners do – but it means something different to each professional. It’s a place for the client to heal, grow, be vulnerable, set goals, get to know themselves and many, many more things.

For Ferrence, therapy is a place to uncouple oneself from pain and find strength.

“Therapy puts people in a vulnerable position because we trust clinicians with our deepest, darkest, most painful secrets; things we haven’t shared with our partners or family members or best friends for various reasons. When we feel safe enough to let down our walls — when we share the burden we’ve been shouldering for years or relive the experiences that haunt us in our dreams — we find the strength to find our voice,” says Ferrence, who considered the topic both as a practitioner and recipient of therapy. “Confronting our pain and reclaiming our lives, without fear of judgment or ridicule, can be extremely cathartic. We feel validated, understood and accepted for the first time in a long time — and maybe even ever. And that’s when healing truly begins. That’s when we realize that the power to break free from the grip of our past lies within us. That our vulnerabilities are no longer vulnerabilities, but rather areas of strength that we draw from. [It’s] where the image of our best self has come into focus, and more importantly, that we have the courage to turn that image into a reality.”

 

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CT Online asked a sampling of American Counseling Association members to consider the question “What does therapy mean to you?”

Read their thoughts below, and add your voice to the conversation in the comment section at the bottom of this page.

 

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As a therapist, to me, therapy is…

  • An honor and privilege. I continue to be humbled by the fact that my clients share with me their most sacred stories. Often these are trauma stories, in which their deepest pain and vulnerabilities lie in the details they have shared with very few, or only with myself.
  • A collaboration between the client and myself. My clients bring their expertise about themselves and their experiences. They bring their stories. They also bring their strength, resiliency and all of themselves – shadow and light. As a therapist, I bring years of clinical experience and education. It is my responsibility to provide a safe, non-judgemental and compassionate space for us to work in. As appropriate, I will offer clients my perspective, as well as evidence-based interventions and information, which they have the right to accept or decline freely, based on what fits for them.
  • An opportunity to support clients in reaching their goals. These goals might involve learning how to cope with the aftermath of loss or trauma, or learning how to manage distress related to stress and/or a mental/physical illness. Sometimes we are working together to adjust their understanding and expectations regarding healthy relationships and boundaries.
  • Often focused on helping clients to recognize that they deserve to be loved, respected, cherished and protected — and that in life they don’t need to be perfect to be “good enough,” but rather they only need to be perfectly themselves – with all of their disappointments, triumphs, strengths and vulnerabilities. Frequently, I find [therapy] is about helping clients learn to view themselves from the perspective of their wisest and most compassionate selves.
  • A place to educate and normalize my client’s reactions and/or symptoms, so that they can get a handle on what it is they are dealing with, what they might expect and strategies they might wish to consider to help them to better manage their distress.
  • A place in time where clients do not have to wear masks or say they are “OK” when they are not. A refuge. A place where their distress will be heard and witnessed by another human being, who will not judge, but rather will reflect back their distress without minimizing, and will also hold up a mirror to their strength, courage and tremendous resiliency.

 

  • Shirley Porter, a registered psychotherapist and a registered social worker in London, Ontario, Canada

 

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To me, therapy is for everyone. It is the opportunity for individuals to get the most out of life.

Though traditionally viewed as a medium for helping someone work through a particularly challenging issue or mental health disorder, therapy offers much more. The reality is that, yes, everybody struggles at various points throughout life and may benefit from some additional assistance. People need not wait, however, until life becomes challenging to seek therapy. That is, effective therapy may help people go well beyond attaining life satisfaction to the point of thriving.

Accordingly, the lens through which counselors view clients should be one that extends well beyond problem resolution. By resolving an issue, a person may shift from a bad place to a neutral one. Pushing beyond this is where we really begin to witness existential growth. This is the place where life satisfaction increases, interpersonal relationships improve, goals are achieved and one begins living a life that — until therapy — seemed unattainable.

As counselors we make the unattainable attainable. While I have yet to meet a new client who comes into the office under the premise of “My life is great, and I am here to make it even better,” counselors have the tools to do just that! When working with clients, then, my thought process is to first help address the presenting problem, then facilitate a personal growth process that exceeds previously thought of expectations.

This is one way, of many, that we may continue to destigmatize the therapeutic process. Therapy is not just for individuals with mental illness or problems—it is for everyone.

  • Matt Glowiak, a licensed clinical professional counselor (LCPC), certified advanced alcohol and other drug counselor, full-time clinical faculty member at Southern New Hampshire University and co-founder/co-clinical director of counseling speaks in Chicago, Park Ridge and Lake Forest, Illinois.

 

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By definition, therapy is sitting in a room with an essential stranger and discussing your inner most intimate memories, feelings and traumas. Sounds fun right?

No.

So, if therapy isn’t always fun, why do so many people continue to go and find such benefit from the process?

Everyone’s answer to the above question is going to be a bit different but being a therapist myself, and a client within therapy throughout my life and currently; I would like to share my current perspective on what therapy is and why everyone should go.

To me, therapy is a helpful tool to use in order to get to know myself on a deeper, more authentic level.

Within our bodies and minds we all hold the answers to our presenting concerns, but the protective factors and defense mechanisms we’ve built up over the years tend to get in the way of effectively working through our life’s difficulties alone. Therefore, we rely on our coping skills and our loved ones to assist us in times of need. But what happens when your go-to coping skills are no longer working? For a lot of people, it means that you now have to adapt your life and accept the fact that you are now anxious, depressed, alone…fill in the blank — and that’s just the way it is. Fortunately, though this doesn’t have to be the case.

Therapy can be a great way to adapt or change your learned way of life in order to gain a better understanding of your inner workings and what happens when your internal and external worlds collide.

By nature, the process of therapy forces you to be vulnerable. And with vulnerability being the key component to experiencing all emotions (the good, the bad and the ugly) the therapeutic process can assist in the education, understanding, integration and execution of your complex emotions. Therefore, allowing you to take what is learned within the therapeutic hour out into the world and apply it to your life in order to reach our full potential.

In summary, I think that everyone should have access to, and be a client within the therapeutic process sometime throughout their life. It is not something I think people should be in forever, because I do think one of the goals of therapy is teaching clients how to be their own therapists. But I do think everyone should be able to experience the benefits that the unique relationship between client and therapist can have.

  • Shannon Gonter, a licensed professional clinical counselor (LPCC) in Louisville, Kentucky who works with young adults and specializes in men’s issues

 

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To me, therapy or counseling is the space in which counselors are able to promote, encourage and support clients in achieving wellness. This space is where clients go to seek out the assistance that they need to improve areas of their lives that contribute to their overall sense of wellness. These areas may include but are not limited to social, cultural, emotional, psychological, spiritual, relational and/or physical.

Therapy is this safe space where I can explore where I am in life, what obstacles I may be facing and what I need to feel whole again. To me, wellness is the experience of wholeness.

  • Ashley C. Overman-Goldsmith, an LPC and doctoral student at North Carolina State University and owner and lead therapist at Sea Change Therapy in Williamsburg, Virginia. Her current research centers on honoring the lived experiences of terminally ill clients while helping these clients resolve issues that affect their end-of-life experience.

 

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As a veteran and mental health professional, I often find myself conducting community presentations in order to reduce the stigma against clinical mental health counseling. Often, I find myself having discussions about what therapy is and what it means.

During these conversations, I draw the line between therapy and Therapy. Many find things helpful and calming that they consider “therapeutic,” like gardening, physical exercise, cooking, art, etc. I have clients that say “_____ is my therapy” and that’s great. The meaning in that context is anything that is emotionally soothing or helpful to them.

The other one, though, is Therapy. It is a formal interaction with a licensed mental health professional that is bound by a set of ethical principles, licensure regulations and expectations of professional conduct. I typically use the term clinical mental health counseling, which is more cumbersome but also clearer than just the word “therapy.”

During Therapy, in the clinical sense, a client identifies areas in their life that are not functioning as well as they would like. They then work with a trained professional to develop and work towards goals that will improve that functioning. The professional does not only have training in therapeutic interventions, but they also have training in evidence-based practices that research has proven can help the client resolve their concerns.

Unfortunately, many of the clients I see do not engage in Therapy until the things they have been using to try and manage their problems don’t seem to work. I often describe it this way: if I were a medical doctor, I would be an emergency room doc. The veterans I see come in to my office either right before a crisis, during a crisis, or after a crisis has occurred. Clinical mental health counseling is often seen as a last-ditch effort, a final resort to try before the wheels fall off the wagon.

Instead, I try to encourage clients to consider clinical mental health counseling as a resource to use in order to prevent a crisis, rather than reaching out in response to a crisis. To use Therapy in conjunction with things they consider therapeutic, rather than thinking they are two separate things. For my clients, I have seen this combination help them live the post-military life they both desire and deserve.

  • Duane France, a U.S. Army noncommissioned officer (retired), combat veteran and LPC who practices in Colorado Springs, Colorado. In addition to his clinical work, he also writes and speaks about veteran mental health on his blog and podcast at veteranmentalhealth.com

 

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To me, therapy is an opportunity. It seems that with any kind of client, in any type of situation, using any option of modalities, therapy is a gateway to a field of possibilities. I believe one of my greatest gifts to my clients is helping them to facilitate possibilities of thought, feeling and action. With possibilities, clients can see opportunity. Two important words come to mind when I think of opportunity: awareness and empowerment.

Clients come to counseling, voluntarily or involuntarily, but most come with some desire to figure out something. Clients may be looking for specific techniques or just a way to be able to communicate with their partners. They may be court ordered for addictions treatment or just feel like something is not right. Whatever the concern, figuring it out seems to bring insight and peace on some level. Being a licensed professional counselor, certified yoga instructor and an artist has allowed me to provide multiple strategies to foster clients’ inquiry into their presenting concerns. But strategy aside, therapy provides clients opportunities for self-awareness and insight about the world around them.

Additionally, opportunity begets empowerment. One of the key principles of counselor identity is empowerment of our clients to help themselves. I remember working in a community mental health center years ago. Then I was working with children and families who did not have a lot and who had experienced violence, abuse and insecurity in their living situations. I wondered what good could I do in one 60-minute session, and with one meeting per week for each client, especially when I was working in the context of highly distressing situations. Therapy was the act of empowering my clients to find options in how they reflected on themselves and responded to their environments.

With options available, clients can find freedom to choose. Feeling free to make decisions – intentional decisions – is one of the most empowering experiences for anyone. Being able to foster opportunity for my clients means that they have a chance to feel their personal power to make their own choices.

I would say that my primary job as a counselor and counselor educator is being an options-maker or a possibilities-creator! I believe it is in therapy where opportunities are born!

  • Megan M. Seaman, an LPC, certified yoga instructor and assistant professor in the Counseling and Art Therapy Department at Ursuline College in Pepper Pike, Ohio. She also maintains a private practice in Beachwood, Ohio where she works with children, youth and families using creative arts healing and yoga therapy strategies.

 

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To me, therapy is providing an open space for people to have the opportunity to discuss life events or problems that are impacting their daily lives. This is a place where someone feels heard. Our lives are often so busy that we don’t listen.

Counseling provides this safe place for someone to “unpack” life problems and look at them with someone who is truly listening and is available for unbiased support. Therapy offers the opportunity for people to discuss and explore ways to improve their lives and find resources to enhance their quality of life. Thus, they find the strength to manage difficult life events such as trauma, illness and adjustment to disability.

Therapy is also the passionate pursuit of learning and effectively using practice-proven and evidence-based practices to help with the healing process. But, it also requires a counselor to have the courage to question, redirect, and, yes, confront a client to keep them on the path to wellness and wholeness.

This is hard work! But it is an honor to be trusted by someone who doesn’t know us to listen, care and support them during their most vulnerable times.

  • Judy A. Schmidt, a certified rehabilitation counselor (CRC), licensed professional counselor associate (LPCA) and clinical assistant professor in the Clinical Rehabilitation and Mental Health Counseling program in the Department of Allied Health Sciences, School of Medicine, University of North Carolina at Chapel Hill. She is the rehabilitation counselor for the acute inpatient rehabilitation unit for UNC Hospital in Chapel Hill.

 

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To me, therapy is a communion of two souls who make an agreement to walk alongside each other for a part of this journey. Therapy calls us to bear witness to another person’s healing process by helping them to come back home to their true and authentic self. It reminds us of our wholeness and asks us to remove any barriers that prevent us from seeing this wholeness.

Therapy reminds us that we cannot have the shadow without the light and that the shadow only exists because of the light. It is about quieting the ego and the mind in order to get us out of our heads and into our hearts and bodies.

Therapy involves being truly seen and heard by another person to help us remember that we are not alone on this journey. It is about accepting someone for who they are (battle scars and all) while also seeing their infinite potential.

  • Jessica Smith, an LPC, licensed addiction counselor, yoga teacher and owner of Radiance Counseling in Denver, Colorado

 

 

 

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

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

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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.

 

 

A script for socialization to the cognitive model

By Brandon S. Ballantyne May 14, 2019

Cognitive behavior therapy (CBT) is an evidence-based treatment approach that has statistically been shown to be effective in addressing a variety of mood disorders and psychological problems. It is my belief that a key component to successful cognitive behavioral treatment is counselor-to-client socialization of theory and concept.

It is essential that clients become socialized to the cognitive model — understanding the rationale behind CBT’s effectiveness — to gain maximum benefit. For that reason, I have developed a script that counselors can use with the clients they serve. This script aims to provide a blueprint for live, in-session socialization to the cognitive model and provides a platform to transition into routine practice of cognitive behavioral technique in future sessions.

 

Script introduction

If I were to ask you to think of a palm tree, what do you think of? You probably just imagined a palm tree. If I were to ask you to think of your very first car, what do you think of? You probably just imagined yourself either in or next to that memorable first automobile. If I were to ask you to think of your favorite food, what do you think of? You probably just imagined your meal of choice.

Now, if I were to ask you to feel anxious, what do you have to do? Most people say they need to imagine a stressful scenario to feel the emotion of anxiety. The point is that we can instantaneously produce any thought. However, when it comes to producing an emotional state, we first need to think of something in order to feel something.

The formation of emotions is a biological process, meaning that it is impossible to shut off or terminate from human experience unless we suffer serious medical injury that leads to such complications. With that being said, there is a specific sequence of internal and external events that not only create, but contribute to, the emotional experiences of you, me and everyone else with whom we share this wonderful planet.

 

Situation

For an emotion to be formed, one must first encounter a situation. A situation is anything that an individual becomes aware of. It can be an external event such as a person, place, thing or activity. It can also be an internal event such as a particular thought or emotion.

Let’s say that tomorrow, I wake up, get in my car and start my drive into work. I encounter a traffic jam, which I anticipate might make me late to my destination. As I approach, I become aware of the traffic jam itself. Both the awareness of the traffic jam and the traffic jam itself become the situation at hand.

 

Thought

Our brain is like a thought warehouse. It has a job of producing thoughts throughout the day — every second, every minute, every hour.

What is a thought? A thought is a sentence that our brain produces about the situation at hand. Thoughts have sentence structure. Each thought has punctuation. It can also take the form of an image or movie that we experience in our mind.

On some occasions, we verbalize our thoughts out loud. Sometimes they stay silent. Regardless, they affect how we feel. If I am driving to work and become aware of the traffic jam, my brain might produce the thought of, “Oh no! I am going to be late. I am going to be behind all day, and I will get reprimanded by my boss. This happens all of the time!”

The first thoughts that our brain produces about a situation at hand are automatic. We don’t really have control over them. But as I mentioned earlier, these thoughts affect how we feel, so they are important to accept and to understand.

 

Emotion

Once our brain produces a thought about a situation at hand, there is the onset of some kind of emotional experience. How is an emotion different from a thought? Emotions can be categorized into mad, sad, glad and fearful. Any emotion that we have at any given time will likely fit into one of these categories of primary emotions.

There is also a subtle category that some identify as “neutral emotions.” However, we are rarely taught about what neutral emotions are. Throughout our life experiences, we are given the message that there must be a way to feel and that emotions need to be either pleasant or unpleasant. Therefore, if we aren’t particularly happy, sad, fearful or mad, we tend to say that we are feeling “nothing.”

Emotions are a biological process. And because our thoughts are automatic, we never really have an absence of emotions. So, when we are feeling “nothing,” we are actually feeling “neutral.” Descriptors such as “content” and “OK” best describe a neutral emotional state.

Now, let’s refer back to the traffic jam scenario. While sitting in the traffic jam, I am having the thought, “Oh no! I am going to be late. I am going to be behind all day, and I will get reprimanded by my boss. This happens all of the time!”

Because of this thought, I am most likely to be feeling anxious. Anxiety is most closely related to the primary emotion of fear. Some emotions occur parallel to physical symptoms as well. For example, if I am sitting in my car feeling anxious from the thought about being late to work, I may also notice that my hands have started to sweat. Physical symptoms help us to identify and label emotions.

So, it is important to pay attention to your patterns in your physical symptoms as you experience emotional states. In general, emotions give us information about the situation at hand. However, it is then our job to examine that information accordingly.

 

Behavior

Our behaviors are influenced by the emotions we experience. Behaviors can usually be observed by others. Based on the specific characteristics of the behaviors — and the specific characteristics of the reactions that the behaviors provoke in others — these behaviors can help us to get closer to our goals, push us further from our goals, or neutralize the pursuit of our goals.

What does it mean to neutralize the pursuit of our goals? Well, some behaviors neither get us closer to nor push us further from our goals. These behaviors can be referred to as “neutralizing behaviors.”

In the example of sitting in the traffic jam and feeling anxious, I may react to the intense anxiety by engaging in behaviors such as beeping my horn and yelling at other drivers.

 

Result

Results can be defined as a set of benefits or consequences that are produced by one particular behavior or set of behaviors. Results can be desirable, undesirable or neutral.

Desirable results are outcomes that take us closer to our goals. Undesirable results are outcomes that push us further from our goals. Neutral results neither take us closer to our goals nor push us further away.

In the traffic jam example, the behavior indicated was beeping the horn and yelling at other drivers. We can anticipate potential results that those behaviors may produce. As a reminder, the goal in that scenario is to get to work on time, or at least not too late, and safely.

One possible result of beeping my horn and yelling at other drivers is that other drivers may begin beeping their horns and yelling at me. This additional conflict may cause my anxiety to intensify further. At the same time, everyone beeping their horns and yelling at each other will not change the fact that I am sitting in the traffic jam itself. Therefore, this outcome can be categorized as an undesirable result.

 

Wrapping it up

The goal of this type of cognitive behavioral style work is to identify where in the process above an individual may have personal control or personal choice of changing the problematic patterns or tendencies. By examining the above scenario in that way, individuals will be able to conceptualize aspects of personal choice and change that can help them reduce intense emotional distress, engage in healthier behaviors, and achieve more desirable results — first in the above scenario and then with the real-life stressors that have brought them into treatment.

Use the following reflection questions to get started with application of this skill:

1) If you were stuck in a traffic jam similar to the one described above, what would be going through your mind? What are some of the automatic thoughts you would be having?

2) What kinds of emotions would your automatic thoughts produce? Would you be noticing any symptoms of those emotions in your body?

3) What type of automatic behaviors might you engage in based on the influence of those emotions or physical symptoms?

4) What type of outcomes or results would those behaviors likely produce? Would those results be desirable, undesirable or neutral based on your goal of getting to work on time, or not too late, and safely?

5) Is there anything else you might be able to say to yourself in the scenario about the traffic jam that would produce less intense distress? If so, what are those thoughts? Remember, thoughts come in the form of sentences or images.

6) If you were able to insert those new thoughts the next time you experience a traffic jam, what types of emotions would those thoughts likely produce? If they do not produce less intense distress or new emotions comprehensively, try identifying new thoughts (sentences) until you find one or two that either reduce the distress or produce new desirable emotions.

7) With less intense distress or new desirable emotions, what are the new behaviors that likely would be produced as a result?

8) Given the likelihood of those new behaviors, what would happen next? In other words, what would be the results of those new behaviors? Would those results be desirable, undesirable or neutral based on the goal of getting to work on time, or not too late, and safely? If those results are desirable or neutral, then you have successfully completed examination of this scenario. If the results are undesirable, repeat steps 1 through 8 until you are left with desirable or neutral results. If a neutral result does not make the situation worse, then it is desirable in itself.

9) What are some situations in your life that have caused stress?

10) What were the automatic thoughts running through your mind at the time?

11) Given those life situations, what were the undesirable results that were occurring?

12) Given those life situations, what were the behaviors that were contributing to those undesirable results?

13) Looking back, could you have said anything different to yourself in those moments to reduce the level of stress? If so, what would those coping thoughts be?

14) Given those life situations, what are examples of healthier behaviors that you want to be able to engage in?

15) Given those life situations, what emotions would be needed to make those healthier behaviors easier to achieve?

16) Given those life situations, what results would you want to be able to achieve, experience or receive?

17) With those desired results in mind, what can you say to yourself about those life situations that might help to produce healthier emotions and healthier behaviors?

18) Copy down those thoughts. Put them on an index card. This will serve as your coping cue to take with you. It will be a reminder that although we may not be able to fix a stressor at hand, we do have the opportunity to access alternative thoughts. It is those alternative thoughts that kickstart the process of reduced distress, healthier behaviors, and the satisfying experience of more desirable results. Thus, we are creating an opportunity for achievement as we assist ourselves in getting closer to our goals, even if certain stressors stay the same. With consistent practice, we teach our brains that we control our thoughts, emotions and behaviors. We give power to ourselves in knowing that we do not need situations to change in order to feel better and do better.

 

 

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Brandon S. Ballantyne has been practicing clinical counseling for 12 years. He is a licensed professional counselor and national certified counselor who specializes in the treatment of anxiety and depression. He currently practices at a variety of different agencies in eastern Pennsylvania. Find him on the web at https://thriveworks.com/bethlehem-counseling/our-counselors/, and contact him at brandon.ballantyne@childfamilyfirst.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.

Counselor self-disclosure: Encouragement or impediment to client growth?

Written and compiled by Bethany Bray January 29, 2019

W. Bryce Hagedorn once counseled a client who was wrestling with intense feelings of shame regarding things he had done during the Vietnam War. The client, a veteran of the U.S. Marine Corps, felt responsible for the soldiers he had lost during combat. He never expressed any details connected to these painful and complicated memories, however, until Hagedorn used a pivotal therapeutic tool: self-disclosure.

Hagedorn is also a Marine Corps veteran who has served in combat. The disclosure of his military service “opened the door to share things that the client had never shared before, even with going to the Department of Veterans Affairs [for treatment] for years. Before he was able to share, he wanted to know if I would be judging him,” says Hagedorn, a licensed mental health counselor and director of the counselor education program at the University of Central Florida.

When used sparingly, professionally and appropriately, counselor self-disclosure can build trust, foster empathy and strengthen the therapeutic alliance between counselor and client. However, counselor self-disclosure also holds the potential to derail progress and take focus off of the client. It is a tool that should be used with care — and in small doses, according to the ethics professionals working at the American Counseling Association (see sidebar, below). Learning how, when or whether to use self-disclosure with clients is best achieved through training, experience and supervision.

Hagedorn notes that once a clinician self-discloses, the client may naturally be inclined to ask questions seeking additional personal information about the counselor. “If you’re going to self-disclose, know ahead of time where your bailout point is,” says Hagedorn, a member of ACA. “Once you open the self-disclosure door, where are you going to stop? When I worked with couples, they could see that I was wearing a wedding ring. I was often asked how long I had been married, if I had kids or if I ever struggled like [the clients were] struggling. Know where you’re going to stop answering questions.”

Hagedorn doesn’t believe that self-disclosure should be an automatic, out-of-the-gate technique for counselor practitioners. Rather, he advises, counselors should consider it a tool to keep in reserve, using it only when appropriate — and with clear intention.

“I’m in favor of less is more with self-disclosure,” Hagedorn says. “If you’re going to self-disclose, you have to do it with dignity and understand the reasons why a client is asking [for personal information from a counselor]. Explain to the client, ‘Even if I have walked down a similar path, it doesn’t mean I have walked down your path.”

 

The many aspects of self-disclosure

Counseling Today recently collected insights about counselor self-disclosure from American Counseling Association members of varied backgrounds and practice settings. Read their thoughts below.

We encourage readers to add their own thoughts to this discussion by posting comments at the bottom of this article.

 

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Kimberly Parrow is a doctoral student at the University of Montana. She is a licensed clinical professional counselor who specializes in working with clients to address grief and posttraumatic growth.

Client comments often spark the urge for self-disclosure. The feelings of connection in a professional counseling relationship tempt counselors to self-disclose, sometimes without warning. I think the consideration of providing personal details to clients occurs regularly [but] believe situations when such disclosures are appropriate are few. Appropriate self-disclosure is client-focused, validates the client’s experience and spurs further exploration. A constructive disclosure is brief, focused on meaning and light on story.

Professional counseling relationships require a harmony of the necessary theoretical and relational components. When the pull to disclose occurs, I take a moment and ask myself three things:

a) Is the disclosure grounded in theory?

b) Is there any other way to keep the locus of the experience within the client’s world?

c) How will the disclosure affect the therapeutic relationship?

For these reasons, I think it is important to keep in mind that the decision to disclose should not be made in the moment. An appropriate disclosure is the product of thoughtful planning.

I once had a young adult client recovering from a tragedy that killed several people and left him clinging to life. Our work began after several months of hospitalization and physical therapy. A number of sessions became focused on his feelings of dissociation regarding his own near-death experience. He would make statements such as, “I almost died, and it feels like I don’t care.” He explained the feeling was getting in the way of connecting with his family and friends. His support people couldn’t understand why he wasn’t more thankful to be alive, and neither could he. Feelings of isolation and confusion were becoming a sticking point in his recovery. He felt alone in a rare experience. However, he wasn’t and isn’t alone; I have had a near-death experience too.

My decision to disclose took several days. The disclosure would be tied to our treatment goals, but keeping the locus on the client was a challenge. A discussion of my experience might be too alluring and could pose a threat to our therapeutic relationship and focus. Eventually I decided on a very brief statement, [saying], “I almost died once too,” and waited for the subject to surface again. When it did, I shared my brief statement. It was simple and powerful. In that moment, he was able to trust that my validation of and explanation for his dissociation was real, because I had also lived it. As a result, our therapeutic bond deepened, and our trauma recovery work gained traction.

 

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Benjamin Hearn is a school-based counselor in Columbia, South Carolina.

Self-disclosure is something that we all do with our clients from the moment we begin interacting with them. Our clothes, offices and other nonverbal communications all disclose things about [us], either intentionally or unintentionally.

Our more common notion of self-disclosure, however, centers on information we share about ourselves verbally with our clients. One piece of information that I have found myself often considering whether to disclose is my identity as a gay male. I most often disclose this information when I have sufficient client rapport and a client voices an incorrect assumption about me, such as asking about my wife. At other times, I may use disclosure to model a healthy gay identity or to promote a sense of similarity between myself and a client.

This latter approach was particularly helpful with a teenage client who had recently come out as gay but did not know other gay people and conceptualized them using common stereotypes. In order to keep the focus on him while disclosing, I framed my disclosure with a question afterward, saying, “I’m not sure if you know this, but I’m also gay and wonder if you see me as fitting within these stereotypes?” This allowed my client to explore differences in gay identities, as well as modeling a secure identity. He noted that he was surprised at how casual I had been in my statement, after which I was able to assist him in exploring reasons that he was anxious about his own disclosure to others.

Regardless of the content being self-disclosed, counselors should consider the possible risks and benefits of disclosure prior to disclosure and how they will keep focus on the client afterward. This can be done by questioning how a client responds to the information or by ending the disclosure using an empathy statement such as, “I remember when my own child left for college. You feel like the house and your life is just emptier.” Though this statement contains a self-disclosure, it is framed in a way that acts as an empathy statement, which the client is then able to evaluate according to their own experience.

Overall, mindful and intentional self-disclosure can act as a powerful technique in the therapeutic relationship [that] can normalize client issues, model healthy behaviors and increase clients’ own self-exploration.

 

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John J. Murphy is a licensed psychologist and professor of psychology and counseling at the University of Central Arkansas. He is the author of the book Solution-Focused Counseling in Schools, published by ACA.

The decision to self-disclose, like any counseling decision, is based on my judgment of its potential to enhance clients’ goals. For me, self-disclosure is never planned but occurs spontaneously, just as it does in other relationships and conversations. Self-disclosure can help convey our humility, humanity and understanding. Research indicates that the most effective counselors are seen by clients as genuine, compassionate and accessible, and self-disclosure can help foster such perceptions.

The following examples of self-disclosure occurred in a psychoeducational group that I led for parents and guardians of children with behavioral difficulties:

  • We started the first meeting by stating that some parents describe parenting as one of the most joyful, gratifying and challenging experiences of their lives. I commented that parenting was much more draining and humbling than I ever expected, adding that “if I made as many mistakes on a job as I do as a parent, I’m pretty sure I’d be fired within a week.” They liked that metaphor and brought it up a few times in subsequent meetings.
  • I made the following comments in a meeting during which a parent stated how hard it was to change her parenting style: “Some of my parenting habits have been really hard to break. One that comes to mind is the use of those short ‘precision requests’ we discussed last week. Even though I teach it to parents, it’s hard for me to do it with my own kids. So, I have these times when I can almost see the words traveling from my mouth toward one of my kids, and I just want to reach out and pull them back before they get there. I’m not sure why I expect these words to work now when they haven’t worked the last 100 times. It’s frustrating and embarrassing.”

Both examples framed the experience of making and accepting mistakes — a valuable skill for any parent — as a shared, inevitable part of any major life journey, parenting or otherwise. While neither example was deeply personal or self-revealing, I hope that acknowledging my own parenting blunders and frustrations helped level the relationship and enhance my approachability.

Self-disclosure, like anything else we do as counselors, is only as useful as clients’ response to it. Obtaining regular client feedback on their experience of the alliance can also help detect a client’s response to self-disclosure and other aspects of our overall counseling style and approach.

 

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Catherine Beckett is an adjunct faculty member in the doctoral counseling program at Oregon State University. She also has a private practice in Portland, Oregon, specializing in grief counseling.

Like many other aspects of counseling, clients are going to have different experiences with different approaches. One question I always ask during the intake process is, “If you have had counseling in the past and it worked well, what was it about the therapist’s approach or style that was positive for you? Or, if it did not work well, were there aspects of the approach or style that contributed?”

Some clients say, “That therapist shared too much; I didn’t like it.” Whereas others may say, “That therapist wouldn’t even answer basic questions about him[self] or herself, and I found it hard to have a relationship with somebody I didn’t know at all.” So, within the bounds of what I believe is ethical and what I feel comfortable with, I will try to be respectful of a client’s preferences in the service of building a positive alliance.

The second principle I have found useful is the practice of requiring myself to have clarity about the purpose of a disclosure prior to making it. I suggest to clinicians whom I supervise that they be able to follow any disclosure with, “The reason I am sharing this is …” This serves two purposes. First, it holds counselors responsible for clarity around intention. Second, it makes the purpose or intention clear to the client, as opposed to — and guards against the possibility of — a disclosure coming across as chitchatty, or as the counselor making the session about him/her.

I also believe that counselors need to be very cautious about using disclosures to convince a client that we understand how she or he feels. Even if we have had an experience similar to what that client is going through, the reality is that we don’t know how she or he feels. We had our own experience, and the experience of our client may be quite different.

 

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John Sommers-Flanagan is a professor of counselor education at the University of Montana and the author of eight books, including Tough Kids, Cool Counseling, published by ACA.

My first thought about self-disclosure is that it’s a multidimensional, multipurpose and creative counselor response (or technique) that includes a fascinating dialectic. On one hand, self-disclosure should be intentional. If counselors aren’t aware that they’re using self-disclosure and why they’re using it, then they’re probably just chatting. On the other hand, self-disclosure should be a spontaneous interpersonal act.

Self-disclosure is an act that involves revealing oneself. As Carl Rogers would likely say, if your words aren’t honest and authentic, then your words aren’t therapeutic. From my perspective — which is mostly person-centered — the purest (but not only) purpose of self-disclosure is to deepen interpersonal connection. As multicultural experts have noted, self-disclosure can facilitate trust more effectively than a blank slate, because transparency helps clients know who you are and where you stand. What’s less often discussed is that it’s impossible to not self-disclose; we’re constantly disclosing who we are through our clothing, mannerisms, informed consent form, office accoutrements and questions.

I remember working with a 19-year-old white, cisgender, heterosexual male. He told me he was diagnosed as having reactive attachment disorder. After listening for 15 minutes, I was convinced that there was no possible way he could meet the diagnostic criteria for reactive attachment disorder. First, I used an Adlerian-inspired question/disclosure: “What if it turned out you didn’t really have reactive attachment disorder?”

You might not consider a question as self-disclosure, but every question you ask doesn’t simply inquire, it simultaneously reveals your interests.

Later, I disclosed directly, using immediacy: “As I sit and listen to all your positive relationships, it makes me think you don’t have reactive attachment disorder.” Despite my interpersonally clever use of an educational intervention embedded in a self-disclosure, my client didn’t budge, countering with, “That doesn’t make any sense, because I’m diagnosed with reactive attachment disorder.”

At that point, I wanted to use self-disclosure to share with him all the ways in which I was a smarter and better health care professional than whoever had originally misdiagnosed him. Fortunately, I experienced a flash of self-awareness. Instead of using disclosure to enhance my credibility, I spontaneously disclosed, “I’ve been talking way too much. I’m just going to put my hand over my mouth and listen to you for a while.”

As I put my hand over my mouth, my client smiled. The rest of the session was — in both our opinions — a rousing success.

 

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Zachary R. Taylor is a licensed professional counselor (LPC) and behavioral health director at a health center in Lexington, Virginia.

I specialize in working with patients who have chronic anxiety and panic, and I regularly disclose that I suffered from these disorders myself for more than 10 years.

The key is being specific about my experiences because many anxious patients feel no one understands what they are going through. Simply saying, “I too was anxious” often doesn’t connect. Instead, I choose specific stories about my many trips to the emergency room, my phobia of checking the mail, the clutching on to my Xanax and my sophisticated driving routes through town to avoid anxiety triggers.

When I share these things, it’s usually out of an effort to normalize their experience and get leverage because, if they know I’ve been there, they’re more likely to accept my help not only as a licensed counselor but also as a former anxiety sufferer who has used these same counseling principles to recover.

Second, I use self-disclosure to reinforce principles we are working on in counseling. For example, to this day, I still experience scary and sometimes tragic images that flash through my mind out of the blue. These used to send me into full-on anxiety spirals, during which I would go through all kinds of safety behaviors to reassure myself that I, and everyone I loved, was OK.

The only real difference between these images then and now is not that the images don’t come back anymore but that I learned how to do things many counselors know as cognitive defusion and psychological flexibility. This is the ability to recognize the imaginary quality of these images and learning how to have the courage to treat them as things I can safely ignore.

This example, in particular, is useful when patients believe every anxious thought, image or sensation and take them as something they need to either respond to or repress. It gives them a new vision that recovery doesn’t mean never having another anxious thought but learning to cope with them when they show up.

However, we must remember there’s a difference between showing patients our psychological scars versus our psychological wounds. There is a significantly greater risk in revealing hurts not yet healed. We must be judicious in self-disclosure, make it brief, always have a clear therapeutic purpose and have a reasonable expectation that the patient can manage the disclosure and that they never feel the need to care for us in the process.

 

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Richard S. Balkin is an LPC and the editor of the Journal of Counseling & Development. He is also a professor and doctoral program coordinator in the Department of Leadership and Counselor Education at the University of Mississippi.

In the second semester of my master’s program, my skills class was taught by a professor who followed a psychoanalytic orientation. She was clear that she would give feedback based on this orientation and that it was OK to reject her feedback as long as we supported any alternative with our understanding of theory. I do not recall any student rejecting her feedback. That being said, I do recall my first session with a client. When the client entered the room, I reached out to shake hands. When reviewing my initial session with the professor and class, I was asked [by the professor] why did I reach out to shake hands? When I indicated I thought that was the polite thing to do, I was told, “That’s about you, not the client.”

I remember being taken aback by this feedback, which seemed to me rather extreme. Not only did I listen to it at the time, but I was influenced by it for many years. Naturally, not shaking hands with the client easily extended to what I could possibly share with a client. If the initiation of a handshake was viewed as countertransference, I could only imagine what my professor would say if I were to self-disclose.

Of course, all of this was challenged in my first year working as a professional counselor, when I worked on a dual diagnosis unit with adolescents. Many members of the multidisciplinary treatment team were active in 12-step support programs, so self-disclosure as a means for teaching about addiction and working together was very natural. More importantly, the adolescents seemed to appreciate the candor and learn something from it.

No doubt, self-disclosure can be helpful, but it can also be self-serving for the counselor, contributing to an unhealthy dynamic in the counseling relationship. If the curative components of counseling truly are based on the counseling relationship, then counselors might do well to consider how self-disclosure will deepen the counseling relationship. In [the ACA-published book] Relationships in Counseling and the Counselor’s Life, my co-author, Jeffrey Kottler, and I mention ways that self-disclosure can be therapeutic, [including] communicating understanding and acceptance and promoting deeper reflection.

 

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Sidney Shaw is an LPC in Anchorage, Alaska, and a core faculty member in the School of Counseling at Walden University.

Researchers often describe two types of self-disclosure: immediate and nonimmediate self-disclosure. Immediate refers to process self-disclosures from the counselor about their own feelings or ways of experiencing the relationship with the client. Nonimmediate self-disclosure or counselor disclosure about their life, personal experiences or biographical information is often what counselors are referring to when they discuss self-disclosure. Immediate and nonimmediate self-disclosure both have potential to deepen the alliance and promote client wellness. That said, there can also be negative effects of indiscriminate self-disclosure. The litmus test of whether or not to engage in self-disclosure is to do so only when it will be therapeutic for the client.

In the spirit of self-disclosure, I’ll share an anecdote about nonimmediate self-disclosure from my own practice. Early in my counseling career, I worked with indigenous communities, and one of my first experiences was to co-facilitate groups on the topic of healthy families and communities. In preparing for the upcoming groups, my supervisor asked me, “Have you thought about what story you are going to share about yourself?” I replied that I had not considered it, and I could feel my anxiety rise as he mentioned it. As a recent counseling graduate, I was highly concerned about negative effects of self-disclosure — e.g., too much emphasis on me, communicating that how I dealt with a situation is how the client should deal with it, etc.

As my supervisor pointed out, and as supported by my subsequent experience and broader research findings on the topic, self-disclosure is frequently an important element of developing trust in working with indigenous clients. One of the groups that I co-facilitated was on the topic of male family relationships. With this in mind, I shared a brief story about my father, how we had been through a long period in which our relationship was conflictual and how we eventually worked to move toward a more harmonious relationship. Cultural context is an important factor to consider in terms of how and to what degree to engage in self-disclosure. Thoughtful and intentional self-disclosure can help counselors build alliances with individual clients and with communities outside of their own.

As counselors, we may initially intend to self-disclose in order to promote client well-being, but self-disclosure can subtly and unwittingly begin to creep toward serving our own needs. The question of whether or not our self-disclosure is therapeutic for the client is not one that counselors should answer in isolation. Ongoing consultation with skilled, wise and competent supervisors and peers is an essential element of helping counselors answer this question.

 

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Caitlyn M. Bennett is a licensed mental health counselor and an assistant professor at the University of North Texas.

One of my areas of clinical expertise is anxiety, especially in adolescents and young adults. Anxiety has a way of making people feel out of control, and oftentimes, clients have told me that they “feel crazy.” Because of this, I have found when processing and making sense of the physiological aspects of anxiety — i.e., racing heart, tightness of chest, etc. — with clients, it can be empowering and validating to self-disclose my personal physical expressions of anxiety.

Prior to this self-disclosure, I find that general psychoeducation about anxiety [and its effects on] the brain and body serves as a catalyst to making sense of anxiety as well as serving as a bit of a normalizing factor. This helps me to gauge whether clients feel connected and understand the physiological impacts of anxiety. For example, their experience of anxiety may not involve as much of the physical experiences. Thus, me expressing my personal physical experiences of anxiety would not be helpful for the client.

After exploring psychoeducation, I begin to encourage clients to share about their personal physical experience of anxiety. If clients have a hard time identifying where in their body they experience anxiety, this is where I introduce self-disclosure by sharing, “When I feel anxious, I may feel my anxiety in my chest or my shoulders tense up. What about for you?”

I have found that this softens and makes exploring anxiety safer and more relatable without taking away from the counseling space being for the client. It also creates an added layer of connectivity for the therapeutic relationship. I have found that some of the most powerful sessions have been when clients feel understood by me as their counselor and also realize that I am only human too.

In all aspects of self-disclosure, I reflect on rapport and encourage my students to do the same. For example, I don’t make it a point to self-disclose prior to establishing a working therapeutic relationship. Self-disclosing prior to creating this relationship may create misunderstanding of what counseling will or will not look like for the client.

It is also important for counselors to remember that self-disclosure can be such a powerful tool. In my personal process of integrating self-disclosure with a particular client, I reflect on the pros and cons of self-disclosure, the difference of impact in emotional (personal feelings) versus content (facts) self-disclosure, the development of the client and multicultural factors. When I have explored this with counselors-in-training, we often focus on using self-disclosure “for good and not for evil.” That is, will the self-disclosure I choose to use be helpful for my client and their process or only benefit myself?

 

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Carol ZA McGinnis is a licensed clinical mental health counselor and approved supervisor. She is a pastoral counselor and clinical director for the AWI Counseling Center at the Fairview United Methodist Church in Phoenix, Maryland, and an associate professor and clinical mental health track coordinator in the graduate counseling program at Messiah College.

As a person-centered [counselor], I rarely self-disclose and only after professional consultation and deep reflection on how that content may be of significant help to the client.

One client who had decided to drop out of high school and pursue her GED received a brief self-disclosure from me at our termination session. I considered the fact that I had dropped out of high school and earned my GED many years prior to completion of my Ph.D. sufficient to disclose. [In doing so, I] meant to encourage and challenge the client to stay the course.

Another client I can recall self-disclosing to was a Muslim adolescent whose parents had asked with concern about my religious orientation. After consultation with my site supervisor and fervent prayer, I decided to disclose my faith tradition along with reiteration of my work that would focus on the client’s beliefs and not my own. It was rewarding to receive a copy of the Koran at our termination session in appreciation from the client and his family.

I do, however, use emotional self-disclosure fairly frequently to validate and normalize client anger. Oftentimes, people who come to me for help with their anger feel shame, guilt or fear, and it has been helpful for them to hear that I am in alignment with them when they report an unfair or unjust event as the source of that emotional response. This disclosure does not include circumstances or stories from my life but instead remains strictly within the realm of emotion in the moment.

One client example of this type of disclosure involved a [client’s] vague memory of an unidentifiable doctor who had engaged in questionable behavior during a medical physical when she was a teenager. The client could not recall what had happened beyond [the doctor’s] request to have her strip naked and do jumping jacks, yet the anger she held toward him was fresh. When this client cursed through tears at this person in the counseling session, I disclosed my own feeling of anger toward this person because he had violated her trust and his professional mandate to act in an ethical manner. Efforts to report this professional were largely unsuccessful due to the client’s blocked memory, yet the client reported feeling affirmed and validated by our work that focused on mitigating that traumatic event.

 

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The ethics of self-disclosure

Practitioners who choose to self-disclose information about their personal lives in counseling sessions often walk a fine line between using it as a tool to connect with clients and diverting attention away from clients and on to themselves.

When used incorrectly, self-disclosure can take focus away from the therapeutic work and the needs of the client. When used appropriately, however, practitioner self-disclosure can build trust, strengthen the therapeutic relationship and help a counselor to express empathy.

So, how much self-disclosure is too much? Practitioners must always put the client first when using any intervention, including self-disclosure, says Joy Natwick, ethics specialist for the American Counseling Association. Counselors should carefully consider their client’s needs and presenting issues and whether the self-disclosure could trigger an issue with which the client struggles, such as excess worry or caretaking behavior, she says.

In addition, self-disclosure should never be used as a response to the counselor’s emotional needs or in situations in which self-disclosure would jeopardize the quality of care to the client, Natwick emphasizes.

Self-disclosure should be regarded as a tool to engage clients and help move them toward their treatment goals. If it would have any other outcome, it is unlikely to be the correct intervention to use, Natwick says.

For additional guidance, consult the following standards in the 2014 ACA Code of Ethics:

  • A.1.a. Primary responsibility
  • A.4.a. Avoiding harm
  • A.4.b. Personal values
  • A.6.b. Extending counseling boundaries
  • B.7. Case consultation
  • C.2.g. Impairment
  • C.6. Public responsibility
  • H.6. Social media
  • I.1.b. Ethical decision making

 

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Related resources from ACA

Books (counseling.org/publications/bookstore)

Counseling Today (ct.counseling.org)

 

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

Letters to the editorct@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.