Tag Archives: Professional Issues

Professional Issues

A counselor’s journey back from burnout

By Jessica Smith April 13, 2017

I do not want to get out of bed, so I press snooze on my alarm again. I feel nauseated and think about calling in sick. Finally, I drag myself out of bed and take my time getting dressed for work. I leave my house reluctantly. On the drive to work, I find myself wishing that I could turn around. I dread going to work. I arrive 15 minutes late.

This was my pattern for longer than six months. Why was I the last one to figure it out? I was in burnout.

Learning to fly

I remember learning about self-care in the first semester of my graduate counseling program. I was so intrigued by the topic that I even wrote a paper about it during my first graduate course. My mentor and professor in graduate school focused on self-care in his course topics and research, so I felt very prepared to prevent burnout.

During my graduate program, I grew passionate about working with substance use and offenders. I decided that my dream job would involve working in a correctional setting. Not long after graduation, I obtained a position working on a treatment team in a local detention facility. I remember the feelings of pride and excitement that I experienced upon finding out that I had gotten the position. I was ready to do what I thought I had been trained to do, which was to help people.

I began coming to work early and made sure I was the last person in the office to leave. I would spend time researching and planning out sessions and group topics. Each day on the way to and from work, I would think about creative interventions that I could use with clients. I bought a bunch of workbooks, read a ton of articles, printed out a variety of activities from the internet and even purchased art supplies, stress balls and play dough for my clients to use in meetings. I recall losing myself in sessions and feeling a high after meeting with a client or finishing a group.

I would sometimes stay late or come in early to meet with clients. When I found out that a client was in crisis or had just returned from a disappointing court hearing, I would routinely rearrange my schedule or add in another session spot, even if I didn’t really have the time or energy for it. If a client asked me to jump, I replied enthusiastically, “How high?”

Free-falling

About a year into my work, I felt lost and confused. I would like to say that I could pinpoint the moment when this shift occurred in me, but as with many things in life, it was more of a gradual, slow burn.

Of course I can remember defining moments that stood out to me, such as learning that a client with whom I had worked for six months had been sentenced to 16 years in prison for a nonviolent crime. I was in the hallway and saw him when he was walking back to his “pod” (the name for the housing communities in the jail). He stopped me and informed me of his prison sentence. I barely made it back to my office before I started sobbing. The news literally brought me to my knees.

Another moment also stands out to me. On one of the many nights when I was working late, I ran into a client in the hallway. This client said to me, “Jess, why are you staying late again? You need to take care of yourself and go home.” I pride myself on being a mirror for my clients, but the truth is that my clients are often my best mirrors and teachers — even if I don’t truly want to see what they are reflecting back to me.

Catching fire

Looking back on everything now, it seems obvious to me: I was so invested that I blurred my boundaries. I had so much empathy and compassion for my clients that I sometimes lost myself in those relationships. I wanted to help others first at the expense of helping myself.

As many of us know, however, when we are deep in the swamp, it can be difficult to see a way out. After all, there were times when the work still felt really rewarding. I could still experience little victories, such as when a client was able to voice change-talk or gain insight into the roots of his criminal behaviors. I held on to these moments for dear life because I was terrified of what I might discover if I let go and shifted the focus back to myself.

It took another year before I went from “crispy” to full-fledged burnout. My physical symptoms of burnout continued to worsen, so I sought therapy, just as I had many times before when things in my life became unmanageable. I realized in counseling that if I stayed in my current position, I might eventually hurt others like I was already hurting myself, so I resigned from my job.

Rebirth

I remember thinking that if only I could meditate enough, exercise enough, vacation enough, love enough, relax enough, then I would be OK. The problem with “enough” is that it never really feels like enough. I was too caught up in “doing” because I was afraid of what I would learn about myself in the “nondoing.”

After resigning from my job, I spent the next month traveling and reconnecting with myself. My journey took me to some amazing places, but, interestingly, the place that had the most profound effect on me was also the most unexpected.

I spent six days as a student at a Zen Buddhist monastery in Crestone, Colorado. Crestone is considered to be one of the most spiritual places in the world. The land was called the sacred center of North America by the native peoples, and tribal members would travel from all over the country to attend healing ceremonies in the valley. The Manitou Foundation has provided grants and financial support to religious and spiritual projects in Crestone, leading to 15 different spiritual centers putting down roots in the area, including ashrams, churches and monasteries. My schedule consisted of the following: wake up at 4 a.m., meditate for two hours, participate in morning service, eat breakfast in silence, engage in morning work practice, eat lunch in silence, engage in afternoon work practice, take a one-hour break, meditate again for two hours, repeat the next day.

At one point I remember thinking that I desperately wanted to get in my car and drive away, but I reminded myself that I had consciously chosen to be here and there was a lesson I needed to learn from this experience. In actuality, I learned many lessons in my six days there, but the one that stood out to me most was that I tend to give much more than I take in and receive from others. Others are waiting on the sidelines, ready to help me carry some of my burden, if only I will ask. Too often, I choose to smile, wave and run right past them.

Rising from the ashes

As counselors, our out-breath tends to be longer than our in-breath. We often feel it is easier to give than it is to receive, yet we need to give and receive in order not just to survive but thrive. We do difficult work each and every day, then offer pro bono services to clients when we are already stretched thin and barely covering our overhead. We volunteer our time and hearts for a worthy cause or a friend in need even when we have no remaining headspace or heart space.

When I feel sad, lonely, disappointed or powerless, I give because that is what I know how to do. But what I really need in those times is to seek and genuinely receive help from others. I would like to share a few ways I have discovered that I can receive from others that truly fill me up when I feel depleted.

Seeking community. Two years ago, a few therapists in our community came together to start a support group that we call a “sangha.” A sangha is a supportive community that meets regularly to share knowledge and practice skills to foster understanding, acceptance and awareness. We meet twice monthly for two hours total. I can honestly say that it has been one of my most rewarding, nourishing and sustaining experiences, both personally and professionally.

It is interesting that as helpers, we often preach the power of community and support groups to our clients, but we rarely engage in this type of group on our own. Nearly every time our sangha meets, we comment on the ability of this group to empower and uplift us. I have spoken with a number of therapists who share the same interest in starting a professional support group. I highly encourage counselors reading this article to begin talking to other interested professionals in their home areas. Consider starting your own group to receive the support, guidance and compassion of other healers.

Naming burnout. Whether it is during our own personal therapy or with other professionals, I think it is important to unpack our counseling experiences in a healthy way. We do incredibly difficult work, and we need a way to empty our cups when they are overflowing. I now surround myself with people who can hold space for the tough emotions and who want to help me carry some of my professional “stuff.”

As therapists, we can sometimes feel shame around voicing our feelings of compassion fatigue or burnout to others. We sometimes think these feelings mean we might be flawed because we are not able to take our own advice. However, I believe shame breads in secrecy. We need to share these experiences with others to take away the power they might have over us. We also need to be able to receive any feedback and insights that others might have for us during these vulnerable times. I encourage you to have an open conversation about burnout with your professors, mentors, supervisors or colleagues to reduce the stigma it holds for us as helping professionals.

Exploring spirituality. As I have mentioned, early on in my career, my idea of self-care was focused in “doing” rather than just “being.” This was a superficial view of self-care. I have since learned that self-care is so much more than the “doing” part.

The missing component in my self-care practice for many years was spirituality. When I added this to my practice, I felt free. My spirituality practice is a hybrid of many different ideologies and approaches, but finding what works best for you is most important.

I remember hearing that prayer is sending a message into the universe, whereas meditation is receiving a message from the universe. This has always stuck with me. There are times when I will sit down to meditate and I will just cry. Sometimes I am not even aware of an emotion until I sit down on my mat in stillness. Spirituality can ground you when you feel like you are floating away. It can humble you by reminding you that you are one tiny part of a vast system and universe. I believe there are many paths to the same destination, but I encourage you to explore and figure out the path that anchors you and allows you to receive whatever insights your practice offers.

Conclusion

Jim Morrison is attributed with saying, “You can’t burn out if you’re not on fire.” Often, we get into this work because we are wounded healers who are passionate about helping others. Passion is fire. If you are passionate about this work, then eventually you will catch on fire, but you ultimately get to choose whether you will burn out and fade away or rise from the ashes.

 

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Jessica Smith is a licensed professional counselor and licensed addiction counselor in private practice in Denver. She is also a trauma-informed therapist who is trained in eye movement desensitization and reprocessing and yoga therapy. Contact her at jsmith@radiancecounseling.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 your 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.

Technology Tutor: Ethical and legal considerations of counseling tech

By Rob Reinhardt March 31, 2017

Last year, I interviewed a counselor who had been conducting text counseling via the Talkspace service (see ct.counseling.org/2016/06/technology-tutor/). Not long after this, two articles were published that brought some of the legalities and ethics of the Talkspace model into question (see bit.ly/ForbesTS and bit.ly/TSVerge). Given the continued growth of telehealth services, it seems a good time to provide an overview of ethics considerations when using technology in counseling.

Although those articles focused on alleged issues at one particular company, it is important that we apply our ethics decision-making lens to all applications of technology in our counseling work. This includes applications used for electronic health records (EHR), telemental health, internet faxing and so on.

Among the possible scenarios with ethical implications that have been raised for counselors using telemental health platforms are:

  • Concerns about potential violations of the Health Insurance Portability and Accountability Act (HIPAA).
  • Platforms removing the ability for clients to speak with their assigned clinicians.
  • Emails being sent to multiple clients in which the email addresses are visible to all recipients, resulting in possible confidentiality/HIPAA violations.
  • Platforms using the term “customer” instead of “client” in communications to those receiving services, suggesting that such platforms have only a business relationship with clients, not a professional one requiring the same level of privacy/confidentiality that is maintained by licensed clinicians.
  • Concerns that platforms do not have a quick and easy way for clinicians to access client contact information in cases of emergency.
  • Issues regarding mandated reporting and other ethical and legal responsibilities.

I am presenting these concerns here as an opportunity to explore potential real-life ethics situations in the digital age. Let’s examine how counselors can think about these issues and assess whether a particular telemental health or other software platform is right for them and their potential clients.

 

HIPAA

When interviewing any vendor that will come into contact with protected health information (PHI) for which you are responsible, a great starting point is to ask how the company complies with HIPAA. If you’re not satisfied with the vendor’s answer, this should be a nonstarter.

The vendor should be able to provide you with detailed information about how it complies with HIPAA and provide a copy of its business associate agreement (BAA). The BAA is the vendor’s contract with you acknowledging that it complies with HIPAA and detailing what its responsibilities are. If the vendor claims it doesn’t need to comply with HIPAA for some reason (a popular excuse is that the vendor “never has access to PHI”), you should proceed with extreme caution. This reason does apply in certain cases, but they are very rare.

Even if your vendor complies with HIPAA, it is very important not to assume that all of your bases are covered. There are still the ethics concerns noted earlier and the HIPAA compliance measures that you need to address yourself (see tameyourpractice.com/HIPAA).

 

Action point

Check your prospective vendors’ level of HIPAA compliance and confirm that they will enter into a BAA with you.

 

Client autonomy

“Autonomy, or fostering the right to control the direction of one’s life,” is the first guiding professional value listed in the 2014 ACA Code of Ethics (and is also an integral facet of HIPAA). Our ethics code says that clients have the right to choose their counselors. Therefore, counselors who are working as providers in these platforms have a duty to understand if this right will be given. It would be problematic if the platform could disconnect clients from their counselors without client consent or absent an ethical violation on the part of a counselor. If this is a possible scenario on a platform that a counselor is using, it should raise a red flag.

 

Action points

Relationship: When involving a third party such as a platform for telemental health in our counseling work, we must thoroughly investigate what the relationship between the third party and the client would be. Does the third party have “control” over that relationship and the associated records, or do the client and counselor maintain that control? It is important to consider what might happen in different situations. For example, if you decide to switch which vendor you partner with to provide a service, is there anything preventing you from working with the same clients through the new platform? If you need to refer out, how is that handled? Interestingly, these are the same sorts of questions to explore for those joining a group private practice.

Contact: As part of this confirmation of relationship dynamics, counselors should ensure that they have accurate contact information for clients or can gain access to that information in an emergency.

 

Handling of emergency situations

The handling of potential emergency situations is particularly relevant to any form of telehealth. As counselors, we are required by the 2014 ACA Code of Ethics to have a plan for handling contingencies, and when we involve a third party, it is important to explore whether that involvement might present new barriers to such a plan. For example, let’s say a counselor has an urgent need to contact a client or that client’s emergency contact. The counselor uses a cloud-based electronic health records (EHR) system to store client information. What happens if the EHR system or the internet connection is offline? Does the counselor or the EHR vendor have a contingency plan for accessing that information?

 

Action points

Vendor policies and procedures: Know how your vendors handle emergency situations. Is there a way to access data when you have lost your usual route of access? What are your vendors’ contingency plans? Do they have any documentation of past “up time” (percent of time they are up and running) or “outages”?

Contingency planning: Once you know your options with the vendor, what is your plan? Do you keep a secure backup of client contact information in case of emergency? Do you have a backup internet connection (perhaps you can access the EHR via your mobile device via the cellular network)?

If you need additional guidance regarding the creation of a contingency plan, see tameyourpractice.com/contingency.

 

Who is responsible for what?

One of the challenges described by clinicians who have worked with these platforms is identifying exactly who is responsible for what. Tied into both of the previous points, questions are raised about who is responsible for handling emergency situations, record-keeping, billing and even coordination of care with other providers.

Action points

Noting key responsibilities: It might help to make a checklist of your key ethical, legal and clinical responsibilities when it comes to clients (informed consent, HIPAA privacy and security compliance, etc.). Although many of these responsibilities are universal, others may differ depending on the environment in which you work and the clients with whom you work. Construct this checklist so that you are clear on who has ownership of each of these responsibilities and, if necessary, what the contingency plan is for each.

Vetting vendors (or “What are you agreeing to?”): What are the policies and procedures of the third-party vendor? What are the terms and conditions? What is the corporate climate and goals of the vendor? Is the vendor’s organization a for-profit venture run by venture capitalists with no experience in mental health care? Do they express an understanding, both verbally and in policy, of the ACA Code of Ethics? What limitations, if any, do they place on your provision of care? Are there additional limitations, such as clinicians being prohibited to talk with the news media about their experience using the software?

 

Terms and conditions

As tempting, and common, as it is to breeze through “terms and conditions” pages, this is definitely not the time to do so. Many of the action points I’ve mentioned will involve finding answers not just by asking vendor representatives, but by reading the terms and conditions or contract. What is written there is likely more binding than something that a customer service or sales representative told you. Furthermore, if what is written in the terms and conditions differs from what was verbally communicated to you, that should raise a red flag.

 

Action point

Go through the vendor’s terms and conditions with a fine-toothed comb. Weigh them against your ethics and legal responsibilities to ensure compatibility.

 

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Please note that this is not an exhaustive list. As we increasingly integrate technology into our counseling work, it also increases the number of risk management items on our plate. Thankfully, if handled well, the use of technology can also be of great benefit to our clients and our work with them.

Have questions about how your situation or the use of a specific service is affected by ethics and HIPAA? Send me an email. For a broader overview of telehealth considerations, read the article at bit.ly/TYPTH.

Note that the American Counseling Association does not endorse or condemn the use of any particular telemental health platform. Counselors should always consider the 2014 ACA Code of Ethics, local and national laws, and their own best judgment before using new technologies.

 

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Rob Reinhardt, a licensed professional counselor supervisor, is a private practice and business consultant who helps counselors create and maintain efficient, successful private practices. Before becoming a professional counselor, he worked as a software developer and director of information technology. Contact him at rob@tameyourpractice.com.

 

Letters to the editor: ct@counseling.org

 

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

Facing the fear of incompetence

By Kathleen Smith March 29, 2017

When Karena Heyward and Jessica Lloyd-Hazlett were enrolled in graduate school together at the College of William & Mary, they agreed to split the cost of a hotel room while attending the American Counseling Association’s annual conference. The two counselors didn’t know each other very well, but over the course of the weekend they found themselves engaging in long, authentic conversations about their lives. Returning home, they reflected on the topic of vulnerability, and the two began to build a friendship based on helping each other through difficult moments in the counseling profession and life in general.

Fast-forward five years, and that first step toward vulnerability has flourished into a series of presentations on the very same topic, including a session titled “Connecting to Our Vulnerability in Clinical Practice, Supervision and Self-Care” at the ACA 2016 Conference & Expo in Montréal. Heyward and Lloyd-Hazlett, now both counselor educators, initially worried about how people would respond to their insights and stories about their awkward moments as counselors. Instead they found a welcoming audience that craved conversations about self-doubt, discomfort and authentic connections in the counseling room.

Vulnerability has certainly become a buzzword in the helping professions in the past few years. Big names such as Brené Brown, a licensed master social worker, TED talker and research professor at the University of Houston, have taken theory about difficult emotions including shame and self-doubt and turned the content into best-sellers. But even though counselors’ clients are told that the very foundation of change is to embrace uncertainty and discomfort, there is a scarcity of research about the impact of self-doubt and the nature of vulnerability among counselors themselves.

Self-doubt among counselors, sometimes referred to in the literature as “fear of incompetence,” is associated with higher levels of stress, professional burnout, symptoms of depression, career changes and ethical misconduct. In a 2006 study of experienced therapists, Anne Thériault and Nicola Gazzola found that lack of knowledge was the most commonly acknowledged source of self-doubt. Other factors cited included a lack of strength in the counseling relationship, personal factors and a discrepancy between the counselor’s and client’s perceptions of outcome.

Intrigued by some of this research, Everett Painter, a counselor education doctoral candidate at the University of Tennessee, presented on the topic of self-doubt and similar “emotional gremlins” at the ACA Conference in Montréal. He guided the room in a discussion about the “oughts” and “shoulds” that often get in the way of good work for counselors.

“This kind of self-talk can be damaging and uncomfortable,” says Painter, a member of ACA. “For counselors, this sometimes sounds like, ‘What if I fail? What if this doesn’t work out the way I planned? What if my best isn’t good enough?’ So we talked about a lot of those expectations, where they come from, are they valid and how to manage them.”

Counselors of all experience levels frequently will face new or unexpected moments of self-doubt when working with clients. These moments are often set off by “triggering events” such as difficult content, a developmental plateau or something as simple as not knowing where to go or what to say next in a session. Counselors can respond to such moments either by pushing forward into the discomfort or turning away from the opportunity and detaching.

Lloyd-Hazlett, an ACA member and assistant professor of counseling at the University of Texas at San Antonio, views the ability to face this self-doubt as the definition of vulnerability. “It’s part of the process and, ultimately, it’s going to help us connect better with our clients,” she says. “We always want to have a certain level of uncertainty going into the counseling session. I don’t ever want to think that I know everything about this person’s life or that I know exactly what to do. Retaining uncertainty is essential to what we do. It’s going to feel uncomfortable, but I think counselors need to expect and embrace that, because that’s what we’re asking our clients to do.”

Though scarce, the research hints at the truth of embracing the presence of self-doubt. A 2011 study in Norway reported that extreme confidence isn’t a recipe for good counseling outcomes in part because counselors who are overly confident are less likely to be sensitive and attentive toward clients. Conversely, therapists with some degree of self-doubt who can admit to their shortcomings are more likely to reflect on their work and, in turn, do better and build stronger relationships with their clients.

In a 2009 descriptive study surveying new counselors, Thériault, Gazzola and Brian Richardson reported that the fear of incompetence also inspired counselors to read more, attend additional trainings and seek supervision. Novice counselors also reported that their fears were reduced when they shifted their focus from technique back to the counselor-client relationship. However, negative responses to self-doubt included feeling stuck or reactive, making technical errors and detaching from the therapeutic relationship.

A theory of vulnerability

Vulnerability can be thought about in multiple ways depending on the theoretical framework a counselor uses. The classic Rogerian principle of congruence, also known as genuineness, is a common foundation used by counselors to create and model vulnerability. Carl Rogers saw congruence as the most essential piece of the counseling relationship, suggesting that a professional facade or external presentation that does not represent the internal workings of the counselor would do little to facilitate change.

“We need to be our genuine selves in order to help our clients move toward change,” says Heyward, an ACA member and assistant professor of counseling education at Lynchburg College in Virginia. “Your genuine counselor self might look a little different than who you are in a friendship or who you are as a professor, but not necessarily. Obviously you have to abide by the ACA Code of Ethics and not make the session about you. So it’s a mixture of our professionalism and our ethical and legal obligations, but it’s also about bringing a piece of ourselves to the session.”

Lloyd-Hazlett admits that she was initially hesitant about the inherent messiness that comes with personal and professional growth. “For many years, I wanted to be vulnerable but without all the messiness — [rather] in a controlled way that still felt nice and neat,” she says. “But I have to be willing to stand in the messiness of not knowing exactly how something is going to go.”

Lloyd-Hazlett finds it useful to think about vulnerability from a cognitive developmental perspective. “As we go through life, hopefully we develop increasingly complex ways of understanding ourselves and others and the experiences around us. And that growth happens when we’re faced with experiences that don’t fit into our current schemas,” she explains. “Then we have a choice — do we lean into them, do we take that vulnerable step and try to grow, or do we avoid it?”

Heyward and Lloyd-Hazlett also regard relational-cultural theory (RCT) as a useful framework for viewing vulnerability as a strength within the counseling profession. Vulnerability can help foster an environment of mutual empathy and empowerment between counselor and client that in turn creates an atmosphere for growth and personal affirmation. Emerging from the feminist movement in psychology, RCT proponents teach that fear of rejection may cause individuals to hide personal flaws from others in a relationship, which can lead to disconnection, incongruence and feelings of isolation.

Lloyd-Hazlett and Heyward suggest that this tendency to avoid vulnerability can manifest for counselors as experiencing impostor syndrome, feeling stuck, assuming that a client doesn’t like them or experiencing countertransference. On the other hand, counselors who embrace discomfort, seek supervision and, to use a Brené Brown-ism, “rumble with their story” are more likely to create a counseling environment that successfully supports clients and also encourages growth.

Avoiding discomfort is not always evident as silence or a cold, detached demeanor on the part of the counselor, however. Fear of incompetence can also manifest as a kind of overfunctioning in the counseling room. Perhaps what is most interesting in Thériault and Gazzola’s interviews of both experienced and novice counselors is the consistent observation that self-doubt decreases when the designation of responsibility is clear.

In other words, counselors who assume too much responsibility for client outcomes are more likely to feel incompetent, whereas counselors who see clients as playing a significant role in creating change are more likely to experience reduced self-doubt and be more realistic about what can be accomplished with a client. But letting clients take responsibility and play a role in the therapeutic process often requires a certain level of discomfort, sometimes in the form of missteps, awkward silences and client resistance.

“It’s easy to stay stagnate and not address those issues of avoidance,” Heyward warns. “Sometimes we might not acknowledge the difficult parts of our job, or we compare ourselves to other counselors and find ourselves lacking. Growth is difficult, and we have to normalize that for ourselves and find a supportive community in our field [with which] to talk about these moments.”

Teaching vulnerability

Assuming the role of counselor for the very first time has its share of unavoidable discomforts. But in a classroom where students are graded and expected to perform to a certain level of competence, how do counselor educators think and talk about difficult emotions and awkward moments?

Painter acknowledges that scant space exists for such discussions in a curriculum that is already full for counseling students. Still, there are opportunities. “A good place is to look at counselor disposition,” he says. “It could be simple things like helping a student be able to tolerate ‘not knowing’ and turning that anxiety into curiosity. We have to help students understand that mistakes are going to happen, and it’s usually not the mistake that’s the problem. It’s how we handle those mistakes. If a mistake turns into fear or avoidance, then it becomes a problem.”

Painter also recognizes how high-risk clients are a potential source of self-doubt for student counselors that could be addressed in the classroom. He reflects on his own experiences working as a beginning counselor with clients who were suicidal and his tendency to second-guess himself.

“That’s a really heavy thing to work through, and when you first start, there’s lots of anxiety and worry, even outside the session,” Painter says. “You go back and think, ‘Did I do everything right? Did I assess everything I needed to?’ For me, early on, that was something I had to think a lot about, and it all came back to being a part of my development as a counselor.”

Heyward models vulnerability by being genuine and embracing awkward moments in the classroom, such as when she finds herself going off topic or those inevitable instances when technology goes awry. She also allows students to ask her questions about her experiences. “If they ever get into a situation with a client, hopefully they can go back to what was said in my class and give themselves permission not to feel guilty or shameful in those moments. Because it’s OK to feel stuck. It’s OK to feel like you don’t know what you’re doing. You can take time to breathe through it and figure out a positive way to recover from it,” Heyward says.

Lloyd-Hazlett uses the metaphor of a swimming pool when talking with her students about uncomfortable moments. “You can stand and look at the pool and talk about what the strokes are. You can imagine what it might be like to be in the pool, but at some point,” she says, “you just have to jump in. The water’s going to be cold, and you’re going to feel like you’re floundering. It’s going to feel unfamiliar until you can reestablish your bearings.”

The counseling arena

If discomfort, self-doubt and anxiety are actually signposts for potential growth, how might counselors know when they are moving toward vulnerability and the connections it can foster with clients?

Asked about her own experiences with self-doubt, Lloyd-Hazlett recalls working with a client referred to her by child protective services. The client, “Grace,” was at risk of losing custody of her child. During the counseling sessions, Grace described a history of personal trauma so severe that Lloyd-Hazlett felt tears well in her eyes on multiple occasions.

“I remember feeling completely overwhelmed by how I was supposed to help her given the severity of her concerns and the limited number of sessions we would have together,” Lloyd-Hazlett says. “As a counselor, I felt myself struggle to instill hope in a situation that just felt
so unfair.”

Grace didn’t show for the last few counseling sessions, but she later sent Lloyd-Hazlett a card. Receiving this card brought up a number of emotions, including guilt, for Lloyd-Hazlett. She talked this through with a colleague, who encouraged her to practice self-compassion and acknowledge the positive impact she had had on Grace’s life. “It didn’t fix everything, but during that time in [Grace’s] life, she had someone who cared for her and honored her story,” Lloyd-Hazlett says. “We forever impacted each other’s lives.”

Lloyd-Hazlett uses this story with her students to talk about self-compassion and the self-doubts that counselors may entertain when clients terminate. “I think it is important that we model our successes, failures and all of the stuff that comes in between,” she says.

Heyward says she knows she is moving toward vulnerability when she finds herself embracing moments of opportunity from which she easily could have retreated, such as the conference where she and Lloyd-Hazlett began to have genuine conversations.

“I know I’m living in the arena [of vulnerability] when it feels rough but I’m pushing myself through it. When I come out on the other side and say, ‘Yeah. That was pretty cool,’” Heyward observes. “It’s really that human connection, the connection with a supportive community in our field, or even that connection with myself that I feel when I push myself through those moments.”

 

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Kathleen Smith is a licensed professional counselor and writer in Washington, D.C. She is the author of The Fangirl Life: A Guide to All the Feels and Learning How to Deal. Contact her at kathleensmithwrites@gmail.com.

Letters to the editor: ct@counseling.org

 

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

What gets in the way? Examining the breakdown between research and practice in counseling

By Samantha McMorrow March 22, 2017

It is frequently noted that counselor practitioners in the field do not contribute nearly enough to research and publications, despite calls for them to do so. It is believed that research should inform counseling practice and practice should inform counseling research, yet there appears to be a breakdown between the two.

The counseling literature has presented several common hypotheses regarding why counselors in practice typically choose not to participate in research and publication efforts. These reasons include a lack of time, a lack of reinforcement, a lack of interest and a lack of experience in research.

Lack of time certainly seems like a valid hypothesis. It is undoubtedly a factor with considerable influence, especially for those counselors who are working in agencies where they must secure a large number of billable hours each week. Still, it is not necessarily the prohibitive factor.

Arguments can definitely be made that there is also a lack of reinforcement or a lack of interest for counselor practitioners to conduct research or to publish. For instance, employers at agencies and schools do not have their systems set up to reinforce this work in the way that universities do. However, this in itself is not inhibitive either.

Inexperience in the area of conducting research also seems like a reasonable factor that could impede practitioners’ contributions to research and publications. However, as a practitioner myself, I contend that a looming factor exists that has not been brought to the forefront. Namely, it is just not very easy to be out in the field and have access to channels to conduct publishable research. There are systems in place that are meant to protect our subjects (and rightfully so), but these systems do not lend themselves well to counselors in the field conducting research.

Furthermore, the path for practitioners to follow to get started in research is not always clear. A counselor in the field has access to clients but not necessarily access to university faculty, and without that, the counselor is stopped before he or she even gets started. The counselor could certainly conduct action research in efforts to inform his or her own practice. However, peer-reviewed, scholarly publications will not accept traditional research for publication without Institutional Review Board (IRB) approval, which comes from universities. Furthermore, universities will not grant IRB approval to research proposals without having a principal investigator (PI), and this PI must be a full-time faculty member of the university.

This is the first and most difficult hurdle to get over in practitioners conducting research. The counselor must find a full-time faculty member at a university that is willing to be the PI on the counselor’s research, which is no small commitment. Then the counselor must hope that the faculty member remains at that particular university throughout the course of the counselor conducting and writing up the research. Otherwise the counselor goes back to the beginning again to locate a new PI and submit an amendment to the IRB board to get approval for this change. The whole process can be confusing and intimidating for counselors in the field to navigate.

Subsequently, the process of getting IRB approval once the counselor practitioner has formed a partnership with a PI is detailed and somewhat lengthy, but not overly complex. Both researchers in this partnership will need to complete certain trainings to ensure that they understand issues surrounding protecting their subjects. They will also complete documents displaying the informed consent process that will be used in their research and submit the detailed and complete plan for the research, which may require cultivating further relationships with other departments if advanced statistical analysis is part of the research plan. This relationship can be the lifeline that keeps practitioners involved in the research effort once the analysis of the data becomes advanced and possibly intimidating for the average counselor in practice.

Furthermore, the university should have comprehensive instructions for how the counselor will submit the research proposal for IRB approval. This will be done once the counselor has a PI and a complete plan for how the research will be conducted. In addition, if counselors plan to conduct their research at their agencies or in their school districts, they will need to secure additional approvals from those specific sites.

This is the less understood and more complicated side of research for many practitioners, but it can be sorted through. Cultivating relationships with faculty members in counseling and other needed departments at universities can ease this process.

In a 2005 article, “Collaborative Action Research and School Counselors,” Lonnie Rowell looked at these collaborative relationships, noting that research-oriented facilities were being developed to bridge this gap between university faculty and practicing counselors. In addition, they serve as a model to link counselors-in-training with counselor practitioners for action-based research.

But despite attempts to build stronger connections between researchers and clinicians, another important factor often impedes counselors from engaging in research. A 2010 study by Darcy Haag Granello published in the Journal of Counseling & Development looked at cognitive complexity among practicing counselors over the course of their careers. The study found that counselors do grow and develop over their careers, especially with 10 or more years of experience. However, seasoned counselors may “forget” that they did not always know a particular technique or approach or did not possess their current conceptual understanding of issues or relationships when starting out in practice. This lack of reflection on their own growth could lead them to erroneously believe that they have nothing to research or write about that other counselors do not already know.

Taking some of our own advice as counselors in this situation could prove to be the solution. If counselors are mindful about their practices and really reflect on what they are doing, how they are doing it and why they are doing it, plenty of ideas will follow. Alyson Pompeo and Dana Heller Levitt proposed in their 2014 article, “A Path of Counselor Self-Awareness,” that practicing counselors have an ethical responsibility to self-reflect on their practices. Being a curious observer of your own work as a counselor can lead not only to professional growth but also inspiration regarding needed research and possible publications.

The literature has identified several factors to explain the existing disconnect between counselor practitioners and research efforts. If we are to truly use research to guide practice and use practice to inform research, then a bridge needs to be built that will bring counselor practitioners into the world of research. If we acknowledge the need for developing connections between university faculty and counselor practitioners, plus the need for increased self-reflection in the field, perhaps the gap that must be bridged will end up being not quite so large.

 

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Samantha McMorrow is a practicing school counselor with K-12 endorsement and a licensed professional counselor. She is also a national certified counselor and is certified as a chemical dependency counselor in Alaska. McMorrow currently serves as an adjunct instructor for the University of Alaska Fairbanks in its Counseling Department. Contact her at sgmcmorrow@alaska.edu.

 

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

The healing language of appropriate touch

By Gregory K. Moffatt March 7, 2017

I learned a lesson about the power of touch totally by accident. I didn’t learn this lesson in graduate school, from a book or journal article, or from any professional training. Instead, it happened in the front yard with my son.

He was 8 years old at the time and already displaying the burgeoning need for the independence of adolescence. We were wrestling in the grass, and I intended to tease him by holding him like a baby, thus challenging his independence. I expected him to immediately resist my grasp, but when I looked into his face and talked to him like a baby, he became surprisingly still. He stared straight into my eyes as one might expect an infant to do. I talked to him about when he was little and how I used to snuggle him in our rocking chair in the middle of the night.

“I can stop if you want,” I told him.

“No, that’s OK,” he answered calmly. Almost mesmerized, he stayed in my arms until I was too tired to hold him any longer.

This incident fascinated me so much that, in the tradition of theorists such as Jean Piaget, I used my child as a miniresearch subject, adding this type of snuggling to my son’s bedtime ritual. Several times over the next couple of weeks, just before sleep, I would snuggle him close, caress his hair or rub his back and talk to him about when he was a baby and what it was like bringing him home from the hospital. Each time I got the same response I had witnessed in the yard. It appeared that my son gained peace by letting me touch him tenderly as he lay in bed at the end of the day. If I didn’t snuggle him, he requested it.

After awhile, I decided to see if there was a use for this type of energy in therapy.

Why we touch

If you take a moment to observe people in the public square, you will be astonished at how often they touch — couples holding hands, a friendly back slap between friends, a couple sitting side by side on a park bench leaning into one another, a friend who touches another’s upper arm while listening intently.

Why do we do this? After all, most of the ways we touch are unnecessary for conveying the basic message. We could easily restrict ourselves only to words. Touch augments our conversations, adding garnish and accent to what we want to communicate, but it is also something much deeper.

Without touch, relationships are less than satisfying. Ask any married military couple when one partner is deployed, people who have loved ones in prison or couples whose relationships are dying. The absence of touch leaves us yearning and empty, even if we still hear statements such as “I love you.”

Conversely, watch the reunions of military families, loved ones outside of prison on the day of release or the power of gentle touches between couples who are trying to repair their broken marriages. These touches communicate that “You are safe” and “You are not alone.” These messages are at the very core of healthy human attachments.

There is great precision in touch, and social rules for touch are highly refined. We can touch only certain people in certain ways. At times touch must be invited, but there are other instances when it is expected; to ask for it would be uncomfortable. In my college classroom, it may be acceptable for me to briefly put my hand on a student’s shoulder as I lean over the desk and provide assistance on a test question, but I can’t leave it there very long. And if I move my hand in any direction at all from that shoulder, the touch immediately becomes awkward at the very least, but more likely unwelcome and inappropriate.

Appropriate touch depends on who is touching whom, the genders and ages of each person involved and the relationship between these individuals. Who we touch, what body part touches what body part, how long and with how much pressure — these are the unwritten rules of touch that, under normal conditions, we develop over time in our home cultures. Similar to the way that we manage personal space, we manage touch using unwritten rules that most of us know, yet we would have a very hard time articulating them.

The importance of touch  

We don’t have to look far to discover the importance of touch from the research. Studies going back to the 1800s demonstrated that babies who were not cuddled beyond their basic needs were more likely to die of fetal failure to thrive. They just didn’t grow.

Attachment theory is built on the importance of touch and has demonstrated that extensive face-to-face and skin-to-skin contact between caregiver and child is important for the bonding process. This is the foundation on which all relationships are built throughout life. Infant massage and the soothing effects of therapy animals are just two more recent areas of touch that are well-documented.

Interestingly, many mammals rely heavily on touch to communicate many things. For example, when an elephant mother delivers a calf, every adult female in the herd touches it. They bump up against it with their legs or trunk or in some other way make contact. This communicates acceptance into the herd. If they do not do this, the mother and calf are shunned. For the first several months of the calf’s life, it stays within touching range of its mother. Dogs, cats, lions, otters and chimps all touch with great frequency.

Early in the past century, John B. Watson advised parents to touch their children “as little as possible.” He couldn’t have been more wrong. Humans are social creatures. We have an innate need to interact with others, and touch is essential to our existence. The difference between good touch and bad touch is timing, place of touch, context and purpose. Touch that communicates giving is healthy. Hugging a crying child who has hurt his or her knee is a giving touch. Physical and sexual abuse are selfish, taking touches.

I saw the important role of touch in assessing relationships in the days when I did marriage therapy. Couples in my practice often didn’t touch at all. They sat on opposite ends of the couch or in different chairs. I could often spot the most troubled marriages by the way the couples touched or the way they completely avoided touching. Couples who were deeply committed to salvaging their marriages would touch one another gently, with compassion and healthy emotion, even in the midst of their hurts, resentments and anger. I remained on the lookout for things such as a pat on the arm, an empathetic hug or a natural snuggle against each other on the sofa.

John Gottman has noted that in healthy marriages, touching is one of the vital signs of positive interaction. According to Gottman, people in very troubled marriages may touch, but they grip, cling or touch with force or desperation. At home they withhold touch or touch too hard (abusively), both of which are deeply damaging.

The physiology of touch 

Touch affects us in the right side of our brains. We don’t think it through logically. In both positive and negative ways, we respond to touch instinctively.

In infancy, even before the cerebral hemispheres are fully developed enough to manage language, the brain stem, through the vagus nerve, connects the brain, the heart and the visceral organs of the abdomen. Interesting research known as polyvagal theory proposes that it is this 10th cranial nerve that gives us our “gut feeling” in some situations.

Touch stimulates this nerve, which is wired to the amygdala, the central switchboard of our emotions. When touch is “good,” it can stop the release of the hormones that cause stress. Good touch promotes the development of attachment. Bad touch does the opposite. In either direction, these routes are classically conditioned and become our default emotional responses; they can be changed only with counterconditioning. Consequently, right-brained emotional regulation may be part of the source of many dysfunctions. These dysfunctions serve as facsimiles for the things we really want.

Children touch freely and naturally. It isn’t until they are socially conditioned to do otherwise that they change. Unfortunately, that is when children join the ranks of even relatively healthy adults who desire to be touched but don’t know the most effective way to ask for it. In short, we don’t know how to say, “Hold me.”

Could it be that simple?

The ethics of touch in therapy

We don’t have to look far to find a reason to avoid touch in therapy. Some people don’t like to be touched; touch can be self-serving for the therapist; touch can be misinterpreted and blur boundaries; touch is especially risky with some client populations such as sexually abused children.

But I believe there is a place for touch in therapy. About 10 years ago while I was attending an ethics seminar for child therapists, someone brought up the issue of touching one’s clients. “I never EVER touch any client,” one therapist adamantly averred. Nods and mumbling agreements from others followed.

After several similar comments, I couldn’t keep quiet any longer. I said, “If you choose never to touch your clients, you probably will be relatively safe from accusations of impropriety, but you may also cheat your clients of one of the most powerful tools you have at your disposal.”

I expected scowls and sneers from the 200 or so professionals in the room, but, strangely, my comment seemed to change the direction of the conversation. One after another, people noted how they had carefully used appropriate touch to bring healing and comfort to their clients. In the end, the general conclusion was that touch is a tool, like any therapeutic tool. To ignore it completely may be unnecessarily limiting to one’s practice. A proper touch in an appropriate way at the appropriate time can be comforting and healing.

The ACA Code of Ethics does not prohibit or, for that matter, even directly address touch. With the obvious exception of Standard A.5.a., which prohibits sexual or romantic relationships with clients, one must think through the various ethical implications of the ACA Code of Ethics regarding touch. Avoiding harm to the client (termed nonmaleficence and addressed in Standard A.4.a.) is probably as close as one can come to the issue at hand.

The question we must pose as counselors is whether touch would be helpful or harmful to the client in any given situation. A recent paper from the Association for Play Therapy proposes that touch should be used cautiously, but the key ethical issues are to avoid exploitation, to touch only in ways that are consistent with the therapeutic goals and needs of the client, and to take developmental considerations into account. The paper suggests that the likely interpretation of the touch by the child is also critical. This conceptual approach to touch is consistent with ethical codes from nearly all professional associations.

Therapeutic applications

I decided to work with children early in my career because, while I was an intern, I saw many people still carrying the pain of childhood abuse with them into their 50s and 60s. If bad touch can be so powerful that its effects can be felt for a lifetime, then maybe good touch can be so powerful that it can help heal these hurts.

At the time of the experiment with my son, I thought I was on to something new. Little did I know that this idea wasn’t novel. Donald Winnicott proposed this idea almost 70 years ago when he taught us that touch could be useful in psychotherapy. It is interesting that Winnicott’s research demonstrated that parents don’t actually have to be “great” parents. They simply have to be “just good enough,” to use his words, to meet the child’s needs. In other words, even marginal parents by social standards can be just good enough if they coo, snuggle and lovingly touch their children.

With a parent’s help, I’ve used touch as I did with my son with some of my clients. For example, one of my 5-year-old clients was exceedingly impulsive and hyperactive. I described what I wanted the mother to do and asked her if she would be interested in sitting in with her son during therapy and trying this behavior with him in session.

“He won’t let me hold him,” she said. “He is just too hyper.” But she agreed to try.

After asking his permission (I always respect a person’s right to not be touched — adult or child), we proceeded, and the results were fantastic. As I expected, his response was exactly like my son’s. He relaxed in his mother’s arms for almost 15 minutes without exhibiting a single hyperactive symptom. For this reason, I have given “touching homework” to parents for years. I am amazed at the number of issues that can be addressed with this simple behavior.

Another of my clients was a 15-year-old girl. She was defiant at home and at school, obstinate and bordered on incorrigible. The relationship between this teenager and her mother was tense to say the least. I suggested to the mother that her daughter really needed a physical connection with her. “Try just holding her and see what happens,” I suggested. Like the mother of the 5-year-old I just described, this mother told me that her daughter wouldn’t allow herself to be held, but she agreed to try.

The next week, the mother called to tell me about her experience. “My daughter came home from school and came in the kitchen. I asked her about her day and got the normal disinterested grunt from her. I said, ‘Come hug your mother.’ My daughter said she didn’t want to, but I said, ‘I’m not asking. Mother needs a hug.’”

She continued: “I stood there holding her for a minute or so, initially expecting her to pull away, but she didn’t. I felt her relax, and weakly she put her arms around me too. We stood there for 20 minutes. Neither of us said anything. You never told me how long to do it, so I just kept standing there!”

The mother finally told her daughter that she could go if she wanted, but — as my son did with me — the daughter declined and continued standing there soaking up the human-to-human contact. Her real need was for contact — especially from her mother — but she didn’t know how to ask for it. This teenager had substituted promiscuity, chemicals and other facsimiles because she didn’t know how to say “touch me” in a healthy way. After this interaction, her dysfunctional behaviors began to abate.

I believe that counselors can also garner great benefits by carefully using therapist-client touch. For instance, I have used hand massage with children who have been physically abused. Their body memory has taught them that touch is a painful thing. At first, some of them have trouble interpreting touch. Others, sadly, but consistent with the research, feel very little at all. This is their bodies’ subconscious defense against repeated painful touch.

My goal is to use hand massage as counterconditioning to retrain the body memory of these children to recognize good touch, pleasant connection with another human being and how touch can be a giving behavior rather than a taking behavior.

During these sessions, the child stands in front of me while a parent watches from a nearby chair. I gently massage the child’s hands with lotion as I talk about his or her value as a human being and what a great gift it is to feel another person in a nonthreatening way. The first time or two that I do this, these children often stare at me and remain motionless, having absolutely no idea how to process a touch that feels so pleasant. Over time, they begin to long for it and, as parents practice this technique at home, the children need me less and less.

Conclusion

The number of reported cases of abuse today is far beyond what it was 20 years ago, in part because people know what to look for. People who routinely work with children are trained to look for signs of abuse in children and also in behaviors that they observe between adults and children. Even laypeople have become acutely aware of various forms of abuse.

For the most part, this has been a very good change. However, it has been accompanied by an increased possibility of being sued for abuse or, even worse, charged with a crime and jailed because of abuse allegations. This has led many professionals who work with children (teachers, counselors, psychologists and others) to completely back away and, like some of my colleagues in the seminar, never to touch children in any way. This is a tragic shift. Children long to be touched — as do most of the rest of us.

A friend recently told me that he and his wife had gone to couples therapy. At the conclusion, the therapist asked if she could hug them both. It offended my friend greatly, and he told me he would never go back to counseling. I suspect this therapist either significantly misread cues or, more likely, was seeking to fulfill her own needs. As we all learn very early in our training, it isn’t about us.

But as is the case with any tool in therapy, appropriate touch can be a powerful tool for healing. Just as we have learned over the decades about the use of personal space, we can find differences in the meaning of touch based on who is touching whom, in what way, with what frequency and in what context. So, I propose that counselors consider using touch as one of the many tools in their therapeutic toolboxes.

By the way, my son is an adult now. Recently he came home for a visit. One of his boyhood friends was with him when he came through the backdoor. Even though his friend was watching, my son hugged me long and hard. It was a deep and meaningful hug and, just as when he was little, I was surprised that he held on so long. But I didn’t mind at all.

 

 

For some good reading in this area, I recommend Touch: The Science of Hand, Heart and Mind by David J. Linden, and Touch in Psychotherapy: Theory, Research and Practice, edited by Edward W. L. Smith, Pauline Rose Clance and Suzanne Imes.

 

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Gregory K. Moffatt is a licensed professional counselor, a certified professional counselor supervisor and a professor of counseling and human services at Point University in Georgia. He has been in private clinical practice for nearly 30 years. For the past 18 years, he has specialized with children ages 3-10, and he has worked with infants and babies, providing developmental analyses and consultation with parents and organizations that deal with children. Contact him at greg.moffatt@point.edu.

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 your 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.