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Professional Issues

It’s time for a financial change in counseling

By Derek J. Lee June 23, 2022

There is a broad awareness that we are in the throes of a mental health crisis in this country. Open discussions of increases in depression, anxiety and suicide attempts are common among news outlets and social circles, while the real impact is being felt in the homes of those suffering every day. When discussing the mental health crisis, the typical focus is the increasing incidence of mood disorders and suicidality. What has been consistently and systemically overlooked is our lack of providers. This article is going to delve into the financial reality that contributes to our mental health crisis.

When someone needs a counselor, the counselor is “worth their weight in gold.” Why is it then that counselors may be the most underpaid, advanced-degree medical professionals in this country? Recently, I was talking to a couple of peers who are also professional counselors, and one stated that a new professional they know was just offered a job starting at $29,000. The other shook their head, looked down and then back up in frustration, and stated, “Last week when I was driving through Michigan, a fast-food place was offering $1,000 sign-on bonuses and $18 an hour.” We will get into the whys later, but this is the disparity that is also a reality in our field.

By the numbers

Let’s start by looking at how much counselors actually make. According to the CareerExplorer website, the average salary of a mental health counselor in the United States is around $35,642 per year. The bottom 20% are placed at $29,800, whereas the top 20% are placed at $57,100. CareerExplorer also offers breakdowns of the average mental health counselor salary by state, with Tennessee coming in at a low of $31,000 per year and Alaska being at the top of the chart with an average salary of $63,900. My current home state of Ohio shows an average salary of $44,100 for mental health counselors, with the bottom 20% at $31,800 and the top 20% at $65,100.

CareerExplorer appears to offer the most accurate of the pay ranges I found in my search because it focuses on master’s-level mental health counselors providing direct care services in a variety of settings. Several other resources show salary ranges of $33,000-$75,000, with some going as high as $100,000, but most of these blur the lines by including Ph.D.-level psychologists, testing, and a number of services that significantly skew the average salary.

As professional counselors, we know what it takes to enter this field, but the general public does not. Educational and experiential requirements can vary somewhat state to state, but for many of us, it starts with a 60-credit-hour master’s degree, which also typically includes an unpaid 100-hour practicum and a 600-hour internship. State boards, the National Counselor Examination, background checks and ongoing supervision get you in the door. Then you must continue with supervised hours, continuing education, training in models and additional hurdles. These are not bad things; they build our body of knowledge, increase standards for the field and lend us credibility. They also come at a cost of both time and money, which are valuable commodities in our field.

With an understanding of the rigor and length of the educational requirements of clinical counselors, and the additional information of what the typical salary range is, how does this compare to national averages? According to the U.S. Bureau of Labor and Statistics (2021), the average salary for someone in the U.S. with a master’s degree is $77,844. The average salary for someone with a bachelor’s degree is $64,896. These are not starting salaries, but average salaries, just as the average salary for a master’s-level counselor in Ohio is $44,100 and nationally is $35,642. If you reference Northeastern University’s Education Pays Chart, you are able to see where counselors fall.

Implications

Now that we have established that counselors are significantly underpaid, it is important to explore likely implications.

The first implication is burnout, which affects the field twofold in that it shortens careers significantly and impairs providers who continue to actively work. The average counselor has a productive life span of 10 years before burnout is almost inevitable.This does not account for increased stress in our society due to the COVID-19 pandemic, politics or a volatile social environment.

Why does average salary impact burnout? Because the lower the income, the more stress is created. According to Matthew Killingsworth (2021), drawing on 1,725,994 experience-sampling reports from 33,391 employed U.S. adults, the results demonstrate that both experienced and evaluative well-being increased with income. Factors include being able to pay student loans, afford housing and not worry about how a master’s-level medical professional will pay for a child’s sporting or extracurricular activities. It also extends professionally, in that increased reimbursement allows for lower caseloads, increased preparation time, and more funding for training and professional development.

This creates a natural transition to the second implication — the link between better care for the professionals and improved patient care. If we are supporting our professionals through decreasing caseloads to more manageable levels, increasing purposeful training and promoting more professional development, we are going to see improvements in patient care. Research demonstrates that when using researched-based interventions, we see significant increases in client care, but also accountability in the profession. Effective care means improved outcomes and reduced durations of service, which not only means happier people, but also healthier and more productive people.

A third implication is the impact on recruiting and retaining quality professionals in our field. Unfortunately, in the past decade we have witnessed a tremendous number of counselors shifting to other professions and fields. Some have moved to aligned fields, such as school counseling or education, and many have moved to much different venues, including real estate, IT and software development.

As mentioned previously, we are often experiencing a productive span of 10 years after an education that required seven years to achieve. This is, by any standard, a very poor return on investment. These moves are frequently the result of burnout and the desire to improve their financial situation.

In a similar vein, it can be difficult to attract individuals to the field when it is widely known how stressful and underpaid the profession is. This is even more complicated, as in the past two years we have seen an unprecedented spike in need, with such limited resources and an extended training period.

If the field is to continue to recruit the best and brightest, it also has to offer them competitive wages. If the goal is to increase our recruitment, that point is even more important. It goes beyond simple difficulty and pushes into societal values and ethics when highly educated counselors are starting at significantly lower salaries than individuals with entry-level positions in business.

As we consider education, recruitment and wages, it is also important to examine this topic in terms of social justice. Counseling is a field that has disproportionately high numbers of women and marginalized populations, while also demonstrating disproportionately low wages. Nothing has been found in the literature to demonstrate a causal relationship, but the correlation is difficult to deny. With a workforce that, according to the U.S. Bureau of Labor and Statistics (2021), is 73.3% female (compared to the U.S. average of 46.8%) and nearly 40% nonwhite (compared to U.S. averages of 22%), this is a field composed largely of minoritized workforce populations.

The fact that counselors are, by nature, helpers and are often willing to give freely of their time does not mean that they should be treated unfairly as a labor force. This lends to revisiting the education required and a comparison with other professions.

The fact that a counselor has completed a 60-credit-hour master’s program is significant, as most master’s programs require 30 credit hours, with “more complex and in-depth programs” increasing this to as much as 40 credits. According to U.S. News & World Report (2021), the average master’s program requires 32 to 36 credit hours. It is also important to note that most programs do not have an intensive internship requirement like that of counselor education.

If we look at similar practitioners, such as nurse practitioners, a master’s in nursing is a minimum of 36 credits, and a doctorate in nursing is an additional 36. Another line of work that could be considered similar would be a physician assistant. To become a physician assistant, a master’s degree is required, which is a standard three-year program, as well as 2,000 clinical hours. As these three have the most similarities regarding education and clinical setting and resulting in jobs that include diagnosing and treating medical disorders, these are my base of comparison.

As we have already established, the average counselor in the United States makes $35,642 per year, while the average annual salary for nurse practitioner is $114,510 and the average annual salary for physician assistant is $115,390. It seems quite reasonable for the counseling field to be funded in a manner that allows for paid internships, starting wages in the $75,000 range, and average earnings to be in the range of a nurse practitioner or a physician assistant.

The solution is simple: to align the reimbursement rate for counselors to a rate commensurate with that of similarly educated professionals in the field of medicine, which would also realign income to that of similarly educated professionals in all fields. Well-run mental health offices carry much of the same overhead as other medical and professional offices, including clean and inviting environments, support staff to assist with clients and administrative needs, commercial-grade furniture to handle heavy use, and solid construction that also provides sound deadening for the space. Offices need technology, which continues to expand with electronic health records and testing, and the electronic health record systems themselves, along with constant upgrades and IT support.

The idea of moving the average counselor salary from $35,642 to the wages discussed above would seem to require reimbursement to triple, but it would not. If we were to share the burden, both by focusing on increased efficiency and increasing reimbursement, these changes could be implemented with a reimbursement increase of approximately 80% as opposed to an expected 300%. This would provide the opportunity for clinicians to decrease caseloads slightly, provide better care and make a wage commensurate with their work, education and ongoing educational requirements.

Ask yourself this question: When you are seeking help from a counselor for your child or significant other who is suicidal, do you want someone who is on the top of their game, or someone who is struggling to make ends meet and may be nearly as stressed out as those they are serving?

ashadhodhomei/Shutterstock.com

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Derek J. Lee is the founder and CEO of Perrysburg Counseling Services and The Hope Institute. In addition to clinical work and administrative roles, Derek is finishing his Ph.D. in counselor education at Ohio State University and teaches in the Department of Clinical Counseling and Mental Health for Texas Tech University Health Science Campus.

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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.

Getting triggered as a counselor

By Lindsey Phillips May 3, 2022

The term countertransference has been discussed and debated since Sigmund Freud first argued that it was something taboo — a personal obstacle that would harm the therapeutic relationship. Today, counselors acknowledge that countertransference is inevitable. They are human and prone to having their own issues emerge, often without them even realizing it. Sessions can trigger past experiences, unresolved issues, implicit beliefs and an array of emotions. 

“There’s no way counselors can really extricate themselves and their personality from the [therapeutic] process,” says Peter Allen, a licensed professional counselor (LPC) and integrated care supervisor at Brightways Counseling Group in Madras, Oregon. “That doesn’t mean we’re always talking about ‘me’ [in session]. But it means that I’m acknowledging that I’m coming in with a lot of baggage and perceptions about things that have to be managed.”

Jessie Guest, a licensed clinical mental health counselor and supervisor in North Carolina, views countertransference through Charles Gelso and Jeffrey Hayes’ definition, which she summarizes as an “inevitable, unresolved conflict that leads to misdirected feelings toward a client that can be triggered by the content of the session [or] the client’s personality or appearance.”

Although countertransference is more widely acknowledged today, counselors, especially those early in their careers, often struggle to disclose it, Guest says, because they are either unaware of it or they fear it will make them appear incompetent to others in the profession. Having negative feelings about a client can also make counselors question themselves — both as people and professionals — because they believe that as helpers, they should always be happy and nice, adds Guest, an American Counseling Association member whose specialties include play therapy, trauma and countertransference.

When she was a new professional, Guest worked in a play therapy room with a young child who yelled, kicked and threw objects throughout the session. This behavior triggered something in Guest, who says she is not a “yeller” herself. She felt her body tense every time the child lashed out, and she could sense her anxiety increasing. She worried that the other counselors in the building would hear the child screaming and think that Guest was a “bad” counselor who didn’t know what she was doing. 

After the session ended, Guest reflected with her supervisor on what had happened and realized that her anxiety stemmed from her own discomfort with yelling and her insecurities of being a new counselor. It wasn’t really about the client.

How counselors handle their countertransference “can either be helpful or hinder the therapeutic relationship,” says Guest, who is a registered play therapist and supervisor. “We all have experiences, and people are going to poke those experiences. … But it’s our job to be aware of it and take the time to reflect on those things so it can be helpful instead of harmful for our clients.” 

Recognizing when you’re charged 

Even if counselors realize that countertransference is inevitable, it can still be challenging to recognize when it is happening in session. From her research, Guest, a clinical assistant professor of counselor education at the University of South Carolina, found that counselors who work with children with challenging behaviors often struggled with unrecognized countertransference. 

The clients’ anger and emotional outbursts frequently caused counselors to become charged and engage in unhealthy therapeutic behaviors themselves, she says. Some counselors scheduled certain clients less frequently or ended sessions early. Others would walk out of session when they became too triggered and leave the child alone. Counselors also recalled talking more flippantly with colleagues about certain challenging clients. Guest has published and presented on countertransference, including at the 2021 ACA Virtual Conference Experience. 

Debra Chatman-Finley, an LPC in private practice in Montclair, New Jersey, says she often notices her own physical reactions when she’s triggered in session with a client. Her body may tense or she may find herself squirming in her seat or tapping her foot on the floor. 

Signs such as those let the counselor know that “something is happening between you and that client other than the typical therapeutic interactions,” she says. “And that is when the onus is on the clinician to examine it because whatever that is, it’s going to come through in the form of a question, the way you phrase a question” or a nonverbal response. 

Chatman-Finley, an adjunct professor in the Silver School of Social Work at New York University, had a Black client tell her that when they mentioned they were a graduate of a prestigious university during a session with a white therapist, there was shock written all over the therapist’s face, although the therapist didn’t verbally express it. The therapist was probably well-intentioned and didn’t even realize they were responding nonverbally, Chatman-Finley adds. 

Sometimes clinicians understand countertransference only at its most noticeable level, such as becoming angry or teary-eyed in session, observes Allen, an ACA member. But avoidance, annoyance and impatience are other potential signs of countertransference, and those, he says, “are much harder to recognize in yourself in the moment and can easily go unnoticed … because they can be subtle and insidious.”

When counselors aren’t sure whether they are charged or triggered in session, they can use the PERMS technique, suggests Alex Castro Croy, an LPC and licensed addiction counselor in Denver. The acronym stands for checking in with one’s physical, emotional, relational, mental and spiritual self. 

Possible physical reactions include feeling fidgety or experiencing cold sweats or elevated blood pressure. Emotional states could involve feeling angry or numb. The relational domain refers to how counselors feel toward themselves and their clients; they may feel incompetent or second-guess themselves, for example. The mental domain is based on one’s thoughts, values and beliefs about oneself such as “I’m not a good therapist” or “I’m messing up.” With the spiritual domain, counselors may question their meaning or purpose; they may wonder if they are cut out to be a counselor and may contemplate leaving the field. 

Being overly supportive is yet another form of countertransference. A counselor might make exceptions for a client because they are fond of them, or they may verbalize to a colleague that they “like this client.” Should something happen along those lines, the counselor needs to explore it further, advises Castro Croy, the owner, director and lead clinician at Life Recovery Centers, a group practice with offices in the Denver metro area. What is it that they like about the client? Is it that the client reminds them of their brother, mother or best friend? The counselor needs to be mindful of this feeling, he says, and consider the ways that it could be productive and counterproductive for the client. 

Clinicians should also pay attention to their ability to remain objective with specific clients, Guest adds. Are they getting overly defensive about a client or finding themselves oversharing in session? Do they refrain from challenging a client (when needed therapeutically) because they overidentify with the client or because the client reminds them of someone who is close to them? 

Implicit biases and beliefs 

Countertransference is often an indicator of implicit beliefs, attitudes and biases, says Chatman-Finley, who teaches workshops on racism, microaggressions and racial trauma. It reveals “what’s going on with you unconsciously that may be in conflict with what you believe or think consciously and how [that] might be showing up in your clinical work,” she explains.

All clinicians have beliefs and biases, and those can enter the therapeutic relationship without clinicians realizing it. For example, as a Black woman, Chatman-Finley believes in Black people getting their education, but she thought she could separate this personal belief from the needs of her clients. Her strong unconscious beliefs surfaced, however, when she was working with a Black mother who wasn’t interested in attending college. Chatman-Finley recalls her body tensing up when the client mentioned this, and her therapeutic questions became skewed in the direction of the client attending college. 

She thought she was being supportive and helpful. School wasn’t a priority for the client at the time, however, so the client perceived the questions as judgmental. Chatman-Finley didn’t recognize the countertransference at first, so it negatively affected her work and caused a rupture in the therapeutic relationship to the point that the client stopped showing up for sessions. 

Chatman-Finley told her supervisor that she was struggling with this particular client and couldn’t figure out why. She assumed it was because the client just wasn’t ready to do the work. But her supervisor challenged Chatman-Finley to examine her own role and responsibility for the rupture: What was she focused on in treatment? What questions was she asking the client? What happened in session right before the client stopped coming? Although this line of questioning was uncomfortable for Chatman-Finley, it forced her to reflect on how her own beliefs and internalized thoughts on race and education were sneaking into session in subtle ways. 

Chatman-Finley reached out to the client and scheduled another session where she admitted that her own beliefs about education had gotten in the way of the work that the client needed and wanted to do. 

One strategy Chatman-Finley and Allen find helpful in identifying potential bias and countertransference is to ask themselves whether they would do the same thing with a different client. “If the answer is no,” Allen says, “then you’re probably in the terrain of unrecognized countertransference.” 

He offers an example: In couples therapy, the counselor learns that the woman had an affair, and the clinician feels judgmental. In the next session, a different couple comes in, but this time the man has been unfaithful, and the clinician thinks, “Well, he must have been lonely.”  

“That’s evidence that the counselor is off,” Allen says. “If I’m seeing the same situation in drastically different ways in different clients, that’s a sign” of countertransference.

It’s not the client, it’s me 

Chatman-Finley recalls learning in graduate school that the client’s issues were the only thing present in the room, so if something felt uncomfortable, it probably had to do with the client, not her. But later when she started seeing clients, she learned that this wasn’t true. Her own thoughts, feelings and beliefs could also enter the session and affect the therapeutic relationship. 

It’s easy for clinicians to slip into assuming that the negative energy in the room or the therapeutic rupture is because of the client, Chatman-Finley says. Counselors can find themselves thinking, “I guess that client is just not ready to do the work,” when in reality, she explains, it may have been something the clinician said or did in session that is the true source of the problem.

Allen acknowledges falling into this type of thinking when he was working with a client who had posttraumatic stress disorder. The client wasn’t applying the skills and concepts they were practicing in session. Instead, the client continued to show up and recount stories that depicted him as the hero, so Allen found himself getting annoyed and dreading sessions with the client. This frustration and annoyance spilled into the way that Allen phrased his clinical notes, writing, for example, that “the client refuses to practice interventions at home” rather than “the client displays difficulty in practicing interventions at home.” Despite the subtle signs of countertransference, Allen still thought his annoyance was being driven by the client’s lack of motivation. 

insta_photos/Shutterstock.com

In discussing the client with his clinical consultation group, Allen eventually realized that he was annoyed with himself, not the client. His annoyance came from anxiety related to his own internal pressure to “heal” the client and his insecurities about not being competent as a counselor. His colleagues also helped him realize that the client was making progress in his own way: He trusted Allen and continued to show up for sessions.

To help counselors determine if the problem lies with them or with their client, Castro Croy recommends that they do a “chicken check-in” — a story that originates from his work helping a man who was employed in a grocery store deli. An older couple would regularly visit the store at lunchtime and ask for free samples, a distraction that led the employee to burn the chicken he was cooking on multiple occasions. The third time that he burned the chicken, he yelled and cursed at the couple, and they filed a complaint. 

Castro Croy worked with the client to put his frustrations in context: Had he lost his job because he burned the chicken? Had the grocery store reduced his work hours? Had his employer docked his pay? To all three questions, the client answered “no.” 

“Then, it’s not your chicken,” Castro Croy told him, meaning that it wasn’t worth him getting dysregulated over a chicken that didn’t belong to him. (Castro Croy discusses this story and the intersection of the professional and human selves in more detail during his recent TEDxCherryCreek talk.)

Castro Croy, an adjunct professor in the Department of Human Services at Metropolitan State University of Denver, now uses the “not my chicken” story both to remind clinicians to stop and assess the situation when they feel themselves getting charged in session and to help them set personal boundaries. If it’s not their chicken, counselors can let it go, but if it is their chicken, then they can temporarily bracket it, refocus on the client and process their own feelings after session, he says. 

Managing countertransference

The moment that counselors assume they have countertransference under control is when they are most vulnerable, Allen asserts. “There are days I’m going to miss it even if I’m looking for it,” he says. “And there are days I’m going to see it coming from way off. If I know I am seeing a challenging client at 2 p.m., I need to get centered about that.” 

So, Allen continues, clinicians must constantly check in with themselves and ask self-reflective questions: Do I not realize countertransference is happening? Do I notice it but it’s not an issue? Is it affecting the decisions I am making in session? 

“Recognizing it doesn’t automatically make it good either,” Allen notes. “If you recognize it and don’t do anything about it, it can still be harmful.”

Castro Croy advises counselors to first do the PERMS check-in during session to recognize if they are feeling charged. If something is affecting them, after the session ends, they can delve deeper into the countertransference they experienced by doing what he calls a “functional analysis of self.” This involves carefully contemplating their reactions and any potential underlying reasons for the countertransference (i.e., reflecting on what’s “their chicken”). 

Allen agrees that checking in with his physical, emotional and mental state is helpful. Throughout sessions, he’ll notice if he’s holding tension in his body or if his thoughts are distracted. When he feels triggered, he relies on the same mindfulness techniques that he often teaches his clients. For example, if a client is yelling, he continues to listen to them, but he also focuses on his own breathing. This helps him stay in the moment with the client and avoid having his own feelings affect the session.

Research supports that emotion regulation interventions such as mindfulness can be a good management strategy for dealing with countertransference when paired with psychoeducation about the client’s disorder or mental health concern, Guest notes. Her research study for her dissertation confirmed this finding. Guest created an intervention that combined psychoeducation on child communication, especially for children who have endured trauma, with a mindfulness-based practice to reduce negative countertransference for counselors working with children who exhibit externalizing behaviors such as yelling and hitting. 

The counselors in the study discussed Erik Erikson’s stages of psychosocial development, the functions of child behavior and the theoretical tenets of child-centered play therapy developed by Garry Landreth. Guest also had the counselors use the mindfulness intervention RAIN (developed by American psychologist Tara Brach): 

  • Recognize the stress. (“The child kicked me, and I feel my blood pressure rising.”) 
  • Allow for feelings to be expressed. (“I feel frustrated, and I’m not sure how to react.”) 
  • Investigate what is happening for the counselor and the client. (“What is the worst part of this for me — the yelling or feeling insecure? What was the child trying to communicate by kicking me?”)
  • Nurture with compassion for self and client. (“I’m human, and it’s OK if I don’t know what to do in this moment. The fact that the client is exhibiting this behavior with me means they are trying to show me something.”)

Guest also asked the counselors to practice breathing exercises (such as the mindful minute, during which they count their breaths before and after each session), body scans and guided meditations daily to make them less reactive in session and allow them to be controlled in how they respond to clients. 

By doing multiple mindfulness practices, we are providing ourselves more of a space between stimulus and response. We are less reactive,” Guest says. So, she explains, instead of responding immediately to the client’s negative behavior, counselors have the space to manage and redirect their countertransference into a healthy reaction, such as considering what the child is trying to communicate by the action, rather than just ending the session quickly out of frustration. 

Taking the issue to supervision 

Successful management of countertransference involves good supervision, Chatman-Finley emphasizes. This means the supervisor normalizes countertransference as a part of the therapeutic process and challenges the supervisee to reflect on how they are feeling in session, she says. 

“Supervision can’t just be about the client,” she explains. “It has to include an examination of the therapist’s thoughts and beliefs about the client because there could be something else that’s unconsciously going on with the therapist.”

Chatman-Finley has a peer supervision group in which each member presents a case and the others in the group pose challenging questions so the counselor can consider how their own feelings, beliefs and experiences may be affecting the therapy session. Group members may ask, for example, “What is it like for you to work with that client? What are your goals in working with this client? Why did you go down that path of questioning or treatment with the client? What happens in your body while working with the client?” 

Allen notes that not all supervisors are prepared to discuss countertransference or even know how or when to bring it up. This can create problems for clinicians if they are struggling with how to manage their countertransference. If supervisors don’t handle this correctly, there is potential for them to inadvertently reinforce the message that should counselors have a reaction or feelings toward a client, it means they are bad at their job, he says. (See Allen’s Psychotherapy.net article “Countertransference: How are we doing?” for more on the social solutions to countertransference, including supervision and consultation.) 

Castro Croy is aware that counselors, especially new professionals, are sometimes hesitant to broach the issue of countertransference. So, when he notices a supervisee stumbling in the way they discuss a client or if they are overly cautious when crafting a question, he’ll prompt them by saying, “OK, what’s the question underneath that one? What are you really asking?” or “OK, now ask me that question as a human in the profession, not as a counselor.” This opens the door for them to explore and discuss those times when they feel charged in session. 

Guest recalls having a supervisor who normalized countertransference without even mentioning the term. When discussing how she felt stuck with a specific client, the supervisor simply asked her, “Do you like your client?” 

She was initially surprised by this question. Of course she liked her client! But then she let the question sink in for a few moments, and she considered whether she did actually like this client, what that even meant and why she felt the need to like all of her clients. 

“It was a great question,” she says, “because it allowed me the freedom and safety to process and accept if I was having frustrations or not.” 

Guest encourages counselors to surround themselves with colleagues who are supportive, who will challenge them, who have diverse experiences and perspectives, and who “can help [them] see any blind spots.” 

Turning countertransference into a therapeutic tool 

Although countertransference is largely discussed in terms of something to be avoided, it can have benefits for both the counselor and the client. Namely, it can provide clinicians with insight to better understand the client, Guest asserts. 

For example, she says, take a counselor who is triggered by a young female client who is often defensive and not receptive to feedback in session. The client’s behavior has caused the counselor to become tense and anxious. The client has mentioned in previous sessions that she struggles with relationships and isn’t sure why. The counselor could choose to use the countertransference as a reflective tool to examine if this experience in the counseling session is also happening outside of the session for the client, Guest says. They could say, “I’m noticing some tension, and sometimes I feel like you may not hear me. I’m curious if this happens for you in your other relationships.”

Allen has used countertransference in a similar way. He once worked with a client who dominated the conversation and rarely gave him a chance to talk. Allen was aware that his own annoyance with this type of personality could result in negative countertransference, but instead he used it as a tool to better understand the client. He said, “I’ve noticed you ask me questions, but you do not give me the space to answer them, so I’m not sure if you want me to answer them or not.” 

He followed up with a few questions to learn more about why the client felt the need to dominate the conversation: “Did you come from a family where you felt like you couldn’t get a word in? Are you uncomfortable with silence?”

Sometimes countertransference even has the potential to strengthen the therapeutic relationship. Allen was doing couples therapy shortly after his own divorce. With one particular couple, he decided to meet with them individually to see if they could identify issues they might have been hesitant to share when the other partner was in the room. In an individual session, one of the partners started to cry as she said, “I don’t think we are going to make it.” 

Allen began to tear up as well. He quickly decided to allow that moment of countertransference to come through because he thought it would be helpful to the client in that moment. His instincts proved correct. The client asked him, “Have you gone through this before?” He acknowledged that he was recently divorced, and she told him that she felt seen by him. 

“If I had locked those feelings away and been professorial and distant, it would have been very disconnecting for her,” Allen says. “But I had a spontaneous reaction, and she saw it, and it was a wonderful moment in therapy.” 

However, Allen cautions counselors to carefully consider each client and situation before showing their personal feelings in session. “It might have been the exact wrong thing to do with another client on another day,” he observes. 

The gift of countertransference 

Countertransference can also provide counselors with greater self-awareness. Castro Croy once worked with a Latino child whose father was reinforcing culturally stereotypical messages at home. The instant the child shared this information in session, Castro Croy blurted out, “Excuse me?” in an appalled tone. 

This client’s experience evoked a strong reaction in Castro Croy because he had also struggled with religious and cultural oppression from his upbringing as a child. But he quickly reminded himself, “This is not my chicken,” and proceeded to focus on the client in session. 

This brief moment of countertransference made him realize that there were still residual parts of his own childhood that he had not fully processed in therapy, and he had more work to do himself. 

“When things from the unconscious show up — whether it’s good, bad or ugly — there’s room for that in the [clinical] space,” Castro Croy affirms. Counselors don’t need to “feel scared or intimidated with the humanness that shows up in the profession,” he continues. “Countertransference is a gift because it reminds us … that we are human, that we still have work to do. So, it should not be seen as something negative but as a strength — this is an area I need to work on.”

 

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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.

Self-diagnosis in a digital world

By Lindsey Phillips March 28, 2022

For better or worse, social media posts about mental health, paired with the ease of Googling one’s own symptoms, are enticing many people to self-diagnose. In fact, a 2021 Vox article, “How mental health became a social media minefield,” asserted that social media is becoming known as the “WebMD for mental health.” 

Some clinicians appreciate the self-awareness that can result from social media postings and online searches about mental health, whereas others focus more on the potential harm that self-diagnosis can cause. Counselors need to be aware of the hazards of self-diagnosis, but many in the profession believe they can also use it to gain insights into the inner world of their clients. 

Micheline Maalouf, a licensed mental health counselor and owner of Serein Counseling in Orlando, Florida, chooses to focus on what she can learn from a client’s self-diagnosis. In her practice, she has noticed more clients asking if they have a particular mental health disorder because of social media content. Recently, a client told her they thought they might have obsessive-compulsive disorder (OCD). When Maalouf asked why, the client explained, “I saw this TikTok video about signs that you may have OCD. I resonated with some of the symptoms but not all, so I’m not sure if I have it. My situation wasn’t exactly like the person’s in the video, but it got me thinking.” 

ImYanis/Shutterstock.com

Maalouf asked more questions about the symptoms from the video that had resonated with the client, and she also educated the client on the process of determining a diagnosis, emphasizing that it is not as simple as matching symptoms from a checklist. Disorders manifest differently for everyone, she told the client, and depend on many factors, including life experiences, gender, race and more. But Maalouf also reassured the client that their awareness about OCD symptoms was “important information … because it could be the first step in figuring out if something is actually going on.”

Maalouf, an American Counseling Association member who specializes in treating anxiety, depression and complex trauma, says she is thankful for conversations such as these for two reasons. First, it means the client has some self-awareness, which is a good thing, she says. And second, it provides her with more insight into her client and the potential issues they need to work on in session — regardless of whether the issues match the client’s self-diagnosis.

Searching for answers 

People are hungry for mental health answers, observes Lindsay Fleming, a licensed professional counselor (LPC) with a private practice, Main Street Counseling Solutions, in Park Ridge, Illinois. They want to learn how a potential diagnosis or certain symptoms are affecting their lives and ways to better manage them. What’s hard, she says, is “when someone is doing that by themselves and doesn’t have a professional guiding them” and helping them understand it.

“A lot of people like to have that diagnosis because it explains [what’s happening],” says Tristan Collazo, a licensed resident in counseling at Wholehearted Counseling in Virginia Beach and Carrollton, Virginia. “Some people think it’s stigmatizing, but a lot of people find hope in it because it finally — for once in their life — explains what’s going on.”

Kaileen McMickle, an LPC and founder of Inner Ascent Counseling in Rice Lake, Wisconsin, often works with clients who are struggling with anxiety disorders. She finds the more anxiety a person has, the more likely they are to seek information about what they are experiencing. “It can be hard to feel so isolated and not know what’s going on,” she notes. “People just want certainty. And with Google and social media, it’s so easy to go [online] and try to make sense of what they are experiencing.”

McMickle specializes in treating anxiety, trauma and OCD, and she frequently sees self-diagnosis with clients who have OCD. They often wonder if what they are experiencing is “normal.” 

“We all have intrusive thoughts. We all engage in safety behaviors in some way,” McMickle explains, “but OCD can feel a lot different … [and outside] the ‘normal’ range of behaviors,” such as feeling compelled to tap one’s car 10 times before going into a grocery store or spending two hours trying to find “just the right” products. “People want to know what’s happening to them; they want to know what they’re experiencing,” she says.

Collazo says that a couple of his clients initially self-diagnosed because they identified with a particular trait of a disorder. Someone may see a video about how controlling behavior and manipulation are traits of narcissistic personality disorder, for example, and fear that they have the disorder because they engaged in this type of behavior once in a past relationship. They might have been upset and accused their partner of not loving them, for instance. Making such a statement can be a form of manipulation used by someone with narcissistic personality disorder, Collazo notes, but he points out that it is also something many people who don’t have the disorder might blurt out in the heat of the moment. 

It is human nature to sometimes relate to a disorder or disease after learning a little bit about it, Collazo says. “We probably all have traits from different personality disorders,” he observes, “but it takes certain criteria to have an official diagnosis, which people don’t often understand. They may have a trait or symptom [from a personality disorder] … but that does not mean they have that disorder.” In his social media posts, Collazo tries to debunk the tendency to self-diagnose based solely on resonating with a particular trait. 

That is why it is so important to help clients distinguish between symptoms or traits and an official diagnosis, says Shani Tran, a licensed professional clinical counselor. If a person sees a post about how an inability to sleep, a lack of energy and feelings of sadness are symptoms of depression, they may assume they are depressed because they are struggling with one or more of those symptoms. But having trouble sleeping could be the result of an array of issues, Tran notes, and not necessarily evidence of a mood disorder. 

Tran, owner and founder of The Shani Project, a group counseling practice in Minneapolis, attempts to personify anxiety, depression and trauma on her TikTok account as a means of educating others about mental health issues. She has noticed people resonating with some of her mental health “characters” by commenting, “Oh, that’s so me.” 

In her online posts, Tran makes a point of saying, “these may be the signs of” rather than “these are the signs of” to underscore that just because someone resonates with a particular trait in one of her videos doesn’t mean that they necessarily have a diagnosable disorder. 

For example, someone can experience a trauma and not have posttraumatic stress disorder (PTSD). It often depends on functionality. “Whenever a diagnosis is being made, there has to be an area of the person’s life” — social life, personal life, work or school — “that they aren’t functioning in for it to be a diagnosis,” Tran notes. Even if someone with a mental health issue is high functioning (meaning they function at a higher level than others with the same condition), thereby making it more challenging to determine a diagnosis, there is often a change in the severity or duration of symptoms from how they were functioning before to how they are handling things now, she adds.

Tran hopes her social media content will invite conversations about mental health and get people who relate to some of the symptoms she highlights to consider talking to a mental health professional. Her book Dope Therapy: A Radical Guide to Owning Your Therapy Journey, which she wrote to help people navigate therapy from start to finish, will be published this summer.

McMickle observes that “when people self-diagnose, they are looking for information about themselves, and that can be a really helpful, positive thing. That might mean they’re experiencing some discomfort or emotional dysregulation and they want to change that.” But given the potential for misinformation online, she also cautions counselors to ask clients where they are getting their knowledge of symptoms and disorders and to be careful about any resources — especially social media accounts — that they provide to clients. 

Potential dangers 

As counselors know, accurately diagnosing mental health conditions is complex, requiring years of education and training to truly understand the nuances. Social media, however, tends to simplify this process and often reduces psychological theories or disorders into brief snippets or common stereotypes. For example, a social media post might boil diagnosis down to “Signs you are with a narcissist” or “Things you didn’t realize were ADHD.” Or a meme may depict someone with “avoidant attachment” agonizing over their choice of either cutting someone out of their life or clinging to the person so the person won’t abandon them. 

These types of posts don’t address the complexity of mental health issues or any new research on the topic, such as how attachment is a pattern and not a fixed state, says Ilyse Kennedy, an LPC and licensed marriage and family therapist. “So, people may think certain things about themselves or may resonate with something without having all the nuisance behind it of what that actually means,” she says. Kennedy notes that it has taken her years of studying attachment disorder and reading several books before understanding her own attachment style.

Some clients who self-diagnose come to counseling wanting to receive that same diagnosis from a professional, but people don’t necessarily think about how certain diagnoses could affect them long term, Tran says. For example, some diagnoses could alter the type of life insurance policy someone can get or hinder their ability to obtain security clearances for their job, she points out. Understanding the potential long-term implications makes her careful and cautious when diagnosing clients, she says.

Tran reframes clients’ attempts at self-diagnosis to emphasize their symptoms. If someone asserts that they have depression, for instance, because they are having trouble sleeping and don’t have much energy, she focuses on those symptoms, which could be because of depression or because of anxiety, PTSD or just daily stressors. “People come to therapy looking for answers, but [therapy] is actually very informational,” Tran says. She spends substantial time asking questions and gathering more information about clients: “Tell me more about this low energy. Is it when you wake up? Does it happen at social functions or when you are doing schoolwork?”

Another problem is that anyone, regardless of their qualifications (or lack thereof), can post what might be interpreted as “expert advice” on mental health issues online, which can lead to widespread misinformation. Even people who are well-intentioned can misread or misunderstand mental health information and portray it inaccurately online, causing others who are simply looking for answers to be misled, says Fleming, an ACA member who specializes in attention-deficit/hyperactivity disorder (ADHD). 

Social media algorithms, which filter content based on people’s interactions, can also play a role in leading someone toward an incorrect self-diagnosis. The first thing people see when they open up TikTok is the platform’s feed of recommended videos, called the For You page. If someone resonates with a TikTok video about ADHD, for example, and they “like” it, then their For You page begins to show them more ADHD videos. This creates a type of self-fulfilling prophecy, Fleming says, because the person begins to feel that they are “meant” to see the videos.

According to Collazo, this misinformation has the potential to create a nocebo effect — someone develops certain negative or harmful side effects or symptoms because they believe or expect that they will occur. In other words, a social media post saying that people with these particular symptoms have a particular disorder could cause someone to feel that they do, in fact, have the disorder or cause them to engage in behaviors that confirm it.

Given the potential for error when it comes to self-diagnosis, McMickle explores what that particular self-diagnosis means to the client and how it affects the way they view themselves or approach certain situations. Learning about a diagnosis online has the potential to reduce the stigma around it and instill hope in the person that they too can get help, McMickle notes. But if they are self-diagnosing without also seeking professional assistance, or if they are misdiagnosing themselves, then they are potentially stuck in a difficult place and not getting the help they need, she says. 

Potential benefits 

On a positive front, social media can foster a sense of community and belonging for those who are looking for mental health answers. Discovering online videos and communities of other people who share similar symptoms and struggles, especially for stigmatizing diagnoses such as bipolar disorder, can be rewarding and encouraging, says Kennedy, founder of the group practice Moving Parts Psychotherapy in Austin, Texas. 

People typically have a general idea about anxiety and depression, but Kennedy says social media has opened the door for more discussions about trauma and neurodivergence, including diagnoses such as autism and OCD that have often been highly stigmatized. 

Kennedy, who specializes in trauma work and individuals with trauma related to dissociative disorders, recalls that when she was first making her professional website eight years ago, colleagues advised her against mentioning trauma because it was a “complex term” and people wouldn’t understand it. Fast-forward to today, and that advice seems ludicrous because there is so much more awareness around trauma. 

One of the biggest benefits to the rise in self-diagnosis, at least when prospective clients follow up and seek professional help, is that it provides counselors with insight into the client’s inner world and how they perceive their experiences, Kennedy says. She notes that she has experienced more female clients resonating with social media content on ADHD lately in part because people are just beginning to highlight how the diagnosis can look different in women than in men. When clients tell Kennedy they think they have ADHD, she can use their self-diagnosis to help them reframe how they view their experiences. These clients can then consider their difficulty starting tasks through the lens of neurodivergence rather than as an inherent flaw within themselves. 

“Self-diagnosing [online and through social media] can help people identify how they feel and what they’re struggling with,” Fleming says. “It can also be the only place people have access to mental health information.” 

From her perspective, client self-diagnosis can provide more context, and the more information she has about the client, the more likely she will be able to help them. A self-diagnosis of ADHD, for instance, gives her the opportunity to ask about when and why the client feels distracted. Are they bored and having trouble focusing, or are they anxious about all they have to do later that day?

McMickle finds that with OCD, the more insight clients have, the better the outcomes. If they realize on their own that they might be experiencing compulsions, obsessions or intrusive thoughts that are interfering with their quality of life, then they may come to counseling more prepared to make changes to improve their situation, she says.

Online mental health searches can be a slippery slope, however, McMickle warns. People can find useful information about what they are experiencing, she says, but they can also “go down a giant rabbit hole with any disorder or any medical problem” and get lost in the possibilities of what is happening to them. There is a difference between being genuinely curious and wondering “Do I have this disorder?” and ruminating about all the ways that a diagnosis is affecting your life, she stresses. That’s why it is important for counselors to do a thorough assessment and figure out where clients are getting their information and how it affects the way they view themselves and their world, she says. 

The need for validation 

Counselors must be tactful when reacting to a client’s self-diagnosis, always keeping in mind how much courage it takes to seek help, even if the self-diagnosis proves to be off base. Counselors who don’t handle this situation well risk making clients feel invalidated and turn away from getting the help they need.

Validation with self-diagnosis is crucial, Collazo stresses, because it’s likely that other people in the client’s life have told them that their symptoms or potential diagnosis is “just in their head” or that they “just need to put a smile on it.” Therapy is the one place where they can finally hear someone reaffirm that they are not “sad for no reason” and they are
not “broken.”

Collazo first listens and validates clients’ thoughts and feelings about a potential self-diagnosis. Then he explains about diagnostic criteria and, depending on the client’s needs, offers to do a formal assessment. “If their self-diagnosis was right, then great,” says Collazo, “but if not, then counselors [can] offer hope; they can still help the client” get better. 

McMickle also errs on the side of validating clients who come in with a self-diagnosis, even while exploring their symptoms further. If a client states that they have had a panic attack, for example, then McMickle would acknowledge that they’ve experienced some type of pain or discomfort (regardless of whether the occurrence was an actual panic attack). She would also ask about the context surrounding the assumed panic attack, any other symptoms the client is experiencing and what the client knows about panic attacks from online or social media. 

Learning how to navigate a client’s self-diagnosis without invalidating the client is a crucial skill, McMickle says, because the therapeutic relationship is the cornerstone of effective counseling. “No matter what clients come in with — right or wrong, accurate or not — they’re coming in [to] a really vulnerable space,” she says. “It’s so important that we are really understanding and sitting with them and holding space for them so they can continue talking about things that are upsetting to them and come back for better assessments.” 

Collazo acknowledges that it can be difficult to balance validating with assessing the accuracy of someone’s self-diagnosis. He finds that asking questions and remaining curious are good approaches to learning more about what the client is experiencing while maintaining a healthy therapeutic relationship. 

Kennedy also relies on questions to discover more about the self-diagnosis. She may ask a client, “What does it means for you to have that diagnosis? Why does it feel important to have it? Does it help you better understand yourself or better learn coping tools? Does it give validation to your pain?”

Even if clinicians disagree with a client’s self-diagnosis, they can still validate the client’s feelings, Tran asserts. If a client says, “I’m feeling sad, and I think I have depression,” she rephrases the statement by saying, “So, what I’m hearing is you are feeling sad. Can you tell me more about that?” This language allows her to clarify what the client is experiencing and provides her with more insight. 

The need for a safe space 

Recently, after TikTok videos about Tourette syndrome went viral, doctors started noticing an increase in teenage girls who were suddenly experiencing verbal and motor tics. Tourette syndrome tics are unique to each person, so when doctors from different geographical regions observed similarities in the girls’ tics, they started to suspect that social media was playing a role. However, the evidence was anecdotal and overlooked other contributing factors (such as anxiety and stress). Others fear that blaming social media could further stigmatize Tourette syndrome, especially for young women, making it harder for people to disclose symptoms
to professionals. 

Likewise, counselors sometimes forget how difficult it is for people to ask for help, Fleming says. By the time someone calls or is sitting in the counselor’s office, they have typically invested a lot of thought and energy in making that decision. 

Fleming cautions counselors to avoid hinting at any negative reaction they might have to a client’s self-diagnosis. They should refrain, for example, from saying, “Oh, everyone has that diagnosis on TikTok.” Reacting in disbelief or dismissal could be harmful to the client.

To make it easier for clients to disclose potential diagnoses or symptoms that resonate with them, Fleming invites clients to text her anything they might be hesitant to mention in session, such as their eating habits or a potential self-diagnosis of an eating disorder. She doesn’t respond to the text, but at some point during the next session, she says, “You texted me that you wanted me to check in about your eating habits. How’s that been going for you this week?” If the client still doesn’t want to talk about it, Fleming doesn’t push it any further in the moment but makes a note to try again in a future session. The important thing is for counselors to give clients a safe space to bring things up so they can address it when they’re ready, she says. 

Counselors also must be aware of their own preconceptions and stereotypes about certain disorders. Kennedy has noticed that some clinicians may be quick to dismiss a self-diagnosis of bipolar disorder, for instance, because the client exhibits healthy boundaries. Because of stereotypes, even some counselors may incorrectly assume that this isn’t possible for someone with bipolar disorder. Or, if the counselor is fond of the client, they may be hesitant to give the person such a stigmatizing diagnosis.

It is particularly important for clinicians to create a safe, welcoming space for younger clients and avoid dismissing their thoughts and feelings around self-diagnosis. “Adolescents are still trying to figure out who they are, and they sometimes latch on to things that aren’t them” in the process of discovering more about themselves, McMickle says. For example, adolescents often pull away from people, especially their parents, as they form their own identities, but this behavior is similar to traits associated with borderline personality disorder, she notes. So, if they see a video about that disorder, they may worry that they have it and interact with the world as if they do have it.

Kennedy has noticed that with some younger clients, self-diagnosing may be more about needing someone to see their pain or seeking validation from their parents than about being accurate. But it is still important to validate and explore this diagnosis, she emphasizes, even if it doesn’t align with what the counselor is noticing in session. 

From self-diagnosis to self-awareness 

“Self-diagnosing is giving people more [of an] ability to advocate for themselves and say, ‘No, I think I have this, and this is why,’” Fleming says. “It’s giving people a voice within the professional world.” 

It’s also helping to normalize mental health. A few years ago, Fleming often had to reassure clients that it was OK to have anxiety or ADHD. Now she’s having fewer of those discussions because with the increase in self-diagnosis, the stigma around mental health is also lessening. 

In addition, social media is helping people develop a sense of self-awareness related to mental health. “People feel less isolated and have a deeper understanding of themselves,” Maalouf says. Many of her TikTok followers leave comments on her mental health videos such as “This explains so much,” “I thought I was the only one” and “This is helpful because now I understand what’s happening with me.” She’s also noticed (based on comments and messages) that this awareness sometimes results in people seeking out counseling to find ways to manage or cope with these issues. 

Tran has noted an increase in self-awareness among clients and prospective clients as well. In fact, she considers self-diagnosis to actually be “self-awareness around symptoms.” Before the COVID-19 pandemic and the rise of mental health on TikTok, Tran would get emails from potential clients saying they were looking for a therapist and she sounded like a good fit. Now, she’s noticed the emails are more detailed: “I’ve been struggling with sleep, and I want to have a better relationship with my brother. I’m looking for a therapist with these particular values. Are you able to help me?” 

When someone has a general idea of what they are experiencing, they tend to seek out a clinician who specializes in the mental health issue with which they are struggling, McMickle says. This also helps her when she needs to refer someone because it gives her an idea of what type of therapist the person is searching for.

Counselors can make self-diagnosis more of a collaborative process in session rather than viewing it as “dangerous” or “misguided.” If a client comes to Kennedy thinking that they have a certain diagnosis, she goes through the criteria with them and asks what resonates with them. When clients seem to want or need a particular diagnosis assigned to them, she asks about the reasoning behind that. Is it to get accommodations at work or school? Is it to get medication? Is it to have peace of mind and a better understanding of themselves? If clients do need accommodations or medication, Kennedy will recommend a more formal assessment, but if they just want to understand what they are experiencing and find ways to manage it, then she uses their self-diagnosis as a framework to learn more about the client and help them find a treatment plan that works for them. 

“When a client comes in with a self-diagnosis, it’s a very brave act,” Kennedy says. “It’s very brave and vulnerable for them to be testing this theory out with you. It’s brave and vulnerable that they’re letting you into their inner world in that way. It can be such a powerful space in the therapeutic relationship to welcome it [the self-diagnosis], even if you don’t quite see it or even if it doesn’t feel ‘right’ for the client. It still allows us to learn so much more about them and to have a moment where we really welcome their vulnerability and create more safety in the therapy room.”

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Read more in an online companion piece to this article, “The rise of counselors on social media.”

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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.

Behind the Book: Counseling Leaders and Advocates: Strengthening the Future of the Profession

Compiled by Lindsey Phillips March 14, 2022

The future of the counseling profession depends on the leadership and advocacy of its current and future members. But what makes a good leader or advocate and what can clinicians learn from current counseling leaders?

Counseling Leaders & Advocates: Strengthening the Future of the Profession, an ACA-published book co-edited by Cassandra Storlie and Barbara Herlihy, explores these questions by examining the personal and professional experiences of prominent leaders and advocates in the field.

The profiled leaders in this book do not name a single leadership theory that guides their work, but as Storlie and Herlihy point out in the introduction, they all “speak of leadership as a process of empowering others and as an opportunity to advocate.” They don’t “espouse a traditional view of leadership as a power-over position,” they note, “rather, they speak of ‘leading from behind,’ working ‘behind the scenes,’ and ‘leading by doing,’ not for their own aggrandizement but to move our profession forward and improve services to our clients.”

The COVID-19 pandemic and systemic racism and injustices will continue to challenge leadership and advocacy. Storlie and Herlihy hope this book will encourage the next generation of leaders and advocates who, they argue, “must embrace the complex issues facing our clients, the profession as a whole, and our national and global societies if we are to advance and continue to distinguish excellence in professional counseling.”

 

Q+A: Counseling Leaders and Advocates: Strengthening the Future of the Profession

Responses are written by editors Storlie and Herlihy. Storlie is a licensed professional clinical counselor supervisor and an associate professor and doctoral program coordinator in the counselor education and supervision program at Kent State University. Herlihy is a professor in practice and doctoral program director in the counselor education program at the University of Texas at San Antonio as well as professor emeritus in the College of Education and Human Development at the University of New Orleans.

 

How are leadership and advocacy similar and how are they different?

As counselors, it is natural for us to consider ourselves advocates. We advocate for clients, groups, families and communities and on behalf of our profession. Advocates are driven by a passion to make positive change in the lives of their clients, in the systems that contribute to marginalization and oppression of clients and client populations, and in the profession for the purpose of increasing our capacity to reach and help those in need. Yet, many of us do not consider ourselves leaders.

Leadership and advocacy are inherently related, and advocacy initiatives taken on by counseling leaders affect our world today. Most importantly, leadership in counseling has been emphasized from the servant leader perspective (a phrase coined by Robert K. Greenleaf in 1970). The leaders profiled in our book did not view leadership as a power-over position. Instead, they saw it as leading by doing and working behind the scenes for the sake of moving the profession forward and improving client services. As such, one can deduce that leadership in counseling is ineffective when leadership practices move away from our core values as professional counselors. That said, if you are a leader in counseling, you are most likely an advocate. If you are an advocate in counseling, you are most likely a leader!

 

What qualities or personal characteristics are essential to being a good leader or advocate?

Taking information from the areas of servant leadership (Greenleaf, The Servant as Leader, 1970), authentic leadership (Bill George, Authentic Leadership: Rediscovering the Secrets to Creating Lasting Value, 2003) and transformational leadership (Ronald Piccolo and Jason Colquitt, “Transformational leadership and job behaviors: The mediating role of core job characteristics,” 2006) literature, good leaders and advocates share power and allow for space to include all voices. They are genuine, relational, ethical, motivating and inspirational. In addition, given the challenging times in which we are living, it is essential for leaders to be adaptive and to help others understand the complexities of their environment to better help people deal with change.

 

How does being culturally responsive change the way a counselor approaches leadership?

We don’t know where we are going if we don’t know where we have been. By striving for culturally responsive counseling leadership, we embark on a journey in which we voluntarily accept both the privilege and responsibility of intervening. Culturally responsive leaders will help our profession become stronger and more inclusive, representing more diverse voices and combatting systemic injustices. These leaders also examine how their intersectionality (a term coined by Kimberlé Crenshaw) affects others. They focus on challenging their worldviews to uncover unconscious bias and move forward reflectively to ameliorate barriers to inclusion.

 

Leadership does not always mean serving in formal positions (e.g., president of a counseling organization). What other ways can counselors be leaders and advocates within and outside the profession?

Formal leadership is just one of the ways you can be a leader and advocate in our profession. In Chapter 3 of the book, Michael Brubaker and Andrew Wood highlight previous scholars who have shown us the importance of developing advocacy dispositions, relationships and knowledge to set up and best execute and evaluate advocacy plans. These efforts can be conducted within the counseling profession or outside the profession. We also think it’s important to carefully select counseling sites or populations you work with and partnerships that allow you to best formulate your leadership and advocacy plans. Perhaps it’s partnering with a school district or joining a local National Alliance on Mental Illness (NAMI) group to better support the mental health needs of your community. There are myriad ways in which counselors can be leaders and advocates — and as we mentioned earlier, you probably already are!

 

What are some key takeaways from the stories of counseling leaders and advocates in the book?

Ahhh … key takeaways! Well, one thing that stood out for us is how many leaders have served as role models and mentors to others within the profession, and how deeply they appreciated their own mentors. Additional principles that were woven throughout their stories were having a vision for the future, encouraging and empowering others, recognizing the contributions of others, and engaging in self-reflection. We think it is also important to point out that each leader shared their own experiences of adversity that they overcame — showing us that these individuals, who have passion and purpose, also had to dig deep to gain resilience as leaders and advocates.

 

How do counselors overcome challenges and setbacks in their career and how does this shape the leader or advocate they become?

Of the leaders and advocates we profiled, each had their own unique challenges and setbacks. As Devon Romero, Madelyn Duffey and myself (Cassie) synthesized in Chapter 17, these leaders were “People who encountered doubt and persevered in the face of grief, loss, and adversity … [and] who made mistakes and desired to learn from them. …[This] adversity shaped who they are, how they lead, and what they value.”

One of the ways counselors can overcome challenges and setbacks in their career is to use their skill sets to be reflective about what they are experiencing. Both of us have reflected on setbacks in our own careers and found it helpful to explore what we have learned from the challenging experiences. If we can use a professional challenge to bring added value to our lives, then we are navigating our professional journey with perseverance.

 

What role do mentors and supervisors play in shaping new leaders and advocates in the profession?

Mentoring is crucial for the development of new leaders and advocates. Good mentors are those who make time to be available to their mentees (often throughout several decades), who convey a belief in these mentees when they don’t yet believe in themselves, and who open doors to provide opportunities to gain leadership and advocacy experience. Mentors can also be sponsors in that they are looking out for possibilities for their mentees when those mentees are not present.

We believe that being a good role model and truly modeling culturally responsive leadership can be a valued lesson for mentees. My (Cassie’s) mentors have been and still are culturally responsive leaders and open to growth in their own development as professionals and individuals.

The counselors profiled in the book spoke with gratitude of their own mentors, and they took pride in the mentoring they have provided to others over the years. Our current leaders and advocates have a strong commitment to “pay it forward,” which seems to make it inevitable that this commitment will transfer to the next generation and to generations to come.

 

What practical advice do you have for counselors as they move into leadership and advocacy positions in the counseling profession?

In the book, we offered five suggestions for aspiring leaders and advocates. First, find a mentor. Mentors can help you navigate your way toward gaining leadership experience and learning to advocate in ways that fit with your passions. Second, start small. Most of us have difficulty even imagining ourselves ever becoming as accomplished as the leaders and advocates profiled in the book. Rather than immobilize yourself with comparisons, realize that opportunities for leadership and advocacy are all around you, and volunteer for a small opportunity to serve a cause about which you care deeply. Third, keep your balance. This suggestion serves as a reminder of the importance of self-care and life-work balance. Fourth, lead to serve rather than acting out of a need to fill a line on one’s vita or to feel important. Servant leaders are absolutely the most effective leaders we have in our profession. Last, trust yourself. If someone sees something in you, it’s because it’s already there.

 

What is the most important or surprising lesson you have learned about leadership throughout your own counseling career?

For Barbara, it was the realization that leadership is composed of a set of behaviors rather than holding a formal title or position. Many, if not most, of our leaders and advocates are working behind the scenes, fostering change and furthering social justice initiatives without a need for recognition.

I (Cassie) second all that Barbara outlined above, and I also want to point out the important need to intentionally “pay it forward” and help to mentor others’ leadership development.

 

What does being a leader mean in today’s social climate, especially considering the ongoing COVID-19 pandemic and social unrest?

That is an excellent question! In the current political and social climate, a starting point for bringing people together in peace is for us to use our basic counseling skills such as listening — really listening — in an attempt to understand beliefs and values that clash with our own. We counselors have the skills to build bridges!

We also need to ensure we can have the crucial conversations necessary to help make sustainable change. We recognize this change does not happen overnight, but we also realize that change will never happen if we don’t talk about uncomfortable topics and honor the human dignity of everyone.

 

What practical actions can leaders take to combat systemic injustices and racism in the counseling profession and society at large?

We believe that silence in the face of injustice and racism is collusion. Leaders who are in the privileged position of being respected and admired have an obligation to speak up and confront injustice and prejudice, both within our profession and in the larger world. Although practical actions may look different at the microsystem level versus the macrosystem level, counselors can tailor their actions to advocate with and on behalf of those most marginalized. Additional actions can be further developed when integrating the Multicultural and Social Justice Counseling Competencies into one’s work.

 

In the book, you call on the counseling profession “to nurture, mentor, and increase diversity among future leaders.” How can the counseling profession address the lack of diversity within counseling leaders moving forward?

One thing we can do is to monitor our own implicit biases as we identify up-and-coming leaders who might benefit from opportunities to join with us in the work we are doing. We can also remember that diversity involves the intersection of multiple identities, not just those that are visible. Many of the leaders profiled in the book were aware of their privilege and were committed to ensuring they were inclusive as they were “paying it forward.”

 

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Counseling Leaders & Advocates: Strengthening the Future of the Profession was published by the American Counseling Association in 2021. It is available both in print and as an e-book at counseling.org/store or by calling 800-298-2276.

Watch ACA President S. Kent Butler’s conversation with Cassandra Storlie in a recent episode of the “Voice of Counseling” video podcast: https://youtu.be/157o_3QrHwk

 

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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.

How to land an internship you’re excited about in 48 hours or less

By Wesley Murph January 19, 2022

The accident happened on a sunny Saturday afternoon.

I was driving home from my internship site, where I had seen clients that morning, when I stopped at a red light. As I changed the radio station on my car’s stereo, I heard screeching tires and crunching metal.

Then, as if I were in a Steven Spielberg movie, a maroon-colored car launched over the back of my car. It landed on its side and skidded down the asphalt against oncoming traffic.

As I stared at the unfolding scene, something big plowed into the back of my car, pushing it into the car in front of me. Glass shards and taillight debris rained down inside of my car.

I glanced in the rearview mirror and saw green liquid spewing from the van that was now embedded in my car. I feared that my car would explode and that I would be burned inside. As quickly as I could, I opened the door on my car and stepped on to the slick pavement. I glanced around to make sure I wouldn’t be hit by an oncoming car and heard a woman screaming from behind the maroon car. I immediately dialed 911.

“There’s been a bad accident,” I said to the 911 operator. “I think people are hurt. Please send help quickly.”

Minutes later, several police cars arrived and began directing traffic. A firetruck and an ambulance arrived next. A first responder said the woman driving the maroon car was shaken up but was otherwise OK. Just to be safe, they were taking her to the hospital.

I sat down on the sidewalk, grateful that nobody was seriously hurt. But when I looked at my car, I knew it was totaled. I also knew I would have to find a new internship site because my site was 60 miles from my home and the majority of clients I saw were in-person.

A few days later, I emailed my internship coordinator at the graduate school I attended and told him what had happened. We met on a video call, and he said it might be three months before I was placed at a new site. “If that happens,” he said, “you may not graduate on time.”

My pulse quickened. I had been in graduate school for nearly two years, and I was six months away from graduating. I needed 150 additional direct client hours to walk with my peers, and there was no way I was going to wait three months to find a new internship site.

So, I put on my marketing hat with one goal in mind: to find a new internship site. I never imagined what would happen, but I am grateful to say that I received five internship offers in 48 hours.

I would like to share what I did so that others looking for an internship site can find one they are excited about. Or you might tweak my campaign to connect with potential supervisors and land a new job.

I can’t guarantee the results if you follow this campaign, of course. But I can say it will help you connect with counselors in your area. It will also strengthen your sense of confidence and freedom by giving you more control over your future.

Google search

The first thing you need to do is find clinical supervisors for whom you want to work.

I played around with keyword searches in Google until these searches brought me to a webpage containing nearly a hundred clinical supervisors in my area. The webpage had a picture of each supervisor, a paragraph about the supervisor, and the supervisor’s email address and phone number.

I carefully read each supervisor’s bio until I found 25 whom I wanted to contact. I then researched the various supervisors using Google to find out more about each person. I went to each supervisor’s website, if they had one, and read their “About Me” page. I wanted to make sure that I genuinely connected with each supervisor before reaching out to them in an email.

I recommend that you complete this step too. Research the clinical supervisors in your area until you have a list of folks you want to work for. Really get to know these people. What clinical theories do they practice? Have they published any studies? If so, what are the results of those studies? How did they get into counseling? Have they written any blog posts or been a guest on a podcast? If so, what did you learn from their post or podcast? Do a deep dive into these people so you can honestly say to yourself whether you would want to work with them or not.

Next, I encourage you to create an Excel or Google Sheets file to help you keep track of your campaign. I created a new Google Sheets file using these headings:

  • Full Name
  • Email
  • Phone
  • Specialty
  • When Contacted
  • Response
  • Result

I filled my Google Sheets file with the 25 clinical supervisors I liked and connected with the most. I then sent a sincere and personal email to each of these supervisors.

Cytonn Photography/Unsplash.com

Email marketing

Here is what I wrote in the email:

 

Subject Line: Clinical Supervision?

Hi (First Name of Supervisor),

 

My name is Wes.

I found your contact information online, and I connected with you because ________. I am reaching out with a question about clinical supervision.

I am completing my master’s degree in clinical mental health from Northwestern University. I am supposed to graduate in March 2022.

Last January, I started my clinical hours at an internship site in Salem, Oregon. I live in Portland, and in August I was involved in a car accident that totaled my car. I am unable to drive to Salem to complete my clinical hours and am looking for a new internship site closer to my home.

Do you know of a licensed mental health clinician in Portland who may be interested in letting me finish my clinical hours underneath their supervision?

If not, do you know someone I can contact who may know someone?

I appreciate you for taking time out of your schedule to read my email.

 

Very respectfully,

Wes

 

Notice how the first paragraph has a blank line. This is where you put the information you gathered from your research. The more specific you are, the better connection you are likely to make.

The third paragraph contains my story. It grabs my reader’s attention because it’s heart-wrenching. You may not have a story like mine. But that’s OK. You can tell your contact another powerful reason why you would like to work with them.

The results

I emailed 25 potential supervisors on a Thursday. I received 18 responses and scheduled video interviews with five of them. I interviewed with one supervisor that Thursday night, three on Friday and another one the following Monday. All five of these amazing supervisors graciously offered to take me on as their intern. Working for any of them would have been delightful, but I chose the one that aligned best with my goals.

I relayed this information to the placement team at my graduate school. A day later, the site at which I wanted to intern was approved.

I also responded to each supervisor who got back to me. I told them I was thankful that they took time out of their schedule to try to help me and that I hoped we would bump into each other at a professional conference in the future.

I made sure to sincerely thank the four sites that offered me an internship but which I politely declined. This is respectful and maintains the relationships I established with each of these generous supervisors.

I was amazed at the outpouring of support from the counseling community in my city. The counseling community in your area is likely just as supportive. All it takes is a sincere and genuine email to open a conversation with someone you admire and want to work for. Who knows what will happen? But this process gives you some control over your future instead of simply hoping that fate is on your side.

 

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Before he began a master’s degree program in mental health counseling, Wesley Murph owned two small businesses, including one that was featured on The Dog Whisperer with Cesar Millan. He currently helps couples communicate more effectively so that each person feels valued, heard and appreciated. He also works with men to resolve anger issues and relationship conflicts that are lowering their quality of life. You can find him at BuildingBetterMenPDX.com.

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