Tag Archives: Professional Issues

Professional Issues

Humility wins

By Ellie Rose September 15, 2021

Guess what? If you have ever been in or are currently in therapy yourself, Carl Rogers might not have been a good fit for you. Neither might have Bessel van der Kolk or Irvin Yalom.

The clout that some of these big names in therapy possess is generally well-earned. Who doesn’t appreciate the advances in thinking on things such as unconditional positive regard, trauma or transference that these experts have provided?

As counselor clinicians, we are fortunate to have a wealth of brilliant minds who have gone before us before we ever step foot in our first theories classroom. But it is OK that we are not them. Inside the walls of a therapy office, there is not a single human on this planet who is (or would have been) the best therapist for everyone.

One of the ways that I market myself as an associate-level clinician still working toward independent licensure is this: leaning into humility. Rather than feeling less than those who already have 20 years in the field, a doctorate-level education or an alphabet of special certifications, I focus on fully occupying my space in this little corner of the world where real and meaningful change can happen for my clients.

Humility is powerful. And accepting all that you are and all that you are not is far more of a strength than a deficit when it comes to attracting and retaining clients. Here are some tips to challenge your thinking on fully embracing what you bring to the therapy table:

1) Accept that you won’t be a good fit for everyone; you will be an excellent fit for some. My website FAQs include the question “Why should I pick you?” My answer leads off with “Maybe you shouldn’t …” before I expand on how important it is to find the right fit in therapy.

Do not be anxious about all the things you are not as a counselor; rather, stand tall in exactly what you are. Even if you are just an intern at the cheapest university in America and receive subpar supervision, you still bring an entire lifetime of experience to your clients. Your very person is a gift.

If you had an abusive childhood, bring it. If you face constant household moves from a military lifestyle, bring it. If you’re happily married or are in the middle of a high-conflict divorce, bring it. Are you a parent? An artist? Do you have attention-deficit disorder? Bring it. All the elements of your very person are tools. They are uniquely yours and uniquely perfect for certain clients.

2) Sell the confidence you have in the client, not yourself. During the first intake session, I am very open with clients that I am not necessarily everyone’s cup of tea. I give them permission to fire me. And I validate the challenge they currently face in going out on a limb with a new therapist. I let them know that I have myself had a string of therapists with whom I didn’t really connect before I finally found the right one.

I look them in the eye and say something like this: “If this doesn’t feel right here, or if you aren’t connecting with what’s happening in this room, by all means, let’s talk about it. I might not be the right person for you, but I trust that the right person is out there, and I will offer some names for you that might be a better fit for your needs.”

Clients have responded really well to this. Some tear up just at that moment of me recognizing how scary it is to start dissecting a lifetime of pain with a stranger. Others thank me for giving them permission to be direct. Candidly, there are very, very, very few clients who don’t come back. In being given the freedom to choose what is right for them, clients will typically stop wondering if you might just be a smarmy businessperson trying to make a buck off them.

Imagine going to a car dealership and, right off the bat, the salesperson indicates that they want you to get the most out of your car-buying experience. Then, they acknowledge that they might not have what’s right for you but will help you find the place that does. Wouldn’t that feel great and immediately earn your trust? When you meet with a professional who is willing to recommend that you take your business elsewhere if warranted, that can lead to a substantial leap in rapport building with that person. When you do this as a counselor, it demonstrates to the client that you are perfectly confident in what you do offer and aren’t desperate for their business. Note: Even if you are desperate for their business, the client won’t benefit at all by knowing that.

3) Consider risking your own time. I found the therapist I’m currently seeing after I had interviewed a few others and was feeling weary in the hunt. Someone recommended him to me, and he stood out to me initially for one reason: The first session was risk-free. No, I’m not talking about the industry standard “free 15-minute consultation”; I mean that he offered an entire session at his expense to see if it would be a good fit. The catch was that if clients wanted a second session, they would book it and then pay the fee for the first session as well as the second. If he was terrible, no loss to the client; they could walk away.

I was immediately struck by his boldness and figured he must feel confident about what he was offering, so I gave it a shot. It paid off. I scheduled a second session right away and gladly paid the cost of the first. That was nearly two years ago, and I still see him regularly to this day. It was a marketing technique that served as a really attractive selling point for me as a client. Some variation of this might work for you too.

4) Be comfortable saying, “I don’t know.” You don’t need to be an expert on everything to be a great counselor. You don’t even need to be an expert on anything specific to be a great counselor! While establishing a niche can be a smart career move and might be personally fulfilling to you, it’s also OK to be a general clinician who handles only things such as anxiety, depression and grief. Evidence has consistently shown that it is not the specialized skill that produces the highest rates of success; rather, it’s the therapeutic alliance … and this is something that exists far beyond textbooks and continuing education workshops.

If a client asks you a question that you don’t have the answer to, say so. Offer to find answers for them or with them. If a client wants a particular type of therapy that is not in your wheelhouse, say what you know and what you don’t, and let them know if you are (or aren’t) willing to learn about the type of therapy they are seeking. Most of all, if you are asked for a very specialized service such as eye movement desensitization and reprocessing or brainspotting and you aren’t trained in it, PLEASE don’t pretend that you are and go home to binge on YouTube videos in hopes of faking it. State clearly your scope of practice and stay within it — while constantly trying to improve on your own time.

acidmit/Shutterstock.com

As a consumer, I am deeply appreciative of those experts who admit the limitations of their knowledge and don’t pretend to have all the answers. This deepens my trust in them. My general physician does this, which is why I would endure scheduling inconveniences just to see him; his word is gold. When you are confident in what and who you are, there is no reason to feel threatened by what you don’t know.

I remember the first time I worked with someone who had a chronic medical condition. She was nervous upon intake and asked what kind of experience I had in this particular area. I told her plainly that I knew nothing more than a couple of paragraphs out of my textbook regarding her condition but that I was honored to give her space to process her own pain and deepen my learning alongside her. During the same intake, I tried to defer by offering to find her names of people with special training in that area if she preferred someone with more experience. She declined, saying that she had a good feeling about me, and we worked through several fulfilling months together. This type of scenario has repeated many times in my young career, but I add the following caveat: There are certain situations or disorders that I insist on referring out because it would be detrimental to the client not to have the right kind of training for their needs in those cases. This brings me to my final point.

5) Never stop learning. Mandated continuing education credits are just the bare minimum. Competent professional therapists immerse themselves in the worlds of counseling, psychology and the human condition. This doesn’t mean reading every new self-help book that gets cranked out, but it does mean being diligent about exposing yourself to books, media, people and experiences that will not only deepen your skill set as a clinician but also deepen your own authenticity. This is especially relevant when you are dealing with couples, families and other unique populations.

Our world has been changing fast. Mental health therapists don’t need to know it all or specialize in everything. That would be an impossible feat. But we do need to constantly be updating our own knowledge and beliefs and fully developing our personhood to humbly bring best practices into the presence of our clients.

 

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Ellie Rose is a licensed mental health counselor associate, national certified counselor and private practice business owner in Vancouver, Washington. She works with individuals, couples and families through a therapeutic lens that encourages her clients to lean into reality, find meaning, and develop skills in handling the onslaught of life’s challenges. She is also a mother, reader, writer and speaker who can be contacted at ellie@ellierosetherapy.com or found on Instagram: @ellie.rose.therapy.

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

Counseling while Black

By Lindsey Phillips June 29, 2021

The counseling field is not immune to racism, systemic or otherwise. Before the Association for Multicultural Counseling and Development (AMCD) formed, nonwhite members of the American Counseling Association paid their dues but had limited representation on ACA’s board and senate. A group of counselors lobbied for AMCD (then the Association for Non-White Concerns) to become an official ACA division, but their initial requests were denied. It was a struggle to get ACA’s leaders at the time to recognize the need for and legitimacy of a division that would focus on nonwhite needs, but the hard work of advocates finally paid off when the AMCD division became a reality at ACA’s 1972 conference. (See more about AMCD’s history at multiculturalcounselingdevelopment.org/amcd-history.)

Ebony White, an assistant clinical professor and the program director of the master’s in addictions counseling program at Drexel University in Philadelphia, points out that the counseling profession — like other smaller systems in our society — has largely tried to dismiss the role that racism has played and continues to play in the profession and society as a whole. 

“The counseling profession has mimicked that model of sweeping it under the rug,” she asserts. “So, it’s important that there is first an acknowledgment about what has happened, and instead of … saying, ‘This is what we are going to do about [racism],’ counselors should ask, ‘How have we perpetuated racism in our profession?’ And they should look at what’s been published in the literature and incorporate what has worked [for others] into our profession and our organizations to make change.” 

To shed light on embedded racism and help others better understand it, six Black counselors shared their experiences of working in a predominantly white field and their hopes for the future of the profession. 

Acknowledging racism in the counseling field

Black counselors’ intersecting identities affect the way they understand the world around them as well as how others perceive them. “I live and experience situations as a Black woman every day more than I live as a counselor,” says Noréal Armstrong, a licensed clinical mental health counselor supervisor in North Carolina and a licensed professional counselor supervisor (LPC-S) in Texas. 

As a Black woman in the counseling field, Armstrong says she has encountered microaggressions and racism from colleagues. For example, when serving as the department chair of the counseling program at a liberal arts college, Armstrong informed her colleagues about a Council for Accreditation of Counseling & Related Educational Programs (CACREP) standard needed to support the success of the counseling program. But, she says, her white colleagues questioned her, debated options without her and asked to speak to a CACREP representative, who simply confirmed that Armstrong had the correct information. This encounter left her wondering: “Are they questioning me because they lack confidence in me, because I’m a woman or because I’m Black?” 

The uncertainty in this and similar situations is “what keeps me up at night,” Armstrong says. “That’s what has my stomach in knots. That’s what has me frustrated.” 

Armstrong, an ACA member and the vice president of the AMCD Women’s Concerns group, says she didn’t ask her white colleagues why they felt it necessary to bring in the CACREP liaison because she was tired of having to navigate their defensiveness and denial that race played a role in their actions, even if it may have been implicit. 

White, who was part of the panel for ACA’s webinar “Our Community Gathers: A Conversation With Counselors About Mental Health in 2020” and is president-elect of the ACA division Counselors for Social Justice (CSJ), says she has been “dismissed … ignored, oftentimes not heard and many, many, many times called the ‘angry Black woman.’” 

White, the immediate past chair of the North Atlantic Region of ACA, recalls a microaggression that occurred in her last meeting as chair-elect. During the video call, she was looking down and typing notes from the meeting. A white colleague unmuted to remark, “Ebony, you look so angry. What’s wrong?” White was stunned. She had been labeled as “angry” simply for taking notes.

“The reality is that for some people, your complexion is more important than your intellectual ability,” says Raphael Bosley, a licensed mental health counselor associate who works at Cross Connections Counseling and at Courageous Healing in Fort Wayne, Indiana. 

Bosley, an ACA member, acknowledges that this truth weighs on him. He says that he questions himself and what he knows more than other clinicians might. He also finds that he frequently has to elaborate on the rationale behind his professional assessments to colleagues and clients. Bosley admits that sometimes he is the one who doesn’t trust his own thoughts, which he believes is the result of living in a society that has conditioned him to trust his athletic ability more than his intellectual ability. 

He also finds that incorrect assumptions about his intellect can be a natural barrier with some clients in the therapeutic space — a space that involves understanding the brain. “They’re not used to seeing a Black male face as the one providing the service when it comes to dealing with the mind and emotions. Why? Because Black men are angry. Black men have rage. Black men are not supposed to be able to teach me how to calm down and ground myself,” Bosley says.

The (in)ability to be one’s authentic self 

Diversity is not just about issues such as race, ethnicity, gender and religion; it is also about the way we communicate, notes Tyce Nadrich, an assistant professor of clinical mental health counseling at Molloy College. Black counselors often can’t communicate in a way that is natural or authentic to them around their white colleagues, students and clients, he says. Instead, they code-switch, adjusting their style of speech, appearance or behavior to appeal to a different audience, often as a means of receiving fair treatment.

“The amount of code-switching that I think [Black counselors] are required to do is egregious,” says Nadrich, a licensed mental health counselor and coordinator of clinical training at Balance Mental Health Counseling in Huntington, New York. “It’s exhausting because I know if I communicate … the way that is natural to me … I will not be heard because folks will pretend that they don’t understand me or they’ll just dismiss it as not worth listening to.” 

For example, Nadrich says that when he gets upset, he may not use three- or four-syllable words — despite having them in his vocabulary — because that’s not the way he talks when he has heightened emotions. He expresses his feelings in a more casual register.  

Bosley, who is also an associate minister at Greater Progressive Baptist Church in Fort Wayne, concedes that as a Black counselor working in a predominantly white field, he often feels the need to be polished in the way he communicates, even in situations that don’t require it. He feels like there is a spotlight on him 24/7 because of his race. 

For Armstrong, whose areas of interest include substance use, Black women in academia, multiculturalism, the deaf community and spirituality in counseling, code-switching involves adopting a professional discourse of privilege. When speaking with white colleagues, she often avoids personal or emotional language and relies on data and numbers to convey her message and ensure they are listening to her. 

White, whose research interests focus broadly on advocacy and social justice within the Black community, came to the realization that no matter how she spoke or presented herself, people would have preconceived notions about her. She says she has reached a point where she will no longer code-switch for white colleagues because she knows she can’t control how others perceive her. So, she is her authentic self with colleagues, which may include saying “ain’t,” dropping verbs or rolling her neck. 

The fatigue factor 

Too often the burden of raising issues related to racism and educating others falls on Black counselors. “It’s a constant and common fatigue,” White says. “Because advocacy is such a huge part of my identity, I’m not one of those people that really chooses my battles. I’m always chosen to battle, which is tiring and exhausting.”  

White recalls sitting in multiple meetings and being so upset by what was being said or not said about race and diversity that she spoke up because no one else would. “It’s angering that I have to be the one to address it,” she stresses. White is a licensed professional counselor who developed the Center for Mastering and Refining Children’s Unique Skills (M.A.R.C.U.S.), a nonprofit organization that provides tutoring, mentoring and mental health counseling to children and adolescents, especially in the Black community.

A few days after George Floyd was killed by police in Minneapolis in May 2020, Nadrich noticed many of his white colleagues remained silent. So, he decided to broach the issue himself because he knew that students and faculty were hurting. 

After addressing the issue, a few white colleagues told him, “I’ve been thinking about this for so long, but it’s just so hard, so emotional. I’ve been torn up about what to say.” Rather than sharing those words after the fact, Nadrich, an ACA member who specializes in racial ambiguity, diversity and social justice work, wishes his colleagues had stepped up and spoken out against racial violence and injustice before he felt compelled to. 

The burden to respond to the wider community shouldn’t have been placed on his shoulders, Nadrich stresses, especially considering that he isn’t in a leadership role and because he was already dealing with the trauma and grief of yet another horrific act of racial violence being committed against someone in the Black community. 

Bosley says he often deals with white guilt and the burden of being expected to answer or pose questions about race himself. He never knows which one of those tasks will be required of him on a given day. He finds that being a mental health professional only compounds this obligation to educate others. “You have that uninvited burden that [you] need to take advantage of this moment to educate because any silence is going to give permission for the fire to keep burning. Whether that’s right or wrong or whether I should take that on or not, it’s my reality,” he says.

White stresses the importance of self-reflection and awareness, especially for white counselors. Counselors must unpack their own privileged identities and examine what that means for how they operate in the world, she argues. 

“We often talk in terms of ‘what do white people need to do,’ so it becomes another version of us having to educate white people and tell white people what to do when they can literally just read and watch what’s been put out there,” she says, offering the Multicultural and Social Justice Counseling Competencies as one example. 

Having courageous conversations 

Right after George Floyd was murdered, white students and colleagues asked Armstrong, who serves as the new executive director for A Therapist Like Me, a nonprofit organization that connects marginalized clients with marginalized therapists, how she was feeling. She wasn’t sure how to describe her emotions or even how this latest instance of racial violence was affecting her. 

“For the longest, I wasn’t able to put a word to it because I kind of didn’t feel anything. And I don’t mean that in a cold, shut off, numb way,” she explains. “I mean it more so in that, unfortunately, I feel like I’ve become desensitized to it because racial violence and injustice are so ingrained now in our society. It’s another thing I carry with me as a Black person in America.”

Armstrong wondered if her white colleagues were also bothered by these horrific acts of murder and violence against the Black community. Did they have knots in their stomachs? Did they call their family members to check on them too? 

So, Armstrong asked them a straightforward question: How did they feel about George Floyd’s death? But her white colleagues dodged the question. Armstrong’s frustration over this exchange resulted in her presentation, “Please Stop Asking, Because I Am Not Okay: The Struggle for Black Counselors During a Racial Pandemic,” at the North Carolina Counseling Association’s 2021 conference. Her goal, she says, was to start a serious dialogue on issues faced by Black mental health professionals.  

When it comes to race and social justice, counselors “have to get out of their own way and allow conversations to happen,” says ACA President S. Kent Butler. “Just like what we are trained to do as counselors … we must take ourselves out of the equation and be there as a culturally competent counselor for our [clients] so that we do no harm and [do not] negatively impact the outcome of what’s happening within the therapeutic relationship. We’re trying to help clients move forward,” he says. “That same philosophy also needs to go into social justice work. Counselors need to take themselves out of the equation because sometimes they may represent or be a part of the problem. And if you are indeed a part of the problem, then it is imperative that you take measures to understand your role in it and figure out how you may in fact help elicit systemic change. That’s what self-awareness is all about.” 

Camellia Green, an LPC-S with a private practice in New Orleans, agrees that lack of self-awareness often prevents society and the counseling field from moving forward. “In the field of counseling, we’re taught you have to know yourself and be aware of all the potential areas of countertransference. … Clinicians [are encouraged] to go to counseling themselves … but many people don’t,” she says. 

But this mandate goes deeper than counselors just knowing themselves. It requires them to dig into their racial identity development, which isn’t something they get in a continuing education unit, and to question their worldview, which has been developed over their lifetime, says Green, an ACA member who specializes in working with people who have experienced trauma. 

Bosley advises white colleagues to give themselves permission to be a beginner at discussing race. “Be courageous enough … to talk about it,” he says. “Because the same lump that’s in your throat is in my throat when I gotta bring it up. But I recognize if I don’t bring it up, you’re not.”

“And have the commitment not just to talk about it but then to do something about it,” he adds. 

fizkes/Shutterstock.com

Agents of change 

Counselors are in a prime position to put these courageous conversations into action. “We’re supposed to be leading the charge because from a psychological and mental health perspective, we know what’s at the foundation of [racism] … and we’re the ones who can speak to it and say here’s how you change it,” Armstrong says. “But counselors are not doing that.” 

Incongruity between counselors’ words and actions is a big part of the problem, Bosley stresses. He finds counselors often say they are against discrimination, but they don’t publicly speak out against those who are discriminating, or they claim to be “an agent for the voiceless” until they have to speak for them. Then, they are silent. 

“Don’t just use your voice for me when I’m there,” Bosley says. “Use your voice when I’m not there and your friend … [or] colleague is saying something [harmful].”

ACA began its own crucial conversations when the Governing Council released an ACA anti-racism statement in June 2020. Later that year, ACA created an anti-racism task force, which was chaired by Butler, who was then the ACA president-elect. 

The task force proposed an ACA anti-racism action plan, which includes nine initiatives to help combat systemic racism and racial injustices. ACA also recently formed a commission to help counselors understand ways to move this narrative forward, promote research, provide counselors with anti-racism resources, and incorporate more action-based projects such as providing scholarships to help underrepresented counselors attend conferences, adds Butler, the interim chief equity, inclusion and diversity officer and a professor of counselor education at the University of Central Florida, as well as a fellow of the National Association of Diversity Offices in Higher Education. 

The need for more representation 

Another problem within the field is the need for more diverse counselors and therapists. According to the American Psychological Association, only 4% of psychologists are Black, compared with 84% who are white.

Nadrich was one of two Black men in his master’s counseling program. When the class started discussing race, the students would often turn to these two men and explicitly or implicitly ask them their thoughts, as if they were appointed spokespeople for the Black community. Although Nadrich’s doctoral program was more diverse, he was still the first Black man to graduate from the program. 

When Nadrich, along with Michael Hannon (an associate professor of counseling at Montclair University) and four other colleagues, researched the underrepresentation of Black men in counselor education, they faced an interesting dilemma: How could they incorporate the voices of the eight Black men they interviewed without exposing or “outing” their identities? With so few Black male counselor educators, they feared other professionals would easily be able to identify their participants by the way they spoke. (The resulting article, “Contributing Factors to Earning Tenure Among Black Male Counselor Educators,” was named Outstanding Counselor Education and Supervision Article for 2020 by the Association for Counselor Education and Supervision [ACES] Awards Committee.) 

The counseling profession needs to make itself more accessible not only to nonwhite clients but also to nonwhite counselors. “There is very little intentional mentorship when it comes to including and getting … Black people into the counseling profession,” says White, the recent recipient of ACA’s Dr. Judy Lewis Counselors for Social Justice Award. “There’s this ruse … [that] we have all these things available, but it’s not accessible if it’s not attractive.” 

By way of explaining, White recalls attending a division meeting of one of the ACA regions a few years ago where she was greeted by a room filled with white faces. She remembers thinking how unwelcoming the space could be for other Black professionals like herself. As the counselors started discussing business as usual, White felt compelled to ask why there was so little diversity in the room. Her question was met with silence for a full minute. Then, passing comments were made about how the group had tried to address diversity. “It gives you the message that they don’t care; it’s not really of importance or value,” White says.

Although the counseling profession still has work to do to attract diverse counselors and clients, White is hopeful because she has noticed a shift in Black people becoming more open to counseling. “We’ve done something right where now more people in the African American community are considering [entering the] counseling [profession], are getting counseling and are recognizing the value of mental health,” she notes.  

White is also excited by the increase of Black counselors entering leadership positions: ACA’s current president is a Black man; the presidents of CSJ and the Military and Government Counseling Association (MGCA) are Black women; and the presidents-elect of ACA, AMCD, ACES, CSJ, MGCA, the American Rehabilitation Counseling Association, the National Career Development Association, and the Society for Sexual, Affectional, Intersex and Gender Expansive Identities are Black women.

These individuals “are more than qualified, but also I know that our voting body is very white. And so that gives me hope that they were able to see promise,” White says. At the same time, she worries that this shift in representation at the leadership level could cause a backlash. She says she has already heard counselors asking, “How did this happen?” 

The ongoing journey toward cultural competence

Multicultural training is central to preparing counselors to understand the experiences of people who differ from them as well as to be aware of their own privilege and bias. But Butler asks, “How can we change the narrative on systemic racism when the profession has some counselor educators and counseling programs that do not value multiculturalism or change?” 

Nadrich says that the multicultural education offered in his master’s counseling program was insufficient, which was more of a reflection on the dynamics of the one multicultural course he took rather than on the institution, he adds. The instructor of the course didn’t know how to navigate conversations about race and culture. “It was a very Black/white course. We didn’t talk much about anything beyond issues faced by Black and white people. We barely spoke about other oppressed groups and never spoke about topics like intersectionality,” he says. 

Some counseling programs require students to take only one multicultural counseling course, and as Armstrong and Green point out, one course is not enough to prepare clinicians to be culturally competent. Armstrong believes there needs to be an emphasis on cultural self-awareness and community awareness from the onset and through the entirety of the counseling program because cultural competence occurs over time and through practice. 

Multicultural counseling involves more than an organization or department saying that they value it and tacking on an extra cultural assignment to the curriculum, notes Green, a doctoral candidate in the counselor education program at the University of New Orleans. She would like to see counseling programs incorporate multicultural awareness into all counseling courses, not just one.

Butler, whose research interests include African American men, spirituality and ethics in counseling, and diversity and social justice in counseling, agrees that multicultural training needs to be integrated into every aspect of counseling, including theories, techniques and research. His forthcoming textbook, Introduction to 21st Century Counseling: A Multicultural & Social Justice Approach, which he co-edited with Anna Flores Locke and Joel M. Filmore, embeds multicultural and social justice competencies throughout each chapter and serves as a guide to enhance teaching and help counselors better understand themselves, their clients and the world around them.

“Cultural competence is not an endpoint. It’s not a destination. It’s a journey,” White says. And part of the journey involves self-awareness, especially for white people. “Your whiteness shapes your … interactions. It shifts the room. It takes up oxygen,” she notes. 

And people’s own perspectives shape their awareness of others, she continues. “How you see me is not fact,” she says. “It’s your perception of who I am.” So, counselors must be “aware of what shapes those perceptions and then be able to constantly trigger [themselves] to be mindful of those things when interacting with colleagues, students, clients [and] communities,” she adds.

White argues that the profession needs to figure out a way to make diversity training a requirement throughout a counselor’s professional development. For example, she suggests requiring counselors to take a set number of continuing education credits on anti-Black racism.

Counselor educators should also consider if nonwhite counseling students have the same opportunities as their white counterparts when it comes to mentorship and financial assistance, Butler says. It may be helpful to engage in some self-reflection: Are you overlooking working with nonwhite students on a research project? Who receives graduate assistantships in your department? Do mainly white students receive the more desirable graduate assistantships? How do you think nonwhite counseling students perceive you as their instructor or feel about the ways they are treated within your courses? 

Early in Nadrich’s career as a counselor educator, he wrote in his academic profile that he was passionate about mentoring and supporting students of color. Another colleague approached him and asked if his statement would dissuade white students from working with him. Although Nadrich was an untenured new faculty member, he declined to change his profile because he wanted to uphold his own beliefs. He told the colleague it would be OK if some white students didn’t come to see him because of his statement. 

Nadrich points out that his colleague’s comment contained two incorrect assumptions. First, it assumed that white students didn’t already have a large number of staff, faculty and professionals who looked like them and shared similar experiences to go to for support and resources while students of color did. Second, it assumed that Nadrich stating his passion for working with students of color was harmful even though stating other professional preferences, such as a passion for behavioral neuroscience or socioeconomic disparities, would have been viewed as less threatening.

Bridging the gap 

Bosley says it breaks his heart when people still insist they are colorblind anytime the specter of racism is raised. They may think they are making him feel better by uttering such statements, but they are in fact saying that they don’t see race rather than addressing it directly. The message they are sending is that “they don’t even think enough of me to try to see me,” he says. 

Nadrich teaches his counseling students why it is harmful to always look to underrepresented groups to explain themselves, the injustices they face and what others should do to help. “You have to figure out what it means to be you and how you can start bridging the gap between your identities and the identities of the people you serve and work with,” he says. 

If Nadrich is working with an adolescent woman of color, for example, then he knows his identity as a person of color might help bridge the gap between them. But he also recognizes that his identity as a man could widen the gap depending on the client’s own history and experiences. “I have to be cognizant of that,” Nadrich says, “and say overtly to myself, ‘How am I going to make sure that I’m bridging across gender in this situation?’”

And in speaking to his white colleagues, Nadrich asks, “Are you willing to be affected by my lived experience? Are you willing for my lived experience to be relevant to yours or necessary to yours when it doesn’t have to be?” 

Nadrich is grateful for the colleagues who don’t avoid the issue and demonstrate a willingness to bridge this gap. “If you’re willing to be affected by it, now you hear me,” he says. “Now you know what’s going on with me and people like me.”

 

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@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.

Therapy services: Money talk

By Stephanie Cox June 22, 2021

Here’s a topic that professional counselors love to talk about and don’t feel awkward at all bringing up: Money!

Let’s get it out there and acknowledge that in the counseling profession, money isn’t fun to talk about. That’s because the nature of our business is a sensitive one. We’re not selling the public “goods,” we’re providing a service. And this service isn’t a run-of-the mill one like doing your taxes or grooming your dog. We’re working with you to heal some of the most painful parts of your life. We’re helping you cope with tragedies. In some cases, we’re trying to keep you alive. It’s because of the sensitivity of the work we do as professionals that we can often feel “bad” for charging you money for this service.

Among my therapist friends, we frequently talk about our fees and all that comes with it. We go into this profession to help people. Still, reality comes in and we have to balance our hearts with our checkbooks. We have to reconcile that in order to use our skills, we have to pay our bills.

Speaking of bills, as therapists, we sure do have a lot of them. Some standard ones: student loans from undergrad, grad school or both, the costly liability insurance required to operate, the licensing fees, the required continuing education courses, our HIPAA (Health Insurance Portability and Accountability Act) secure phone lines, email and practice management software, marketing and advertisement costs, office space rent, material for clients — things add up. This doesn’t begin to touch the normal living costs we all have to consider such as other bills, mortgage payments, health insurance and food.

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As counselors, we know that we need to make money to live, but that guilt when we have to raise our fees or charge a client after a particularly emotional session is real. Something I try to remind my therapist friends (and myself) of is that at the end of the day, we are a business. It feels gross to say that because what we do feels like more than that.

However, when I think of all the people who are doing such hard work and seeing such positive change in their lives, it helps to reassure me. To stay in this business and stay available to use my skills to help people who are changing their lives for the better, I have to keep my lights on and pay my bills. I love what I do and am glad that I can keep doing it. I worked hard for these skills so that you can work hard to get better.

Even so, this question can be and needs to be explored in deeper context: Why isn’t mental health therapy more affordable?

Why isn’t mental health therapy more affordable?

This is an important and complicated subject. To start, as stated above, therapy is a service just like any other. Therapists are doing a job, and to do that job, they need to be paid a fee. But why can that fee seem so high?

If you think about the structure of therapy and compare it with similar industry services — such as CPAs, attorneys and other professionals whom you pay for providing a service rather than a product — it begins to make sense. Instead of selling a product, we’re selling time and expertise.

We don’t question why attorneys charge so much for their time. We understand that they had to go to school to become the best at their craft. In turn, we pay for access to that knowledge. The same holds true for professional counselors and other therapists. We had to go through extensive training and schooling (and accumulate substantial debt) to master the skills to serve you in the office.

Even so, this argument can feel shaky when we apply it to therapy because there is an assumption that therapists should be more compassionate to the needs of the population. Good mental health should be a human right, so why not cut people a break and provide these services at discounted rates so that more people can benefit for longer? After all, this is mental health — shouldn’t everyone be given the tools for better living?

Without a doubt, mental health services should be accessible to everyone and finances being a barrier is a societal ill. What isn’t always understood is that therapists also fall victim to this conundrum. We do not benefit from society not valuing mental health services.

Believe me when I say we wish we could provide all of our clients with a reduced fee. What makes this impossible is that most therapists whose fees are the highest are in private practice. There is no product to sell to make their profit, so it is their time and service that become their only source of income. Without a salary and a steady paycheck from a corporation, they rely on their fees alone to cover the costs of running their business, as well as the leftover income to pay their bills and support their families. This puts them in a bind.

What can be done?

This bind is one that could be remedied if mental wellness and mental health were prioritized by our society. For example, if the government had programs that supported mental health professionals and supplemented our incomes, we could reduce our fees and more people could be seen without us requiring assistance to live. If programs were created to provide mental health allowances to individuals so that services didn’t have to be paid for out of pocket, that would be another great way to allow therapy for all. If insurance companies raised their rates and paid a livable reimbursement rate for therapists (more on that later), more of us would accept insurance and our clients could pay less.

I hate the way that mental health is devalued in our country. Those of us who are therapists got into this field because we want to help people, and we’re aware there are whole swaths that we can’t reach. If we did, we couldn’t be in business for long, and then no one would benefit. I am hopeful though that change is coming. The more vocal people become about wanting mental health rights, the more likely we are to see them given.

If you’re looking for a professional counselor or other therapist and finding that the finances are not working out, I encourage you to ask if the therapist is able to offer a sliding scale or reduced fee. Until then, I know it’s a bummer seeing that price tag. We don’t like it either.

Why many therapists don’t take insurance

It’s true that you can find therapists in private practice who take insurance, but it won’t always be the case. Previously, I touched on some of the reasons behind the fees that therapists charge. Now, I’m going to explain why we don’t always accept insurance as a way to cover those costs.

If a therapist wants to accept insurance, there is considerable time and cost associated with this form of payment. To begin with, therapists have to apply to insurance companies in order to take their insurance. This process is complicated and lengthy. It can take anywhere from four months to a year to get approved. An insurance group will approve a therapist only if it recognizes a need in that area for the therapist’s services that isn’t already filled by another provider. It is common to be denied because there are already enough providers in the therapist’s area.

If you are among the chosen, the process gets more complicated from there. You must sign a contract with the insurance group and agree to a fee schedule. While I can’t share the specific fees that insurance companies pay to therapists, it is almost always less than what a therapy session costs. In fact, it can be anywhere from one-third to one-half of what a therapist normally charges for their services.

Additionally, therapists are not actually paid when they render the service to the client. After having the session, therapists must complete a time-consuming process of medical billing to submit a claim to the insurance company requesting pay for the service provided. Depending on a number of factors, the insurance company can deny the claim. In that case, the therapist has then worked for free. If an insurance company does approve the claim, they pay the therapist weeks later.

Mental health therapy agencies and group practices that have specific medical billing and coding teams have the time to dedicate to this complicated process. Providers who work with these agencies are also usually paid a steady salary so that the delays in insurance payments are not felt as acutely. That’s why you are more likely to find providers that take insurance in these settings.

In contrast, private practice therapists usually forgo these challenges because the cost in time and money does not make for the most efficient business practice. Self-pay among private practice therapists is simply a lot easier. In addition, insurance companies require therapists to diagnose clients in the first session and submit that to the insurance company or else services will not be covered. Not all therapists (or clients) agree with this practice of requiring a diagnosis, so this is another barrier to accepting insurance.

No surprise, this is a broken system. There should be alternative affordable systems in place to make therapy accessible to all people who want it and feasible for all therapists to provide it. Some therapists try to lower the barrier of finances by doing pro bono work or offering reduced-fee sessions.

Reduced fees and pro bono work

Therapists are encouraged by their codes of ethics to provide a portion of their sessions at a lower cost or, if possible, to offer some services pro bono (free).

Because we have limits to how many services we can provide at a reduced fee or for free, there is usually a cap on the number of clients who can receive this benefit at a given time. This depends on the individual therapist’s finances and choices, but most therapists will have a line on their business page stating whether they are open to “sliding scale” fees. This means that therapists will work with clients to determine what they can afford.

Sometimes this sliding scale comes with stipulations such as a set number of sessions or a set frequency, but talk with your therapist about what they can do for you.

Pro bono services work in a similar fashion. Therapists can provide some services for free, either directly or in a more generalized setting such as providing services for a charity, school or church.

If a therapist does not currently have any open slots for reduced-fee work, don’t lose hope. Whenever those clients graduate or phase out, those spots may become available again, so be sure to keep asking your therapist to be put on a waitlist for such services.

If you are a therapist and don’t currently provide these services, I highly encourage you to reconsider. I offer several reduced-fee spots on my caseload and am glad that I do because, as stated previously, therapy should be accessible to everyone.

Money talk as therapists is not fun, but it is necessary. If finances are a barrier for you to receive services, I encourage you to be honest about that with a potential therapist. We truly do want to help, and most therapists will work with you to get you the help you need. Now that you’ve been given some insight into the financial workings of this field, I hope you will have the confidence to seek help if you’re a potential client and to provide help if you’re a practitioner.

 

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Related reading, for counselors:

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Stephanie Cox is a licensed mental health counselor in Florida specializing in therapy with children, families and adults with mild to severe mental health and relational issues. She holds a degree in psychology from the University of North Florida and a Master of Science degree in counseling psychology from Grand Canyon University. Contact her via:

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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.

Pandemic telehealth: What have we learned?

By Bethany Bray April 27, 2021

Last year, safety precautions and restrictions brought on by the COVID-19 pandemic in early spring caused most counselors’ in-person interactions with clients, colleagues and students to come to an abrupt halt. To continue treating clients, many clinicians shifted to conducting counseling sessions through video or other digital media. For some practitioners (and clients too), it was a “like it or not” change with a steep learning curve, especially if they had not been offering any telebehavioral health services prior to the pandemic.

Now, some counselors are beginning a return to in-person sessions or a blend of in-office and virtual sessions. What did practitioners learn — about themselves and the process of counseling — while using and adapting to telebehavioral health over the past year-plus? Did counselors pick up anything that they might apply to in-person work with clients if and when they return to a traditional office setting? From Zoom fatigue to eye-opening lessons in resilience and humility, there are stories to tell.

Counseling Today recently collected insights from American Counseling Association members who have used telebehavioral health to counsel clients through some or all of the past year. Read their thoughts (in their own words) below.

 

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Gale Brunault is a licensed mental health counselor (LMHC) with a private practice, Honoring Endings After Loss (HEAL), in Amesbury, Massachusetts.

When the pandemic first hit and all physical contact with the outside world came to a screeching halt, I remember asking myself, “How am I going to continue serving clients in a meaningful and productive manner?” After all, I only knew one way to conduct business, and that was face to face. 

Using telehealth for the first time and/or phone calls as a vehicle for serving clients was extremely challenging in the beginning. I no longer had the physical presence of observing the individual, which meant
I couldn’t “time” my response effectively. Between that and dealing with technical strains, my focus shifted, and I found myself distracted by issues that had nothing to do with client needs. Not only did it become a challenge for me to stay on task, but I was expending more energy than I wanted to each session.

Over time, the program I chose became more efficient and user friendly, which afforded me the chance to focus more on improving my skill set. I no longer had concerns that telehealth was diminishing the client-therapist relationship. In fact, the process was proving to be encouraging. 

Using telehealth has taught me that anything is possible. Though initially I had concerns that it may not be a favorable vehicle for working with grief and loss, telehealth proved to be a solid match for those unable or unwilling to leave home, particularly following a major loss. One of the most difficult tasks for bereaved individuals is living in a world without their loved one. Being able to stay home and receive therapy can be extremely helpful, particularly when initially all you want to do is isolate and hide. 

Many of my clients have asked to continue using telehealth. Some look forward to coming back to the office. Either way, I will be available. 

Some of what I’ve learned since using telehealth is that while the body reveals a lot about a person, so too does the face. There is a certain level of intimacy involved when you are only focused on someone’s face. I have become more in tune to a client’s eye movement, the pauses they take, how they play with their hair, the thinking process and word choice, etc. Though all of these pieces were evident during face-to-face time, having less to look at can deepen one’s observation and assessment of client patterns and behaviors.

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Julie Hine is a licensed professional clinical counselor at a private practice in Albuquerque, New Mexico.

Having been in the field of counseling for almost 30 years, telebehavioral health has not only offered another opportunity for professional and personal growth, I also believe it has served as a catalyst to break down barriers for access to mental health services. While an entire world lives through a pandemic, common themes have risen among almost all persons. People are experiencing a gamut of emotions, often while they feel alone and alienated from loved ones and the world around them. People are feeling hopeless and helpless, riddled with feelings of nervousness. So, what happens when the entire world is feeling like this? Telebehavioral health (or telehealth) has provided an answer.

Telehealth has given access to mental health services to all persons … where [they] live. Especially in rural communities, such as those in New Mexico. Many people who live in smaller communities or on reservations do not always have access to mental health services, whether it’s because there are no counselors in their area, or they have no means of getting into an office on a regular basis. Telehealth has opened the doors for people to access services, no matter where they live, no matter if they have a car and no matter if they have gas for that car. If a person has access to a phone or computer, they can get in-person help, without actually being [there] in person. I can now provide counseling for someone who lives four hours away without even leaving my home.

Throughout all of this, communities of people have recognized the importance of positive mental health, and I have realized that self-care is a crucial gift to ourselves as counselors. If you’re a counselor providing telehealth, remember to stand up frequently, sit up straight, take breaks, rest your eyes, eat healthy snacks and, most of all, be kind to yourself. During sessions, encourage your clients to also be kind to themselves. Emotions are heightened, so remind them not to overanalyze everything, to ask for support when needed, learn to be proactive instead of reactive, and remember to laugh because nothing is permanent, and we will get through this. People are resilient.

As a clinician in the mental health community, I plan on continuing to provide telehealth services, even when returning to an office becomes a reality. That way, I can continue to help individuals, no matter the circumstances. However, I must admit, I look forward to leaving the chair in my home office and sitting in the same room, face to face, with the individuals I serve. Nothing beats human contact and smiles of hope.

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Justin Jordan is a licensed professional counselor (LPC) and certified substance abuse counselor who treats mental health issues and substance use at his private practice in Salem, Virginia. He recently completed his doctorate in counselor education and supervision at Virginia Tech and will join the faculty in the mental health counseling program at University of Wisconsin-Parkside this fall.

Transitioning to telecounseling in the spring of 2020 was an easy decision based on my family’s situation. I learned very quickly that my biases had limited my ability to see the potential of telehealth software in connecting with my clients and reducing barriers to attending sessions [prior to the pandemic]. I never intended to use telehealth software for counseling and strongly believed that direct presence with clients was essential for the relationship and perceiving my clients’ needs. While I would still prefer to safely be in their presence, I now see that with the loss of presence, what is gained is a flexibility for both the client’s and counselor’s home/work lives and a chance to see clients where they are most comfortable.

In the context of COVID-19, clients felt safer meeting online, and so did I. Beyond the context of the pandemic, clients with children had [fewer] barriers [for] adapting their child care for sessions. Clients were able to meet more easily during their lunch breaks at work without commuting. And some clients who were very anxious about going into public were able to be seen in the comfort of their home. Many of these benefits will hold true once physical distancing is less of a concern, which is why I would continue telecounseling if I were not closing my practice to start a faculty position this fall.

Additionally, as a humanistic counselor, I have always tried to diminish power dynamics and have relationships based in mutuality with my clients. Telecounseling taught me that asking clients to enter my office [in person] always comes with some authority, as having to log in to sessions from my office/bedroom, often with the sounds of young children in other parts of the house, erased that [imbalance]. I had to relinquish some of the boundaries I have worked hard to create with my physical counseling space, which came with discomfort but also a beneficial humility on my part that I was in less control — of technology glitches, distractions in my home and the state of the world. I also see that my clients often feel freer expressing themselves when meeting with me from the comfort of their own couches or other parts of their home. I have consistently received feedback from my clients that there are aspects of telecounseling that have improved the process.

One of my main suggestions to counselors and students who must choose to integrate telecounseling into their practice is to have a solid plan for backup communication when technology issues occur. Realize that host platforms have issues sometimes, clients’ hardware can have problems, your hardware can have problems, and software or internet connections can crash. Also, many clients need to be coached on how to use the technology properly, and they need to have access to a usable digital device (which most clients in my private practice do).

I also think that humility, honesty and authenticity remain key counselor traits with telecounseling, which means acknowledging when the technology is creating a barrier or problem in communication.

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Stephanie Brookins is an LPC in private practice in Columbus, Georgia, who specializes in the treatment of posttraumatic stress disorder (PTSD).

I was initially resistant to the idea of telehealth and would not have imagined that it might become a permanent part of my practice. I realize now that much of my negative view was shaped by the discomfort of the unknown and not having considered how the initial stress might resolve. My first experience with telehealth was several years ago with a client who had temporarily moved to another part of the state and wished to continue individual therapy with me. Issues regarding privacy and internet connection and overall discomfort with the technology led to a negative experience for [me] and the client, and I referred her to another provider. 

What I’ve found in the past year is that after the initial adjustment to technology and change, it’s relatively easy to forget that we are connecting via technology. However, that’s not always the case. Due to schools being closed, some clients have issues with child care and will have to interrupt their session to help their child with school or manage some parenting crisis. Other clients have plumbers dropping by or pets that want attention. Initially, some clients would attend telehealth sessions in bed, half awake and dressed in pajamas. This necessitated discussions about boundaries and structure that could be uncomfortable. 

There have been some unexpected benefits of telehealth. Clients with chronic health issues and periodic flare-ups would have to miss appointments in the past [because] they were unable to drive and physically get to appointments. Now we’re able to meet online and just limit the amount of time if needed. This has led to a decrease in last-minute cancellations. Some clients are able to access care now when transportation or time have presented limitations for them in the past. 

As an eye-movement desensitization and reprocessing certified therapist, I’ve had to adapt the mode of bilateral stimulation used in processing. I’ve been surprised at the work clients have still been able to do, even [with us] being physically apart and using self-tapping in place of eye movements or theratappers. 

With environmental safety precautions, I’ve been able to maintain in-person counseling as an option for clients during the past year. Some people are not comfortable with using technology, need the human connection of seeing a therapist face to face, or do not have reliable internet connection, so it’s been important to me to continue to offer that option. I imagine I’ll continue to adapt to my clients’ needs and will continue to provide both telehealth and in-person therapy.

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Nicole Sublette is a licensed clinical mental health counselor and certified hypnotherapist who also serves as a social justice advocate, as a public speaker, and as an anti-racist educator for the state of New Hampshire.

I have learned that telehealth makes treatment more accessible to people who might not otherwise be able to engage in treatment due to scheduling or distance. I have not found too many differences between telehealth and in-person [counseling] in my practice. However, I will have increased gratitude for in-person sessions in the future. There will not be trouble with sound or video. There will not be the interruption of therapeutic flow due to technical difficulties.

Through the past year, I have learned about my own resilience and adaptability. This was momentous for me, specifically in these uncertain times. Previously, I would not qualify myself as tech savvy. Using telehealth and adapting to an online format for treatment has expanded my growing edges and helped me to also lean into my own capacities. In uncertain times, it helped me to also learn my strengths and ability to adapt. Also, techniques that I previously thought could only be done in person, such as cognitive processing therapy for PTSD, can also be done via telehealth.

I have adapted [to telebehavioral health] by asking more somatic questions of clients and discussing how the body is handling symptoms. Asking questions about what I was previously able to observe with my eyes has opened up dialogue in ways I would not have imagined. Asking increased questions can decrease the potential for avoidance for both the therapist and the client.

To my counseling colleagues, I would say conducting sessions via telehealth gets easier with time. Utilizing the same rapport techniques that one uses in person can be very helpful with telehealth, such as asking open questions and conveying authentic curiosity. Also, address the elephant in the room about any discomfort for both the therapist and the client. Share about how you can learn together. Process together any discomforts one might have with using telehealth, then work together to create a plan to ease discomfort. Humor is also a great way to ease tension.

I absolutely plan to use telehealth in the future. It is my hope to do a mix [of telehealth and in-person counseling]. Currently, I am one of the very few BIPOC (Black, Indigenous and people of color) therapists in my state. Nationally, BIPOC [constitute] about 4% of practitioners in the mental health field. Telehealth has made therapy accessible to BIPOC folx around the state. I am able to provide treatment to clients who would otherwise not be able to travel to my office due to the distance. With continued escalating events of police brutality, therapy for BIPOC has been very critical.

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Laura Sladky is an LPC and licensed chemical dependency counselor who works as a school counselor in Dallas.

Through video/telehealth as a school counselor, I have learned that being able to quite literally see into someone’s world offers such insight into the way they organize and carry out their daily lives (pets, plants, family relations) as well as their sense of self. In short, telehealth offers the opportunity to know clients differently and inadvertently know their world beyond my office.

Throughout the past year, I have been acutely aware of my sense of justice and desire for equality. Of course, these traits are essential when developing a therapeutic alliance and conveying unconditional positive regard to a client, but on a systems and global scale, I have become painfully aware that individual problems do not exist in a vacuum, and change requires advocacy. In sum, this year was the “real life” representation of many theoretical concepts like Maslow’s hierarchy of human needs. Humans cannot be thoughtful, insightful and self-reflective if their basic needs (food, shelter, safety) are not met. Individuals’ autonomic nervous system becomes activated under threat and chronic stress (winter storms, unemployment, death of a loved one, fear of contracting a disease) and, consequently, higher-level thinking at the prefrontal cortex level is inaccessible. Moreover, I have learned about the inextricable link between humanity, trauma and the imperative nature of sensory integration. While the past year has been exceptionally disruptive and devastating in a variety of ways, our ability to make sense of our experiences and enact pro-social connection predicts our ability to recover — and not become further traumatized — by our experiences.

This year, with the social/political climate, I have asked more intentional questions to check in regarding media coverage/social media and how that has impacted the individuals I work with. Whether we are consciously aware of it or not, our brains become easily biased. Hearing a negative headline can begin a downward spiral and, before you know it, everything can seem awful. It helps me understand the level of distress knowing how much screen time people are exposed to.

In addition, helping individuals sift through what is in and out of their control (acceptance vs. change skills) and actionable steps to take to alleviate distress has been paramount. Asking questions is so important because you don’t know what you don’t know. In equal measure, not having the client in full view can impact nonverbal cues (bouncing leg, posture, etc.) but further reiterates the importance of tracking, asking questions and helping clients be aware of their bodies/ feel safe in their bodies.

It is so refreshing for those we work with to understand that we also experience undesirable situations (Zoom glitching, our pets interrupting calls, when we miss the client’s meaning) and witness how we cope in the moment. Radically open dialectical behavior therapy tells us that making mistakes is pro-social, helps us feel connected to others and eases our nervous system. For counselors who are working to connect or finding this challenging, I think briefly self-disclosing your own minor inconveniences helps build rapport with clients.

Our lives were unceremoniously upended, leaving us to confront grief and ambiguous loss daily and, in fact, it is weird even after a year. However, weird does not inherently mean bad. One of the best ways to work through the weirdness of Zoom life is to acknowledge it. In doing so, counselors can validate this experience, give it a name (awkward, different, etc.) and help facilitate the client management of these feelings.

I think offering a variety of mediums for therapy is the future of our profession, and I plan to make myself accessible through a variety of settings.

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Michael T. Greelis* is an LPC, licensed marriage and family therapist and approved clinical supervisor in private practice in Herndon, Virginia, who has seen adolescents and adults with mood and anxiety disorders and other life challenges for 25 years.

On March 17, 2020, I made a complete transition from in-person, face-to-face [counseling] to videoconferencing for my practice — about 30 sessions per week. The change was immediate for all clients from March 18 on. Based on the Centers for Medicare & Medicaid Services and [National Institute of Allergy and Infectious Diseases Director] Dr. Anthony Fauci’s statements, we either converted to virtual visits or risked our health and that of our clients if we continued in-person meetings. I saw that my clients and my colleagues reflected a high value on treatment by making this complete transition on very short notice. I learned that therapists and clients can make a major transition work with commitment and flexibility and that the work itself — face to face in person or on video — is what matters.

I immediately adapted my approach so that I focused on content rather than the medium and avoided incorrect assumptions (some cognitive behavior therapy on my part). I assumed that my clients and I would make teletherapy work and that we’d pick up on the requirements for that. What works is a focus on substance over style and letting [your counseling] style evolve as necessary.

My overall impression of videoconferencing for therapy (we call it teletherapy in Northern Virginia) is very positive. Prior to the COVID-19 crisis and emergency measures, I was a skeptic. On March 17, 2020, it was clear that I had to either migrate to teletherapy entirely or stop practicing. My ability to adapt to that change and the receptivity of my clients to make the change had a reciprocal positive effect. Every client in the transition remained in treatment, and clients who started during the virtual-only period followed a course of treatment similar to that expected during in-person times.

Post-COVID-19, I plan on a hybrid approach combining in-person with teletherapy based on client conditions and needs. This is both my preference and that expressed in very clear terms by my clients.

My advice to counseling colleagues is to focus on the work and client needs, pay extra attention to your experience of videoconferencing at the outset with each client, and ask clients how they think treatment is progressing. Also, use the special features of the medium. I’m always surprised to see that none of my colleagues use a green screen to project backgrounds more appealing than the same wall, office, etc., for every meeting. I am pushing myself to have a set of images, videos and text passages on hand [to use in sessions], if they’re beneficial. And I’m learning how to insert materials from the internet or from my files in real time during sessions.

*Greelis is advocacy chair for the Northern Virginia Licensed Professional Counselors and was involved in NVLPC’s recent survey on the use of telehealth by LPCs during the COVID-19 pandemic. See the survey results here.

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Rob Freund is an LMHC and an assistant professor at Nova Southeastern University in Davie, Florida, who also works in private practice with couples and individuals.

Prior to the pandemic, I had received training in telehealth counseling and conducted it across state lines in Florida and New York, where I was dually licensed. The format therefore wasn’t too strange for me, but the frequency of my utilizing it was more challenging. I, like many, experienced “Zoom fatigue” from using telehealth communication platforms exclusively. I learned that more so than usual, pandemic notwithstanding, I needed to separate myself from my workspace and engage in deep, deliberate self-care in order to bring my best self to the therapy space. Spending time in meditation and communication with nature became essential for me. I also realized just how much value there is in shutting off the computer and disconnecting so that I can better reconnect with my clients.

One aspect of this work that I do plan to bring to my in-person therapy is the utilization of technology in the therapy space itself — using my tablet to bring up materials for discussion, real-time sharing of resources, using digital drawing tools to portray and invite collaboration with the client. It has provided an opportunity to evolve the tools I bring into the space.

We rely so much on being in the room with clients that the absence of many shared experiences of the space — behavioral cues of seeing the full body, the opportunity to have natural eye contact patterns, smell and other sensory cues — is at times disorienting. What’s fascinating is to experience the human capacity for adaptation. I noticed myself beginning to have heightened attention to the sensory information that I did have access to — facial cues, speech patterns and nonverbal speech cues — and adjusting my work accordingly. We can be remarkably resilient, and I found clients to be the same.

I do think there are concrete things that counselors can do to facilitate adaptation to this new model of conducting therapy. Firstly, developing grounding strategies and preparatory work for before and after the session is personally important to the clinician, particularly if you are working/living in a smaller space. Secondly, I would encourage counselors to pursue training in emotional communication and recognition of nonverbal behavior. The Paul Ekman Group has excellent training resources for recognizing micro- and subtle expression displays, and books like Unmasking the Face: A Guide to Recognizing Emotions From Facial Expressions (by Paul Ekman and Wallace V. Friesen), Emotions Revealed: Recognizing Faces and Feelings to Improve Communication and Emotional Life (by Paul Ekman) and What Every Body Is Saying: An Ex-FBI Agent’s Guide to Speed-Reading People (by Joe Navarro and Marvin Karlins) are excellent for expanding one’s nonverbal/emotional acumen.

Like any tool, telehealth has its pros and cons. The portability and absence of commute often benefited [me] and my clients. However, I noticed that for some, there is increased value in experiencing therapy outside of the home environment.

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Grace Hipona is an LPC at NeuroPsych Wellness Center P.C. in Fairfax, Virginia, who holds a doctorate in counselor education and supervision.

The pandemic has challenged me to view the counseling process from a different perspective. It has challenged me to be more flexible and to reassess my own coping strategies. It has tested my resiliency and ability to continue helping others while I navigate my own circumstances. The process has given me the opportunity to truly connect with clients, since we are all experiencing the pandemic at the same time. Even though we may not discuss the pandemic directly, I am aware of how we may be impacted. I also continue to evaluate and monitor my own thoughts and emotions so the client’s perspective is primarily front and center, and I help support them based on their lived experiences.

Prior to the pandemic, my overall impressions of telebehavioral health were neutral to negative. However, since March 2020, I have only used telebehavioral health to provide counseling services. Through this time, I have shifted my thoughts and feelings, and I now have a more positive outlook on telebehavioral health. I appreciate the convenience and flexibility it provides. My clients appear to have similar feelings and thoughts about telebehavioral health. I have had several mention that they likely wouldn’t have participated in counseling if this opportunity was not available.

Our practice continues to assess and reassess the role that telebehavioral health plays in counseling. We have a provider meeting at least once a month, and since the beginning of the COVID-19 pandemic, we consider all the benefits and challenges. However, we have not made any long-term decisions about the role of telebehavioral health. Being able to partner with health insurances will be a guiding factor. If health insurances continue to cover telebehavioral health, it will provide flexibility. Moving forward, I believe in our field, and across other fields, providing opportunities for either or both [in-person and telehealth] will be one of the lasting impacts of the pandemic.

To better connect with clients, my counseling approach has shifted over the past year to being more directive or straightforward. In other words, if I am at all uncertain about how I am interpreting a client’s thoughts or feelings, I directly ask. For example, I say, “I am not sure how you are feeling or what you are thinking right now. Do you mind explaining it to me further?” Generally, clients have been appreciative of the opportunity to clarify their perspective.

To emit levels of sympathy, empathy and understanding, I find myself amplifying my facial expressions, nonverbal cues and verbal statements in general. For this reason, I believe remote counseling can be more exhausting. Reflexively, I place more effort in self-care so I can recover and refuel for future sessions.

The use of formal assessments or evaluations has also become more integral in my counseling process. Aside from the initial intake, I found using formal brief assessments intermittently beneficial to help support my clients. I also verbally make a concerted effort to ask evaluation-related questions such as “How are you feeling today — better, worse or about the same?”

 

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The future of telehealth

Insurance coverage has expanded and regulations regarding telebehavioral health have been relaxed in many states out of necessity during the COVID-19 pandemic. Will these changes remain as pandemic restrictions are loosened and many helping professionals return to in-person office settings? Find out more in our online article “The future of telehealth: Looking ahead.”

Also be sure to read this month’s “Risk Management for Counselors” column on page 8 of the print version of Counseling Today‘s May magazine, available for ACA members to download here.

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Action steps to learn more

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

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

The future of telehealth: Looking ahead

By Bethany Bray April 22, 2021

During the COVID-19 pandemic, many counselors adapted to counseling clients via video while in-person appointments were not possible or severely restricted. Correspondingly, insurance coverage expanded and regulations regarding telebehavioral health were relaxed in many states out of necessity.

Now, as pandemic restrictions are being loosened and some helping professionals return to in-person office settings, many counselors are wondering about the future status of telebehavioral health. Will all the “old” regulations suddenly return, or will changes introduced during the pandemic remain long term?

Lynn Linde, the American Counseling Association’s chief knowledge and learning officer, says that a number of factors point toward telebehavioral health remaining a viable option for counselors in the months and years ahead.

“People have discovered that there’s a tremendous desire on the part of clients to continue telehealth, and that’s what will drive this,” says Linde, who is also a past president of ACA. “I think states aren’t going to be quick to go back to the way things were. … Counselors traditionally have not received a lot of training in telebehavioral health. We all have had to learn how to live a Zoom existence and get work done remotely — and people’s perspectives [about telebehavioral health] have changed.”

Regulation of telebehavioral health for professional counselors varies state to state. Prior to the pandemic, a handful of states had statutes that allowed for the use of telebehavioral health under counselors’ scope of practice. During the pandemic, other states relaxed and expanded the regulations surrounding telebehavioral health via executive orders from governors of regulation boards, Linde explains.

Now, more than a year later, state legislatures in several states are considering omnibus bills that would allow for the use of telehealth permanently, Linde says.

“There has been a lot of push by [state] governments for health insurance companies to cover telehealth. I think now that the efficacy of telehealth is being demonstrated, insurance companies are going to view things differently,” Linde says. “As telehealth expands, they’re going to have to rethink some of their policies around reimbursement. Some of them already are, and some states are also putting pressure on them to change. This is a huge change in the field of medicine and mental health. It’s partly counselors and clients becoming accustomed to doing things differently, and regulators and insurance companies noticing the difference.”

Telebehavioral health is also a major aspect of the interstate counseling compact project that has been gaining momentum this spring. The compact, an initiative that would allow counseling practice across state lines, is finalized and will take effect once 10 states pass legislation to adopt it. In March, Georgia was the first state to pass such legislation, followed by Maryland.

Language in the agreement ensures that any state that adopts the compact will allow counselors to use telebehavioral health permanently, Linde says. Launched in 2019, the compact project is a partnership between ACA and the Council of State Governments’ National Center for Interstate Compacts. Once a 10th state adopts the compact, it will become live and those 10 states will form its governing body.

Leaders involved in the project, including Linde, expect that the compact will reach the 10-state threshold in the summer of 2022. There is a “critical mass” of states — more than 20 — that have shown interest in joining the compact in the coming year, she says.

“It’s not a question of if we will have a compact but when,” Linde says. “We’re really seeing progress, and there is excitement [among those involved].”

Convenience and improved access

The increased use of telebehavioral health among counselors over the past year-plus has shed light on its benefits as well as how it can improve access for clients who face barriers to in-person treatment, Linde notes.

“The pandemic, in many ways, showed the deficits in our mental health delivery system,” she adds.

Telebehavioral health has allowed clients who struggle with transportation and other barriers, as well as those who live in communities or areas without a counselor, to access counseling more easily. It has also benefited college students who had to return home — often to a different state — when many campuses closed in the spring of 2020 and shifted instruction online, Linde notes.

“Necessity is the mother of invention. When everything locked down, everyone was scrambling on how to continue services. One year later, [telebehavioral health] is no longer a one-off. It’s become more of a way of doing things,” Linde says. “Counselors are trained to do face-to-face, in-person counseling. That’s our training. But we’ve seen that it is possible to pick up on some of those cues that we usually depend on seeing in person [during sessions]. It’s not the horrible situation that a lot of counselors thought it would be it. Actually, it can be very positive, and there can be benefits and time savers both for counselors and clients.”

Photograph of a person sitting with a laptop in front of them and several paper notebooks, taking notes

 

  • Read more on this topic in a feature article, “Pandemic telehealth: What have we learned?” in Counseling Today’s upcoming May magazine.
  • Find out more about the ethical standards for telebehavioral health and other important information on ACA’s COVID-19 resource page here.
  • Also see Section H, “Distance Counseling, Technology, and Social Media,” of the 2014 ACA Code of Ethics at counseling.org/ethics.

 

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

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